User login
Clinical Edge Journal Scan Commentary: Contraception August 2021
Levonorgestrel intrauterine devices (LNG IUD) are a hot topic in contraceptive research. A recent study on LNG IUDs published by Fay KE et al evaluated pregnancy rates in US women who received LNG or copper IUDs for emergency contraception and reported intercourse within 7 days of insertion. Zero pregnancies were reported in women who resumed intercourse within 7 days of IUD insertion for both the LNG IUD and copper IUD, even in women who had multiple unprotected sexual encounters. LNG IUDs are more readily accessible and better tolerated than their copper IUD counterparts, and expanding their use will only continue to improve access to reliable contraception. Women often resume penetrative intercourse shortly after initiating new contraceptive method despite counseling. Patients can be reassured that placement of a LNG IUD appears to provide immediate contraceptive benefit.
A new estrogen is on the market for use in combined oral contraceptive pills (COC). Estetrol is a natural estrogen produced by the human fetal liver only found in circulation during pregnancy. Estetrol was previously studied for use in menopausal hormone therapy as it acts as a mixed agonist and antagonist, offering a potential improved side effect profile with less activity in the breast and liver. Estetrol (15 mg) was combined with 3 mg of drospirinone for a novel combined oral contraceptive option in a study by Gemzell-Danielsson K et al. The pregnancy rate was similar to traditional COCs, demonstrating good contraceptive efficacy. Bleeding patterns and side effects were similar to traditional COCs, and one case of venous thromboembolism was reported in the large study population. A phase III trial with similar results has been completed and this new oral contraceptive formulation recently received FDA approval and is now marketed as Nextstellis. This new oral contraceptive pill hopefully represents a novel option for women who desire COCs with a low androgenic profile and VTE risk or have failed other COC formulations.
Women are increasingly delaying childbearing, utilizing a variety of contraceptive options to avoid pregnancy. Many proactively seek to determine their fertility potential and clinicians often utilize anti-Müllerian hormone (AMH) as the standard biomarker for assessing ovarian reserve, as it is cycle independent and can be drawn at any time during a woman’s clinical assessment. Hormonal contraception suppresses ovulation by gonadotropin suppression as a means of contraceptive action, and thus could impact an AMH value. A fascinating study by Hariton E et al looked at all contraceptive options and their impact on AMH values. AMH levels were significantly lower in women using COCs, implants, progestin-only pills, and vaginal rings compared to patients not using contraceptives, and AMH levels were slightly lower in women using hormonal IUDs. These results help clinicians counsel patients on expectations for AMH levels while on contraceptives and can guide future research to generate contraceptive-specific ranges. Women using contraceptives should be counseled to retest after stopping if AMH levels are low.
Levonorgestrel intrauterine devices (LNG IUD) are a hot topic in contraceptive research. A recent study on LNG IUDs published by Fay KE et al evaluated pregnancy rates in US women who received LNG or copper IUDs for emergency contraception and reported intercourse within 7 days of insertion. Zero pregnancies were reported in women who resumed intercourse within 7 days of IUD insertion for both the LNG IUD and copper IUD, even in women who had multiple unprotected sexual encounters. LNG IUDs are more readily accessible and better tolerated than their copper IUD counterparts, and expanding their use will only continue to improve access to reliable contraception. Women often resume penetrative intercourse shortly after initiating new contraceptive method despite counseling. Patients can be reassured that placement of a LNG IUD appears to provide immediate contraceptive benefit.
A new estrogen is on the market for use in combined oral contraceptive pills (COC). Estetrol is a natural estrogen produced by the human fetal liver only found in circulation during pregnancy. Estetrol was previously studied for use in menopausal hormone therapy as it acts as a mixed agonist and antagonist, offering a potential improved side effect profile with less activity in the breast and liver. Estetrol (15 mg) was combined with 3 mg of drospirinone for a novel combined oral contraceptive option in a study by Gemzell-Danielsson K et al. The pregnancy rate was similar to traditional COCs, demonstrating good contraceptive efficacy. Bleeding patterns and side effects were similar to traditional COCs, and one case of venous thromboembolism was reported in the large study population. A phase III trial with similar results has been completed and this new oral contraceptive formulation recently received FDA approval and is now marketed as Nextstellis. This new oral contraceptive pill hopefully represents a novel option for women who desire COCs with a low androgenic profile and VTE risk or have failed other COC formulations.
Women are increasingly delaying childbearing, utilizing a variety of contraceptive options to avoid pregnancy. Many proactively seek to determine their fertility potential and clinicians often utilize anti-Müllerian hormone (AMH) as the standard biomarker for assessing ovarian reserve, as it is cycle independent and can be drawn at any time during a woman’s clinical assessment. Hormonal contraception suppresses ovulation by gonadotropin suppression as a means of contraceptive action, and thus could impact an AMH value. A fascinating study by Hariton E et al looked at all contraceptive options and their impact on AMH values. AMH levels were significantly lower in women using COCs, implants, progestin-only pills, and vaginal rings compared to patients not using contraceptives, and AMH levels were slightly lower in women using hormonal IUDs. These results help clinicians counsel patients on expectations for AMH levels while on contraceptives and can guide future research to generate contraceptive-specific ranges. Women using contraceptives should be counseled to retest after stopping if AMH levels are low.
Levonorgestrel intrauterine devices (LNG IUD) are a hot topic in contraceptive research. A recent study on LNG IUDs published by Fay KE et al evaluated pregnancy rates in US women who received LNG or copper IUDs for emergency contraception and reported intercourse within 7 days of insertion. Zero pregnancies were reported in women who resumed intercourse within 7 days of IUD insertion for both the LNG IUD and copper IUD, even in women who had multiple unprotected sexual encounters. LNG IUDs are more readily accessible and better tolerated than their copper IUD counterparts, and expanding their use will only continue to improve access to reliable contraception. Women often resume penetrative intercourse shortly after initiating new contraceptive method despite counseling. Patients can be reassured that placement of a LNG IUD appears to provide immediate contraceptive benefit.
A new estrogen is on the market for use in combined oral contraceptive pills (COC). Estetrol is a natural estrogen produced by the human fetal liver only found in circulation during pregnancy. Estetrol was previously studied for use in menopausal hormone therapy as it acts as a mixed agonist and antagonist, offering a potential improved side effect profile with less activity in the breast and liver. Estetrol (15 mg) was combined with 3 mg of drospirinone for a novel combined oral contraceptive option in a study by Gemzell-Danielsson K et al. The pregnancy rate was similar to traditional COCs, demonstrating good contraceptive efficacy. Bleeding patterns and side effects were similar to traditional COCs, and one case of venous thromboembolism was reported in the large study population. A phase III trial with similar results has been completed and this new oral contraceptive formulation recently received FDA approval and is now marketed as Nextstellis. This new oral contraceptive pill hopefully represents a novel option for women who desire COCs with a low androgenic profile and VTE risk or have failed other COC formulations.
Women are increasingly delaying childbearing, utilizing a variety of contraceptive options to avoid pregnancy. Many proactively seek to determine their fertility potential and clinicians often utilize anti-Müllerian hormone (AMH) as the standard biomarker for assessing ovarian reserve, as it is cycle independent and can be drawn at any time during a woman’s clinical assessment. Hormonal contraception suppresses ovulation by gonadotropin suppression as a means of contraceptive action, and thus could impact an AMH value. A fascinating study by Hariton E et al looked at all contraceptive options and their impact on AMH values. AMH levels were significantly lower in women using COCs, implants, progestin-only pills, and vaginal rings compared to patients not using contraceptives, and AMH levels were slightly lower in women using hormonal IUDs. These results help clinicians counsel patients on expectations for AMH levels while on contraceptives and can guide future research to generate contraceptive-specific ranges. Women using contraceptives should be counseled to retest after stopping if AMH levels are low.
Clinical Edge Journal Scan Commentary: Contraception April 2021
Patients receive the full range of contraception options when providers are educated on the proper use and spectrum of contraceptive options. When an educational intervention was introduced in three countries (Democratic Republic of Congo, Somalia, and Pakistan), aimed at training providers on counseling and provision of immediate postpartum LARC, a significant number of women opted for LARC. This was in comparison to countries that did not implement this educational intervention (Rwanda, Syria, Yemen). The rate of LARC adoption was 10.01% versus 0.77%, respectively in countries providing the educational intervention versus those that did not.
The copper IUD has long been utilized for emergency contraception, providing nearly 100% efficacy in pregnancy prevention, as well as long-acting, reversible contraception. Recently, the levonorgestrel (LNG) IUD was considered for similar use as emergency contraception. Turok et al studied the pregnancy rate of the LNG IUD compared the copper IUD and found that the LNG IUD was noninferior to the copper IUD when used for emergency contraception, with pregnancy rates of 1 in 317 (LNG) compared to 0 in 321 (copper). LNG IUDs are often more readily available in OBGYN offices and could improve access to higher efficacy emergency contraception compared to traditional emergency contraceptive pills.
When placing IUDs, providers have a range of devices to measure the length of the uterus for correct IUD placement, including endometrial biopsy pipelles, uterine sounds, both plastic and metal, as well as the device inserters. In a biomechanical ex vivo analysis, Duncan et al examined the maximum force generated for IUD placement with the levonorgestrel placement instrument, the copper IUD placement instrument, and a metal sound. Using their model, the investigators found that the metal sound caused uterine perforation, but the plastic IUD placement device did not. Although the study authors utilized the device inserters themselves, we recommend the use of plastic uterine sounds or biopsy pipelles over the device inserters in accordance with IUD packaging instructions. IUD packaging should not be opened until both the ability to access the uterine cavity and appropriate uterine size are determined to avoid needing to discard the IUD.
Patients receive the full range of contraception options when providers are educated on the proper use and spectrum of contraceptive options. When an educational intervention was introduced in three countries (Democratic Republic of Congo, Somalia, and Pakistan), aimed at training providers on counseling and provision of immediate postpartum LARC, a significant number of women opted for LARC. This was in comparison to countries that did not implement this educational intervention (Rwanda, Syria, Yemen). The rate of LARC adoption was 10.01% versus 0.77%, respectively in countries providing the educational intervention versus those that did not.
The copper IUD has long been utilized for emergency contraception, providing nearly 100% efficacy in pregnancy prevention, as well as long-acting, reversible contraception. Recently, the levonorgestrel (LNG) IUD was considered for similar use as emergency contraception. Turok et al studied the pregnancy rate of the LNG IUD compared the copper IUD and found that the LNG IUD was noninferior to the copper IUD when used for emergency contraception, with pregnancy rates of 1 in 317 (LNG) compared to 0 in 321 (copper). LNG IUDs are often more readily available in OBGYN offices and could improve access to higher efficacy emergency contraception compared to traditional emergency contraceptive pills.
When placing IUDs, providers have a range of devices to measure the length of the uterus for correct IUD placement, including endometrial biopsy pipelles, uterine sounds, both plastic and metal, as well as the device inserters. In a biomechanical ex vivo analysis, Duncan et al examined the maximum force generated for IUD placement with the levonorgestrel placement instrument, the copper IUD placement instrument, and a metal sound. Using their model, the investigators found that the metal sound caused uterine perforation, but the plastic IUD placement device did not. Although the study authors utilized the device inserters themselves, we recommend the use of plastic uterine sounds or biopsy pipelles over the device inserters in accordance with IUD packaging instructions. IUD packaging should not be opened until both the ability to access the uterine cavity and appropriate uterine size are determined to avoid needing to discard the IUD.
Patients receive the full range of contraception options when providers are educated on the proper use and spectrum of contraceptive options. When an educational intervention was introduced in three countries (Democratic Republic of Congo, Somalia, and Pakistan), aimed at training providers on counseling and provision of immediate postpartum LARC, a significant number of women opted for LARC. This was in comparison to countries that did not implement this educational intervention (Rwanda, Syria, Yemen). The rate of LARC adoption was 10.01% versus 0.77%, respectively in countries providing the educational intervention versus those that did not.
The copper IUD has long been utilized for emergency contraception, providing nearly 100% efficacy in pregnancy prevention, as well as long-acting, reversible contraception. Recently, the levonorgestrel (LNG) IUD was considered for similar use as emergency contraception. Turok et al studied the pregnancy rate of the LNG IUD compared the copper IUD and found that the LNG IUD was noninferior to the copper IUD when used for emergency contraception, with pregnancy rates of 1 in 317 (LNG) compared to 0 in 321 (copper). LNG IUDs are often more readily available in OBGYN offices and could improve access to higher efficacy emergency contraception compared to traditional emergency contraceptive pills.
When placing IUDs, providers have a range of devices to measure the length of the uterus for correct IUD placement, including endometrial biopsy pipelles, uterine sounds, both plastic and metal, as well as the device inserters. In a biomechanical ex vivo analysis, Duncan et al examined the maximum force generated for IUD placement with the levonorgestrel placement instrument, the copper IUD placement instrument, and a metal sound. Using their model, the investigators found that the metal sound caused uterine perforation, but the plastic IUD placement device did not. Although the study authors utilized the device inserters themselves, we recommend the use of plastic uterine sounds or biopsy pipelles over the device inserters in accordance with IUD packaging instructions. IUD packaging should not be opened until both the ability to access the uterine cavity and appropriate uterine size are determined to avoid needing to discard the IUD.