Contraception

A novel approach to cervical dilation for second-trimester dilation and evacuation in a myomatous uterus

Cervical preparation prior to dilation and evacuation can be challenging in the presence of uterine or cervical fibroids. In cases of distorted cervical anatomy, a transcervical Foley balloon with stylet can be considered to achieve cervical dilation.

Multidisciplinary surgical planning for a patient with hyperthyroidism complicating a twin gestation of a complete hydatidiform mole and a coexisting fetus

This case report demonstrates hyperthyroidism complicating a twin gestation consisting of a complete hydatidiform mole and coexisting fetus. The patient underwent medical optimization of hyperthyroidism with a thionamide and beta blocker prior to undergoing uncomplicated dilation and evacuation under spinal anesthesia. She was cared for by a multidisciplinary team.

Improvement in contraceptive coverage and gynecological care of adult women with cystic fibrosis following the implementation of an on-site gynecological consultation

Our study aimed to evaluate the impact of the introduction of a new gynecologic referral service in our adult Cystic Fibrosis (CF) center on contraceptive coverage, gynecological follow-up regularity, and cervical cancer screening coverage. We implemented an on-site gynecological consultation in our adult CF center in 2015. We compared the results of two surveys conducted successively in 2014 and in 2017 in a cohort of women with CF attending the Lyon CF center. Women completed the same self-report written questionnaire as in 2014. Main outcome measures were the comparisons of contraceptive coverage, gynecological follow-up regularity, and cervical cancer screening coverage between 2014 and 2017. All the 136 women (100%) who attended the clinic in 2017 participated. Contraceptive prevalence rate increased from 69%(CI95%:60.3-78.1) to 86%(CI95%:79.6-92.9) between 2014 and 2017 (p = 0.005). Among transplanted patients, the contraceptive prevalence rate was 92.3%(CI95%:82.0-100) in 2017. Long acting reversible contraceptive use markedly increased from 10% to 21.6% (p = 0.005). The proportion of women that reported an access to gynecological care increased between 2014 and 2017 (74%(CI95%:66.3-82.0) vs 91%(CI95%:86.9-95.4), p < 0.005) and reached 100% among transplanted patients. Cervical cancer screening improved (55%(CI95%:51.2-68.8) vs 85%(CI95%:78.6-90.6) women ever screened) (p < 0.0005) and reached 100% among transplanted patients. We observed an improvement in contraceptive coverage and gynecological care of adult women with CF following the implementation of a dedicated gynecological consultation in the CF center. Service linkages and formal links between CF centers and gynecologists can facilitate access to disease-specific contraceptive counseling, adequate gynecological management and cervical cancer screening.

Acceptance of HPV vaccination at the abortion visit at a clinic in New York City in 2017 to 2018

Human Papillomavirus vaccination remains a public health concern. Our primary objective was to examine whether eligible people, in an underimmunized population, seeking abortion find the abortion visit an acceptable opportunity to receive the Human Papillomavirus (HPV) vaccine. Our secondary objectives include comparing vaccine acceptors to vaccine decliners on knowledge and attitudinal factors related to the HPV vaccine. We conducted a cross sectional study in which we offered free HPV vaccine series initiation and completion to eligible patients presenting for abortion services at an outpatient health center. We administered surveys to both vaccine acceptors and decliners, to assess utilization of health services, knowledge of the HPV vaccine, and reasons for not having initiated or completed the vaccine series previously. 101 study participants were offered HPV vaccination; 50 participants accepted and 51 participants declined. All participants completed the survey. Seven of fifty vaccine acceptors completed the vaccine series. Vaccine acceptance was associated with new knowledge that HPV causes cervical cancer. (acceptors = 72.0%, decliners = 52.9%, p = 0.05) The most common reason among both groups for not previously initiating the vaccine was "No one offered it to me" (acceptors = 58.0%, decliners = 53.5%, p = 0.46). A considerable number of participants had not previously heard of the HPV vaccine, 44% of those who accepted, and 35.3% of those who declined (p = 0.64) vaccination at the time of their abortion. The abortion visit offers an important opportunity to start or to finish the HPV vaccine series. Most patients are receptive to receiving additional services and were never previously offered the HPV vaccine. Practices and policies aimed at utilizing missed opportunities for HPV vaccine catch up can increase HPV vaccine prevalence among young adult women to reduce lifetime risk for cervical cancer. The abortion visit may be an opportunity for HPV vaccination catch up in an underimmunized population. Abortion providers may consider offering patients other preventive health care services.

Society of Family Planning Clinical Recommendation: Contraceptive considerations for individuals with cancer and cancer survivors part 3 – Skin, blood, gastrointestinal, liver, lung, central nervous system, and other cancers: Joint with the Society of Gynecologic Oncology

Society of Family Planning Committee Statement: Contraceptive considerations for individuals with cancer and cancer survivors part 1 – Key considerations for clinical care Joint with the Society of Gynecologic Oncology

Society of Family Planning Clinical Recommendation: Contraceptive considerations for individuals with cancer and cancer survivors part 2 – Breast, ovarian, uterine, and cervical cancer: Joint with the Society of Gynecologic Oncology

This Clinical Recommendation provides evidence-informed, person-centered, and equity-driven recommendations to facilitate the management of and access to contraceptive care for individuals who are diagnosed with, being actively treated for, or who have previously been treated for breast, ovarian, uterine, or cervical cancer. For individuals with a history of breast cancer, we recommend nonhormonal contraceptives as the first-line option (GRADE 1B); additional guidance is provided for hormonal contraception depending on breast cancer hormone receptor status. For individuals with a history of or active ovarian cancer, we recommend clinicians provide access to all available contraceptive methods utilizing a person-centered approach (GRADE 1B); in individuals diagnosed with hormonally-sensitive ovarian malignancies, such as adult granulosa cell tumors, low-grade serous, and endometrioid adenocarcinomas, who are considering hormonal contraception, we suggest shared decision-making with the individual and their oncologist (GRADE 2C). Estrogen-containing contraceptives should be avoided by individuals treated with estrogen-blocking therapy (Best Practice). For individuals with a history of endometrial cancer, we recommend clinicians provide access to all available contraceptive methods utilizing a person-centered approach (GRADE 1B); in individuals with active endometrial cancer requesting an intrauterine device (IUD), we suggest shared decision-making with the individual and their oncologist (GRADE 1B). Recommendations for individuals with gestational trophoblastic disease are provided based on factors such as evidence of persistent intrauterine disease, human chorionic gonadotropin (hCG) levels, and the individual's preferred contraceptive method. For individuals with cervical dysplasia or a history of cervical cancer, we suggest clinicians provide access to all available contraceptive methods (GRADE 2B); we suggest against IUD placement in individuals with active cervical malignancy (GRADE 2C). This document is part 2 of a three-part series that updates the Society of Family Planning's 2012 Cancer and contraception clinical guidance. It builds upon the considerations outlined in the Society of Family Planning Committee Statement: Contraceptive considerations for individuals with cancer and cancer survivors part 1 - Key considerations for clinical care and parallels recommendations outlined in the Society of Family Planning Clinical Recommendation: Contraceptive considerations for individuals with cancer and cancer survivors part 3 - Skin, blood, gastrointestinal, liver, lung, central nervous system, and other cancers. Readers are encouraged to review parts 1 and 3 for this additional context.

Advanced endometrial cancer following the insertion of the levonorgestrel-releasing intrauterine system in a 34-year-old woman: A case report

Advanced endometrial adenocarcinoma was diagnosed two years after a 34yo women had a 52-mg levonorgestrel-releasing intrauterine system (LNG-IUS) inserted for the treatment of atypical hyperplasia. The LNG-IUS can be an alternative treatment for women with atypical hyperplasia who desire to preserve their fertility. However, the risk of endometrial cancer should raise concern.

Contemporary hormonal contraception and risk of endometrial cancer in women younger than age 50: A retrospective cohort study of Danish women

To examine the association between contemporary hormonal contraceptives and endometrial cancer risk in women younger than age 50. Cohort study of women living in Denmark aged 15-49 years through 1995-2014. National registries provided information about hormonal contraception use, incident endometrial cancer and confounders. Ever, current or recent, and former users of any hormonal contraception were compared with non-users, using Poisson regression to calculate incidence rate ratios (RR) with 95% confidence intervals. Duration, time since last use, tumor-specific and product-specific analyses, and population prevented fraction, were calculated. During 21.1 million person-years, 549 incident endometrial cancers occurred, with ever users of any hormonal contraception having a reduced premenopausal endometrial cancer risk compared with non-users; RR 0.60 (95% Confidence Interval 0.49 to 0.73). A lower risk of endometrial cancer was seen in all current or recent users of any hormonal contraception; 0.65 (0.52 to 0.83) and combined contraceptives; 0.57 (0.43 to 0.75), but not progestin-only contraceptives; levonorgestrel intrauterine system, LNG-IUS; 0.97 (0.66 to 1.42); other progestin-only contraceptives; 0.61 (0.27 to 1.37). Increased RRs were found for current use of any hormonal, combined contraceptives or LNG-IUS of ≤one year, probably because of protopathic bias. Longer durations of use were associated with significant reductions that became stronger with longer use. Former users of any hormonal contraception continued to benefit from a reduced risk of endometrial cancer >10 years after stopping. There was little evidence of differences in risk reduction by the type of progestin in combined oral contraceptives. Current or recent use of any hormonal contraception was associated with an approximate halving of risk of the most common tumor type I carcinoma, and an increased risk of the rarer sarcoma. Overall the estimated absolute reduced risk of endometrial cancer in ever users of hormonal contraceptives was 1.4 per 100,000 person-years, or approximately one less endometrial cancer for every 71,400 women of reproductive age who used hormonal contraception for one year. Use of hormonal contraception was estimated to prevent 25% of endometrial cancers in this population. Currently available combined hormonal contraceptives are still associated with enduring protection against endometrial cancer, particularly for type I carcinomas. We report substantive evidence of the association between different types of contemporary hormonal contraception and endometrial cancer risk in a national cohort of young Danish women. Currently available combined hormonal contraceptives are still associated with enduring protection against endometrial cancer, particularly for type I carcinomas.

Uses of ulipristal acetate beyond emergency contraception: A narrative review

Ulipristal acetate (UPA) is a selective progesterone receptor modulator and the most effective oral emergency contraceptive (EC) method available in the United States. The aim of this review is to identify and describe uses of UPA beyond EC and to further discuss the concerns regarding the possible off-target liver effects. We conducted a literature search in August 2024, using Embase, Medline (PubMed), and Cochrane, utilizing a combination of MeSH and keywords for UPA, excluding animal studies, and limiting to English language publications. After excluding duplicates using covidence, two authors reviewed the remaining 610 results and identified 340 studies. We further excluded case reports and case series. UPA has shown significant promise for indications outside of EC, most notably treatment of uterine leiomyomas, but also ongoing contraception, prevention and treatment of breast cancer, and abnormal uterine bleeding. While UPA has extensive potential for use both within and beyond reproductive health, unfortunately any ongoing development is at a standstill due to concerns regarding its possible role in causing serious liver injury. The role of UPA in causing drug-induced liver injury is not confirmed and preclinical studies during development did not demonstrate a concern that UPA causes drug-induced liver injury. Access to UPA is crucial not only for EC but for the treatment of many other gynecological and nongynecological conditions. Ulipristal acetate (UPA) has shown significant promise for indications outside of EC, including uterine leiomyomas, prevention and treatment of breast cancer, and abnormal uterine bleeding. Access to UPA is crucial not only for EC but for the treatment of many other gynecologic and non-gynecologic conditions.