Contraceptive Considerations for Women with Gastrointestinal Disorders.

Gastroenterologists are in a unique position to assist women with chronic gastrointestinal disorders in order to optimize their health prior to pregnancy. Women, whether with chronic conditions or not, and their infants are more likely to be healthy when pregnancies are planned. Achieving a planned pregnancy at the ideal time or preventing pregnancy altogether requires the use of appropriate contraceptives. There is a broad range of contraceptives available to women in the USA, and the majority of women with digestive diseases will be candidates for all effective methods. Guidance from the Centers for Disease Control and Prevention aids clinicians in prescribing appropriate contraceptives to women with medical disorders. This review will focus on contraception for women with inflammatory bowel disease and chronic liver disease, including liver transplant.

Contraception and mental health: a commentary on the evidence and principles for practice.

Among the most prevalent and disabling chronic diseases affecting reproductive-aged women worldwide, depression and anxiety can contribute to adverse reproductive health outcomes, including an increased risk of unintended pregnancy and its health and social consequences. For women with these common mental health conditions who want to avoid an unintended pregnancy, effective contraception can be an important strategy to maintain and even improve health and well-being. Reproductive health clinicians play a critical role in providing and managing contraception to help women with mental health considerations achieve their desired fertility. In this commentary, we review the literature on relationships between mental health and contraception and describe considerations for the clinical management of contraception among women with depression and anxiety. We discuss issues related to contraceptive method effectiveness and adherence concerns, mental health-specific contraceptive method safety and drug interaction considerations, and clinical counseling and management strategies. Given important gaps in current scientific knowledge of mental health and contraception, we highlight areas for future research.

Interventions for pain with intrauterine device insertion.

BACKGROUND: Fear of pain during insertion of intrauterine contraception (IUC) is a barrier to use of this method. IUC includes copper-containing intrauterine devices and levonorgestrel-releasing intrauterine systems. Interventions for pain control during IUC insertion include non-steroidal anti-inflammatory drugs (NSAIDs), local cervical anesthetics, and cervical ripening agents such as misoprostol. OBJECTIVES: To review randomized controlled trials (RCTs) of interventions for reducing IUC insertion-related pain SEARCH METHODS: We searched for trials in CENTRAL, MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov, and ICTRP. The most recent search was 22 June 2015. We examined reference lists of pertinent articles. For the initial review, we wrote to investigators to find other published or unpublished trials. SELECTION CRITERIA: We included RCTs that evaluated an intervention for preventing IUC insertion-related pain. The comparison could have been a placebo, no intervention, or another active intervention. The primary outcomes were self-reported pain at tenaculum placement, during IUC insertion, and after IUC insertion (up to six hours). DATA COLLECTION AND ANALYSIS: Two authors extracted data from eligible trials. For dichotomous variables, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). For continuous variables, we computed the mean difference (MD) with 95% CI. In meta-analysis of trials with different measurement scales, we used the standardized mean difference (SMD). MAIN RESULTS: We included 33 trials with 5710 participants total; 29 were published from 2010 to 2015. Studies examined lidocaine, misoprostol, NSAIDs, and other interventions. Here we synthesize results from trials with sufficient outcome data and moderate- or high-quality evidence.For lidocaine, meta-analysis showed topical 2% gel had no effect on pain at tenaculum placement (two trials) or on pain during IUC insertion (three trials). Other formulations were effective compared with placebo in individual trials. Mean score for IUC-insertion pain was lower with lidocaine and prilocaine cream (MD -1.96, 95% CI -3.00 to -0.92). Among nulliparous women, topical 4% formulation showed lower scores for IUC-insertion pain assessed within 10 minutes (MD -15.90, 95% CI -22.77 to -9.03) and at 30 minutes later (MD -11.10, 95% CI -19.05 to -3.15). Among parous women, IUC-insertion pain was lower with 10% spray (median 1.00 versus 3.00). Compared with no intervention, pain at tenaculum placement was lower with 1% paracervical block (median 12 versus 28).For misoprostol, meta-analysis showed a higher mean score for IUC insertion compared with placebo (SMD 0.27, 95% CI 0.07 to 0.46; four studies). In meta-analysis, cramping was more likely with misoprostol (OR 2.64, 95% CI 1.46 to 4.76; four studies). A trial with nulliparous women found a higher score for IUC-insertion pain with misoprostol (median 46 versus 34). Pain before leaving the clinic was higher for misoprostol in two trials with nulliparous women (MD 7.60, 95% CI 6.48 to 8.72; medians 35.5 versus 20.5). In one trial with nulliparous women, moderate or severe pain at IUC insertion was less likely with misoprostol (OR 0.30, 95% CI 0.16 to 0.55). In the same trial, the misoprostol group was more likely to rate the experience favorably. Within two trials of misoprostol plus diclofenac, shivering, headache, or abdominal pain were more likely with misoprostol. Participants had no vaginal delivery. One trial showed the misoprostol group less likely to choose or recommend the treatment.Among multiparous women, mean score for IUC-insertion pain was lower for tramadol 50 mg versus naproxen 550 mg (MD -0.63, 95% CI -0.94 to -0.32) and for naproxen versus placebo (MD -1.94, 95% CI -2.35 to -1.53). The naproxen group was less likely than the placebo group to report the insertion experience as unpleasant and not want the medication in the future. An older trial showed repeated doses of naproxen 300 mg led to lower pain scores at one hour (MD -1.04, 95% CI -1.67 to -0.41) and two hours (MD -0.98, 95% CI -1.64 to -0.32) after insertion. Most women were nulliparous and also had lidocaine paracervical block. AUTHORS' CONCLUSIONS: Nearly all trials used modern IUC. Most effectiveness evidence was of moderate quality, having come from single trials. Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain. Some lidocaine formulations, tramadol, and naproxen had some effect on reducing IUC insertion-related pain in specific groups. The ineffective interventions do not need further research.

Reproductive coercion and co-occurring intimate partner violence in obstetrics and gynecology patients.

OBJECTIVE: Reproductive coercion is male behavior to control contraception and pregnancy outcomes of female partners. We examined the prevalence of reproductive coercion and co-occurring intimate partner violence among women presenting for routine care at a large, urban obstetrics and gynecology clinic. STUDY DESIGN: Women aged 18-44 years completed a self-administered, anonymous survey. Reproductive coercion was defined as a positive response to at least 1 of 14 questions derived from previously published studies. Women who experienced reproductive coercion were also assessed for intimate partner violence in the relationship where reproductive coercion occurred. RESULTS: Of 641 women who completed the survey, 16% reported reproductive coercion currently or in the past. Among women who experienced reproductive coercion, 32% reported that intimate partner violence occurred in the same relationship. Single women were more likely to experience reproductive coercion as well as co-occurring intimate partner violence. CONCLUSION: Reproductive coercion with co-occurring intimate partner violence is prevalent among women seeking general obstetrics and gynecology care. Health care providers should routinely assess reproductive-age women for reproductive coercion and intimate partner violence and tailor their family planning discussions and recommendations accordingly.

Opill: The Over-the-Counter Contraceptive Pill.

The U.S. Food and Drug Administration has approved the first oral contraceptive pill (OCP) for over-the-counter status. This progestin-only pill contains norgestrel 0.075 mg taken daily, with a Pearl Index estimated at 4.4 (95% CI, 1.9-8.8). This formulation has an excellent safety profile, with current breast cancer as the only absolute contraindication and few relative contraindications. Ultimately, this approval has great potential to improve the accessibility of effective contraception for many pregnancy-capable Americans, especially those who have poor access to the health care system for prescription-required contraception, most notably people who hold marginalized identities. The pill's overall success in reducing rates of unintended pregnancy will rely on its availability, particularly in rural communities that may rely on one pharmacy, and affordability, especially for uninsured or underinsured individuals. However, given the need for improved contraceptive provision, particularly in abortion-restrictive settings, the over-the-counter approval of this daily OCP is a major advancement in the nation's contraceptive ecosystem.

Helping patients choose between pain control options for outpatient procedural abortion at less than 12 weeks' gestation.

OBJECTIVES: This study aimed to identify predictors of patient satisfaction with their chosen pain control regimen for procedural abortion at <12 weeks' gestation in the outpatient setting. STUDY DESIGN: In this prospective cohort study, we developed an instrument to evaluate predictors of satisfaction with pain control regimens among patients choosing local anesthesia alone (paracervical block with 20 mL of 1% buffered lidocaine) or local anesthesia plus intravenous (IV) moderate sedation with 100 mcg of fentanyl and 2 mg of midazolam. Our primary outcome was to identify predictors of satisfaction with both anesthesia cohorts as measured on a 4-point Likert scale, but due to high satisfaction levels in the IV group, we focused our analysis on the local anesthesia group. RESULTS: We enrolled 149 patients in the local anesthesia group and 155 in the moderate IV sedation group. The mean procedure pain scores were 6.9 (±2.1) out of 10 in the local group and 4.0 (±2.7) in the IV group (p < 0.0001). More women in the IV group (92%) were satisfied or very satisfied with the amount of pain relief they experienced compared to the local group (66%; p < 0.0001). In the univariable model, only being afraid of a minor medical procedure was predictive of less satisfaction with local anesthesia for pain control (relative risk 0.8 [95% CI, 0.6-0.9]). Age, gestational age, anticipated pain, self-reported pain tolerance, self-reported anxiety, discomfort with the abortion decision, and history of prior vaginal or cesarean delivery or induced abortion did not predict satisfaction levels. CONCLUSIONS: Fear of minor medical procedures was the only variable that predicted decreased satisfaction with local anesthesia alone for procedural abortion under 12 weeks. IMPLICATIONS: Reliable predictors for satisfaction with local anesthesia alone for procedural abortion in the outpatient setting remain elusive. Fear of minor medical procedures may serve as an indicator of decreased satisfaction and could be incorporated into patient counseling. Moderate IV sedation is associated with high satisfaction levels.

Longitudinal impact of a residency-based postplacental levonorgestrel intrauterine device insertion program: Expulsion rates in years 1, 2, and 3.

OBJECTIVE: To evaluate expulsion rates in the first 3 years of an academic postplacental levonorgestrel intrauterine device (LNG-IUD) insertion program. STUDY DESIGN: Retrospective case series, January 2016 to December 2018. We measured LNG-IUD expulsion rates by 12 weeks postpartum. RESULTS: Of 235 LNG-IUD insertions, in years 1, 2, and 3, expulsion rates were 11/39 (28%), 9/94 (10%), and 15/102 (15%) (p = 0.03). After vaginal delivery, manual insertion was associated with a higher expulsion rate than ring-forceps (10/28 [36%] vs 17/105 [16%], p = 0.04). CONCLUSIONS: LNG-IUD expulsion rates decreased after program year 1, suggesting program maturity may be associated with a lower expulsion risk.

Barriers to abortion provision in primary care in New England, 2019-2020: A qualitative study.

OBJECTIVE: To assess barriers to and facilitators of abortion provision among abortion-trained primary care providers. STUDY DESIGN: We conducted 21 qualitative in-depth interviews with 20 abortion-trained family physicians and one internal medicine physician in five New England states. We dual-coded interviews, using a consensus method to agree upon final coding schema. Through iterative dialogue, using an inductive content analysis approach, we synthesized the themes and identified patterns within each domain of inquiry. RESULTS: The most commonly reported barriers were a lack of organizational support, the Hyde Amendment, which prevents the use of federal funds for most abortion care, and the mifepristone Risk Evaluation and Mitigation Strategy, a federal regulation which prohibits routine mifepristone pharmacy dispensing. The logistical barriers created by these policies require cooperation from additional stakeholders, creating more opportunities for abortion stigma and moral opposition to arise. Other salient barriers included inter-specialty tension (particularly with obstetrician-gynecologists), perceived need for pre-abortion ultrasound, absence of a clinician support network, and lack of knowledge of existing resources for establishing abortion care in primary care. CONCLUSIONS: Increased abortion provision in primary care is one of many necessary responses to the human rights crisis produced by the Dobbs decision. Eliminating the Hyde Amendment and ending federal regulations restricting pharmacy dispensing of mifepristone are key interventions to address barriers to primary care abortion provision. Building interspecialty partnerships between family medicine and OB/GYN and spreading awareness of the evidence-based ultrasound-as-needed protocol and other educational resources are also likely to increase primary care abortion access. IMPLICATIONS: By exploring barriers to and facilitators of primary care abortion provision, this study outlines a targeted approach to support increased access to abortions. In states with legal abortion post-Roe, it is important that motivated and trained primary care providers can offer abortions, rather than referring patients to overburdened specialty clinics.

Contraception and Abortion Care for People Living With HIV: A Clinical Guide for Reproductive Health Practitioners.

People capable of pregnancy are disproportionately affected by HIV. Family planning needs and services are often unmet in this population, and clinical care guidelines regarding contraceptive options and abortion care are not well elucidated. Individuals living with HIV often face unique barriers in accessing contraception and abortion services due to internalized stigma, medically complex care (eg, drug-drug interactions, adverse effects of antiretroviral therapy), and distrust of health care providers. There is also a lack of clarity among reproductive health, primary, and infectious disease care providers on best-practice contraceptive counseling and contraceptive care for individuals living with HIV, given limited opportunities to enhance expertise in reproductive infectious disease. In this review, we summarize existing and updated evidence and clinical considerations regarding contraceptive counseling and abortion care in this population.

Necessity of hysterosalpingography after Essure microinsert placement for contraception.

OBJECTIVE: The objective of our study was to determine whether hysterosalpingography is necessary after Essure microinsert placement by evaluating the rates of appropriate placement and of satisfactory tubal occlusion in a general population. MATERIALS AND METHODS: We identified all patients who underwent hysterosalpingography after Essure microinsert placement for desired sterility between January 1, 2008, and August 1, 2010. We recorded demographic information and the hysterosalpingographic results. The images and operative reports of all cases with abnormal hysterosalpingographic findings were reviewed. The hysterosalpingographic results were reviewed for appropriate placement of the microinsert, for successful tubal occlusion, and for any additional abnormalities. We also reviewed the medical records for documentation of subsequent pregnancies. RESULTS: Two hundred forty hysterosalpingographic examinations were performed after 237 hysteroscopic microinsert placement procedures in 235 women. The mean age of the subjects was 35 years (range, 20-50 years). Twenty-two examinations (9.2%) were abnormal. Fourteen (5.8%) revealed inappropriate placement: six with tubal occlusion, seven without tubal occlusion, and one with an indeterminate finding for tubal occlusion. Fifteen examinations (6.3%) showed tubal nonocclusion: Microinsert placement was inappropriate in seven cases and appropriate in eight. Of the 22 abnormal hysterosalpingographic examinations, 20 had operative reports available. Eleven (55%) described difficulties with device insertion. Forty-two endometrial abnormalities were described in hysterosalpingographic reports of 38 patients. One subsequent pregnancy was documented in a patient with satisfactory device placement and tubal occlusion on hysterosalpingography. CONCLUSION: Hysterosalpingography after Essure microinsert placement is necessary because 6.3% of examinations showed abnormalities requiring an alternative form of contraception.

"We're called upon to be nonjudgmental": A qualitative exploration of United States medical students' discussions of abortion as a reflection of their professionalism.

OBJECTIVES: Medical educators may assess learners' professionalism through clinical scenarios eliciting value conflicts - situations in which an individual's values differ from others' perceived values. We examined the extent to which United States (US) medical students' discussion of abortion highlights their professionalism according to the 6 American Association of Medical Colleges (AAMC) professionalism competencies. STUDY DESIGN: We conducted anonymous, semistructured qualitative interviews with 74 US medical students applying to OB/GYN residency. Interviews explored attitudes toward abortion and abortion case vignettes. We analyzed interview transcripts using directed content analysis for alignment with the AAMC professionalism competencies: humanism, patient needs superseding self-interest, patient autonomy, physician accountability, sensitivity to diverse populations, and commitment to ethical principles. RESULTS: Students' genders, races, religions, and geographic regions were diverse. Attitudes toward abortion varied, but all students commented on themes related to at least 1 AAMC professionalism competency when discussing abortion care. Statements demonstrating students' humanism, prioritization of patient autonomy, and sense of physician accountability were common. Most comments reflected positive professionalism practices, regardless of personal views on abortion or provision intentions; very few students made statements that were not aligned with the AAMC professionalism competencies. CONCLUSIONS: All students in this study exhibited professionalism when discussing abortion, regardless of personal views on abortion or intention to provide this care. Case-based discussions involving abortion could be used to explore professionalism competencies among medical learners. IMPLICATIONS: Discussing abortion has the potential to elicit values conflict, which enables learners to exhibit professionalism. Case-based abortion education should be included in medical school curricula to measure medical professionalism in future physicians, and to serve as a tool for teaching professionalism in medical school.

Mindfulness meditation for women with chronic pelvic pain: a pilot study.

OBJECTIVE: Chronic pelvic pain (CPP) is a common condition that can be difficult to treat. Mindfulness meditation improves outcomes in patients with cancer pain, low back pain and migraine headaches. This study evaluates feasibility and efficacy of mindfulness for patients with CPP. STUDY DESIGN: Women with CPP were enrolled in an 8-week mindfulness program. Pre-assessments and post-assessments included daily pain scores, the Short Form-36 Health Status Inventory, Kentucky Inventory of Mindfulness Score and the Inventory of Depressive Symptomatology. RESULTS: Twelve out of 22 enrolled subjects completed the program and had significant improvement in daily maximum pain scores (p = 0.02), physical function (p = 0.01), mental health (p = 0.01) and social function (p = 0.02). The mindfulness scores improved significantly in all measures (p < 0.01). CONCLUSION: Data from this pilot study show the feasibility of mindfulness meditation in women with CPP. Initial pilot data suggest that quality of life and mindfulness outcomes may improve with mindfulness meditation and justify further investigation with a randomized, controlled trial.

Oral compared with intravenous sedation for first-trimester surgical abortion: a randomized controlled trial.

OBJECTIVE: To test the equivalency of oral sedation and intravenous sedation for pain control in first-trimester surgical abortion. METHODS: Women undergoing suction curettage at less than 13 weeks of gestation were randomly assigned to oral sedation, 10 mg of oxycodone and 1 mg of lorazepam, or intravenous sedation, 100 micrograms fentanyl and 2 mg midazolam. All patients received 800 mg of preoperative ibuprofen and a 20-mL paracervical block with 1% lidocaine. The primary outcome was intraoperative pain as measured on a 21-point verbal rating scale that had a range from 0 to 100 (0=no pain and 100=worst pain ever) with an equivalence margin for the treatment group comparison of +/-10. RESULTS: Of 130 women, 65 were randomly assigned to oral sedation and 65 to intravenous sedation. The groups differed at baseline by age and preoperative ratings of depression, stress, and anxiety; however, when adjusted for these differences, the primary results were unaffected. Mean intraoperative pain scores, controlling for age and preoperative depression, stress, and anxiety, were 61.2 for oral sedation and 36.3 for intravenous sedation (mean difference 24.9, 95% confidence interval 15.9-33.9). Other findings included no difference in postoperative adverse effects and less satisfaction with pain control with oral sedation compared with intravenous sedation. CONCLUSION: Oral sedation, as studied, is not equivalent to intravenous sedation for pain control during first-trimester surgical abortion. CLINICAL TRIAL REGISTRATION: : ClinicalTrials.gov, www.clinicaltrials.gov, NCT00337792 LEVEL OF EVIDENCE: I.

Expanding access to intrauterine contraception.

The intrauterine device is a safe, highly effective, long-lasting, yet reversible method of contraception. Expanding access to intrauterine contraception is an important measure to reduce the rate of unintended pregnancy in the United States. Clinicians should consider intrauterine contraception in appropriate candidates, including women who are nulliparous, adolescent, immediately postpartum or postabortal, and desiring emergency contraception, and as an alternative to permanent sterilization. Barriers to intrauterine contraception such as requiring cervical cancer screening before insertion, routine testing for gonorrhea and chlamydial infection in low-risk women, or scheduling insertion only during menses are unnecessary.

Interventions for pain with intrauterine device insertion.

BACKGROUND: Fear of pain during intrauterine device (IUD) insertion is a barrier to use of this contraceptive method. Interventions for pain during IUD insertion include non-steroidal anti-inflammatory drugs (NSAIDs), local cervical anesthetics, and cervical ripening agents such as misoprostol. OBJECTIVES: To review all randomized controlled trials that have evaluated a treatment for IUD insertion-related pain. SEARCH STRATEGY: We searched the computerized databases MEDLINE, POPLINE, CENTRAL, and EMBASE for relevant trials. We also examined reference lists of pertinent articles and wrote to known investigators for information about other published or unpublished trials. SELECTION CRITERIA: We included all randomized controlled trials in any language that evaluated a treatment for IUD insertion-related pain. The intervention could be compared to a placebo or another active intervention. DATA COLLECTION AND ANALYSIS: Two authors independently abstracted data from relevant trials and data were entered into RevMan 5.0 for analysis. For dichotomous variables, the Peto odds ratios with 95% confidence intervals was calculated. For continuous variables, the mean differences with 95% confidence interval was computed. MAIN RESULTS: Four trials met the inclusion criteria; the total number of participants was 2204. Nonsteroidal anti-inflammatory drugs of varying types and doses were not effective for reducing pain during IUD insertion. Misoprostol for cervical ripening did not reduce pain with IUD insertion in nulliparous women. Two trials evaluated pain that occurs after IUD insertion using nonsteroidal anti-inflammatory drugs. In one trial, naproxen taken prior to IUD insertion was effective in reducing pain compared with placebo in the first two hours after IUD insertion in mostly nulliparous women. However, this trial utilized the Dalkon Shield, an IUD with a wider diameter than modern IUDs. In another trial, ibuprofen 600 mg taken before IUD insertion did not show evidence of an effect on pain four to six hours after IUD insertion. AUTHORS' CONCLUSIONS: No interventions that have been properly evaluated reduce pain during or after IUD insertion. One poorly controlled trial suggested that topical lidocaine gel may reduce insertion-related pain and warrants further investigation.

What Is New in Abortion Care?: Best Articles From the Past Year.

This month we focus on current research in abortion care. Dr. Allen discusses five recent publications, which are concluded with a "bottom line" that is the take-home message. A complete reference for each can be found on on this page along with direct links to the abstracts.

An exploratory study of the perception of contraceptive safety and impact on lactation among postpartum nurses at Women and Infants Hospital in 2017.

OBJECTIVE: To describe contraceptive knowledge and counseling practices of postpartum nurses. METHODS: We surveyed postpartum nurses at the largest women's hospital in Rhode Island. RESULTS: We distributed 117 anonymous questionnaires and received 58 responses (response rate=50%). Twenty-three of 51 nurses (45%) reported routinely offering contraceptive advice to new mothers. Only 5/55 (9%) responded correctly that combined hormonal contraceptives were an "unacceptable health risk" in the immediate postpartum period. A minority of respondents correctly classified the progestin-only pill, depot medroxyprogesterone acetate, the etonogestrel implant, the levonorgestrel intrauterine system and the copper intrauterine device as safe to use during lactation [14/56 (25%), 24/56 (43%), 27/56 (48%), 19/55 (35%) and 9/55 (16%), respectively]. Thirty-three of 51 nurses (65%) incorrectly responded that depot medroxyprogesterone acetate decreases milk supply if started immediately postpartum. CONCLUSION: There are opportunities to improve knowledge regarding contraceptive safety and impact on lactation among postpartum nurses at our institution.

Society of Family Planning clinical guidelines pain control in surgical abortion part 1 - local anesthesia and minimal sedation.

Satisfactory pain control for women undergoing surgical abortion is important for patient comfort and satisfaction. Clinicians ought to be aware of the safety and efficacy of different pain control regimens. This document will focus on nonpharmacologic modalities to reduce pain and pharmacologic interventions up to the level of minimal sedation. For surgical abortion without intravenous medications, a multimodal approach to pain control may combine a dedicated emotional-support person, visual or auditory distraction, administration of local anesthesia to the cervix with buffered lidocaine and a preoperative nonsteroidal anti-inflammatory drug. Oral opioids do not decrease procedural pain. Oral anxiolytics decrease anxiety but not the experience of pain. Further research is needed on alternative options to control pain short of moderate or deep sedation.

Eliminating parental consent for adolescents receiving human papillomavirus vaccination.

Human papillomavirus (HPV) is a sexually transmitted infection (STI) causing nearly all cases of cervical carcinoma and genital condyloma worldwide. While HPV vaccination rates are higher in Rhode Island compared to other states, still 27% of female adolescents are not fully vaccinated. The requirement for parental consent for vaccination administration poses a barrier to HPV vaccine uptake and hinders adolescent autonomy. This requirement lies in stark contrast to the goals of the Family Planning Title X Program, which provides all adolescents with access to contraception and STI prevention and treatment without parental consent. In this commentary, we propose that HPV vaccination should be available to all pre-teens and adolescents as part of teen reproductive and sexual healthcare, and thus be exempt from parental consent in a similar way to other reproductive and sexual health services such as STI testing and contraception. [Full article available at http://rimed.org/rimedicaljournal-2018-09.asp].