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Contraception Highlights September 2012

This month’s featured editorial

Featured research at the 2012 North American Forum on Family Planning
Carolyn Westhoff, Lawrence Finer, Stephanie Teal 
pages 187 
The Society of Family Planning (SFP) and Planned Parenthood Federation of America (PPFA) will host the second annual North American Forum on Family Planning (the Forum), to be held in Denver, CO, on October 28–29, 2012. The raison d'être of the meeting is the presentation of contraceptive and abortion research, mainly through investigators presenting results for the first time to an audience of their peers. The Forum Scientific Committee reviewed this year's abstracts and accepted 124 for presentation at the meeting. As it did last year, the Committee selected 20 of the abstracts for an oral presentation, four of which will be highlighted in a plenary session. These four include outstanding work that can immediately influence how we practice. 
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This month's commentary

Multi-specialty family planning training: collaborating to meet the needs of women
Jody Steinauer, Christine Dehlendorf, Kevin Grumbach, Uta Landy, Philip Darney
pages 188-190
The specialty of family medicine is recognized as having an important role in the delivery of family planning services in the United States. Not only do many women receive their contraceptive services from family physicians, but there is a growing recognition of the role family physicians can play in ensuring that women have access to safe and timely abortion service. Passage of the Affordable Care Act has drawn attention to this role, as increased insurance coverage may result in many women accessing contraceptive care within primary care services, as opposed to using dedicated family planning clinics.
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This month's commentary

Multi-specialty family planning training: collaborating to meet the needs of women
Jody Steinauer, Christine Dehlendorf, Kevin Grumbach, Uta Landy, Philip Darney
pages 188-190
The specialty of family medicine is recognized as having an important role in the delivery of family planning services in the United States. Not only do many women receive their contraceptive services from family physicians, but there is a growing recognition of the role family physicians can play in ensuring that women have access to safe and timely abortion service. Passage of the Affordable Care Act has drawn attention to this role, as increased insurance coverage may result in many women accessing contraceptive care within primary care services, as opposed to using dedicated family planning clinics.
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Clinical Guidelines

Cancer and contraception: Release date May 2012 SFP Guideline #20121
Ashlesha Patel, E. Bimla Schwarz
pages 191-198
As a result of advances in cancer diagnosis and treatment, young women within the reproductive-aged group are now more likely to survive cancer. Reproductive-aged women with cancer may be interested in deferring pregnancy either temporarily or permanently at cancer diagnosis, during therapy or after treatment. Currently, there are limited guidelines to aide clinicians in managing the contraceptive needs in this special population. After reviewing the evidence regarding the safety and efficacy of available methods of contraception for women who have been diagnosed with cancer, the Society of Family Planning recommends that women of childbearing age who are being treated for cancer avoid combined hormonal contraceptive methods (containing estrogen and progestin) when possible because they may further increase the risk of venous thromboembolism (VTE) (Level A). The copper T380A intrauterine device, a highly effective, reversible, long-acting, hormone-free method, should be considered the first-line contraceptive option for women with a history of breast cancer (Level A), although for women being treated with tamoxifen, the levonorgestrel-containing intrauterine system (IUS) which decreases endometrial proliferation may be preferable (Level B). Women who develop anemia may benefit from use of a progestin-containing contraceptive (Level A). Women who develop osteopenia or osteoporosis following chemotherapy should avoid the progestin-only contraceptive injection (Level B).
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Original research articles

Contraindications to progestin-only oral contraceptive pills among reproductive-aged women
Kari White, Joseph E. Potter, Kristine Hopkins, Leticia Fernández, Jon Amastae, Daniel Grossman
pages  199-203
Background: Progestin-only oral contraceptive pills (POPs) have fewer contraindications to use compared to combined pills. However, the overall prevalence of contraindications to POPs among reproductive-aged women has not been assessed.
Conclusions: The prevalence of contraindications to POPs was very low in these samples. POPs may be the best choice for the first OTC oral contraceptive in the United States.
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Trends in contraceptive patterns and behaviors during a period of fertility transition in China: 1988–2006
Xiaoying Zheng, Lingfang Tan, Qiang Ren, Zhijun Cui, Junqing Wu, Ting Lin, Jie He, Hua Chen
pages 204-213
Background: Immediate postplacental insertion of intrauterine devices (IUDs) during cesarean delivery could reduce a substantial barrier to access to long-term effective contraception. Initiating IUD use prior to discharge from the hospital postpartum eliminates a 6-week postpartum waiting period and an additional office visit.
Conclusions: Immediate postplacental IUD insertion at the time of cesarean delivery is safe and acceptable.
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Intracervical lidocaine gel for intrauterine device insertion: a randomized controlled trial
Karla Maguire, Anne Davis, Linette Rosario Tejeda, Carolyn Westhoff
pages 214-219
Background: Pain during intrauterine device (IUD) insertion can be a barrier to initiation. Clinical trials have found misoprostol and nonsteroidal drugs to be ineffective (Am J Obstet Gynecol 2006;195:1272–1277, Hum Reprod 2011;26:323–329, Hum Reprod 2007;22:2647–2652). One study suggested that 2% lidocaine gel decreased pain; however, study design problems limit its validity (Brit J Fam Plann 1996;22:177–180). We tested whether intracervical 2% lidocaine gel decreased insertion pain compared to placebo.
Conclusions: Intracervical 2% lidocaine gel does not decrease IUD insertion pain. Understanding predictors of increased pain may help providers with preprocedure counseling.
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Drospirenone- and levonorgestrel-containing oral contraceptives and the risk of gallbladder disease
Susan Jick, Dinci Pennap
pages 220-223
Background: Studies have found an association between the use of estrogen-containing oral contraceptives (OCs) and the risk of gallbladder disease. This study evaluated this relation as well as the role of progestogen on the risk of gallbladder disease among users of drospirenone-containing OCs compared to users of levonorgestrel-containing OCs.
Conclusion: There is no evidence in these data that drospirenone- or levonorgestrel-containing OC use confers an increased risk of gallbladder disease compared to women not currently exposed to an OC. Nor is use of drospirenone OCs associated with a higher risk of gallbladder disease than use of levonorgestrel-containing OCs.
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Doxycycline in the treatment of bleeding with DMPA: a double-blinded randomized controlled trial
Hany Abdel-Aleem, Omar M. Shaaban, Mahmoud A. Abdel-Aleem, Gihan N. Fetih
pages 224-230
Background: Increased matrix metalloproteinase (MMP) activity in the endometrium is a predisposing factor for bleeding with depot medroxy progesterone acetate (DMPA) injectable contraception. Doxycycline (DOX) has been proven in vitro to inhibit MMP-mediated degradation of stromal matrix. The current study examined the effect of DOX compared to placebo in treating a current bleeding episode during DMPA use.
Conclusions: Doxycycline as MMP inhibitor is not effective in stopping a current attack of bleeding with DMPA. It also does not improve the bleeding characteristics of women for the subsequent 3 months following the treatment.
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Discriminant analysis of the metabolic effects of a new combined contraceptive vaginal ring containing Nestorone/EE vs. a second-generation oral contraceptive containing levonorgestrel/EE
Mandana Rad, Jacobus Burggraaf, Marieke L. de Kam, Adam F. Cohen,Cornelis Kluft
pages 231-237
Background: Discriminant analysis (DA) was performed on data of two combined hormonal contraceptives (CHC) differing in estrogen ratio to explore whether a combination of variables rather than a single variable distinguishes CHCs better.
Conclusion: DA identifies differences between CHCs and may provide information on the factors associated with thrombotic risk.
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Lowering oral contraceptive norethindrone dose increases estrogen and progesterone receptor levels with no reduction in proliferation of breast epithelium: a randomized trial
Linda Hovanessian-Larsen, DeShawn Taylor, Debra Hawes, Darcy V. Spicer, Michael F. Press, Anna H. Wu, Malcolm C. Pike, C. Leigh Pearce
pages 238-243
Background: This study was conducted to compare breast epithelial-cell proliferation and estrogen and progesterone receptor levels in women taking one of two oral contraceptives (OCs) containing the same dose of estrogen but different doses of the progestin norethindrone (NET).
Conclusions: Both treatments were effective in HMB control. Fewer resources and complications were observed in LNG-IUS acceptors when compared to hysterectomy. The LNG-IUS represents a good strategy for reducing the number of hysterectomies and the resources required for women with HMB.
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Resources and procedures in the treatment of heavy menstrual bleeding with the levonorgestrel-releasing intrauterine system (LNG-IUS) or hysterectomy in Brazil
M. Valeria Bahamondes, Yuri de Lima, Vanessa Teich, Luis Bahamondes, Ilza Monteiro
pages 244-250
Background: Heavy menstrual bleeding (HMB) is the most common complaint of women seeking gynecological care. Treatments included surgical or medical options including hysterectomy and the levonorgestrel-releasing intrauterine system (LNG-IUS) due to the profound suppression of endometrial growth that intrauterine LNG exerts which results in amenorrhea or in a reduction of blood loss.
Conclusions: The importance of different risk factors associated with contraceptive use varies between different ethnic groups. Cross-national comparisons are essential for the design of public health policies that decrease the burden of sexual ill health.
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A randomized controlled trial of different buccal misoprostol doses in mifepristone medical abortion
Erica Chong, Tamar Tsereteli, Nhu Ngoc thi Nguyen, Beverly Winikoff
pages 251-256
Background: An 800-mcg dose of buccal misoprostol following mifepristone has been shown to be highly effective in terminating pregnancies through 63 days since the last menstrual period (LMP) (B. Winikoff, I.G. Dzuba, M.D. Creinin, et al., Two distinct oral routes of misoprostol in mifepristone medical abortion: a randomized controlled trial. Obstet Gynecol 2008; 112: 1303–1310). However, a two 200-mcg misoprostol pill option would simplify administration, and potentially reduce costs and increase women's satisfaction. This study compares a 400-mcg dose (Group I) to an 800-mcg dose (Group II) of buccal misoprostol.
Conclusions: Four hundred micrograms of buccal misoprostol is as effective as the standard 800-mcg dose in terminating pregnancies up to 63 days LMP and reduces side effects.
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Ovarian size and vascularization as assessed by three-dimensional grayscale and power Doppler ultrasound in asymptomatic women 20–39 years old using combined oral contraceptives
Ligita Jokubkiene, Povilas Sladkevicius, Lil Valentin
pages 257-267
Background: The aim of this study is to estimate ovarian volume, number and volume of antral follicles, and ovarian power Doppler vascular indices as assessed by three-dimensional (3D) transvaginal grayscale and power Doppler ultrasound in women using combined oral contraceptives (COC).
Conclusions: Our results show estimated ranges of 3D grayscale and power Doppler ultrasound measurements in ovaries of women using COC.
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The effects of 2 mg chlormadinone acetate/30 mcg ethinylestradiol, alone or combined with spironolactone, on cardiovascular risk markers in women with polycystic ovary syndrome
Carolina Sales Vieira, Wellington P. Martins, Janaína Boldrini França Fernandes, Gustavo Mafaldo Soares, Rosana Maria dos Reis, Marcos Felipe Silva de Sá, Rui Alberto Ferriani
pages 268-275
Background: Polycystic ovary syndrome (PCOS) is an endocrine disorder associated with metabolic dysfunction and changes in cardiovascular risk markers, and using oral contraceptives (OCs) may exert a further negative effect on these alterations in patients with PCOS. Thus, the primary objective of this study was to assess the effects on arterial function and structure of an OC containing chlormadinone acetate (2 mg) and ethinylestradiol (30 mcg), alone or combined with spironolactone (OC+SPL), in patients with PCOS.
Conclusions: The addition of spironolactone to an OC containing chlormadinone acetate and ethinylestradiol conferred no cardiovascular risk-marker advantages in young women with PCOS.
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Sex education and adolescent sexual behavior: do community characteristics matter?
Joan Marie Kraft, Aniket Kulkarni, Jason Hsia, Denise J. Jamieson, Lee Warner
pages 276-280
Background: Studies point to variation in the effects of formal sex education on sexual behavior and contraceptive use by individual and community characteristics.
Conclusions: Variation in the effects of sex education should be explored. Research might focus on programmatic differences by community type and programmatic needs in various types of communities.
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Case reports

Vaginal misoprostol aids in difficult intrauterine contraceptive removal: a report of three cases
Whitney L. Cowman, Jean M. Hansen, Abbey J. Hardy-Fairbanks, Colleen K. Stockdale
pages 281-284
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Missing IUD and utilization of fluoroscopy for management: a case report
Jashoman Banerjee, Roohi Jeelani, Jay M. Berman, Michael P. Diamond
pages 285-287
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Use of the levonorgestrel-releasing intrauterine system in renal transplant recipients: a retrospective case review
Tasneem Ramhendar, Paul Byrne
pages 288-289
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