Desire to avoid pregnancy and contraceptive use among female methadone patients in Los Angeles.

OBJECTIVE: Opioid use disorder (OUD) is increasing among U.S. women. Research indicates higher levels of unintended pregnancy among women with OUD as compared to the general population. Following formative in-depth research documenting the complexity of considerations around pregnancy in this population, we collected information on pregnancy preferences and contraceptive use among women attending methadone treatment. STUDY DESIGN: We surveyed women attending methadone clinics in Los Angeles in 2018. We used the Desire to Avoid Pregnancy (DAP) Scale, a 14-item instrument (0-4; 4 = highest desire to avoid pregnancy) to capture pregnancy preferences across 3 domains: cognitive desires, affective feelings, and anticipated consequences. We conducted factor analysis, descriptive analyses, and linear and logistic regressions to assess the DAP scale and to examine relationships between pregnancy preferences, sociodemographic characteristics, and contraceptive use. RESULTS: Women (n = 46) expressed the full range of pregnancy preferences (DAP score range: 0.4-4.0; mean: 2.24, standard deviation: 1.02; Cronbach's α = 0.92). Overall, 40% used contraception at last sex. Women who reported a greater preference to avoid pregnancy were marginally more likely to use contraception at last sex as compared to women who were more open to pregnancy (odds ratio = 1.73; p = 0.09). CONCLUSIONS: Similar to findings from other populations, responses to the Desire to Avoid Pregnancy scale among a sample of women with OUD revealed a broad range of pregnancy preferences. Pregnancy preferences were marginally associated with contraceptive use in this sample suggesting that the DAP may provide useful insights on pregnancy preferences that may facilitate contraceptive and preconception counseling in this population. IMPLICATIONS: Given the complexity of considerations around pregnancy for women with opioid use disorder, the DAP scale may be a valuable tool to identify women's pregnancy and childbearing preferences and to facilitate alignment of women's sexual and reproductive health desires with appropriate services.

A mixed methods study exploring methadone treatment disclosure and perceptions of reproductive health care among women ages 18-44 years, Los Angeles, CA.

INTRODUCTION: Opioid use disorder (OUD) and methadone treatment are increasing among women ages 18-44 years old, a population with unique healthcare needs. Despite this increase, there is little research on the healthcare experiences of women with OUD, particularly experiences with reproductive healthcare. METHODS: We designed a sequential, mixed-methods study in three Los Angeles methadone clinics. In the first phase, we conducted in-depth interviews with women in methadone treatment (n = 22) (September-December 2016). After thematic coding and analysis, we designed and administered a survey to understand patterns in women's experiences and reproductive health knowledge, attitudes, and behavior (n = 50) (January-April 2018). We conducted descriptive statistics, then integrated the quantitative and qualitative findings to contextualize and understand perceptions and experiences with healthcare providers among women in methadone treatment. RESULTS: We found that women experienced and anticipated that providers would treat them poorly when they disclosed that they were in methadone treatment for OUD. Women's actual experiences with disclosure, shared in in-depth interviews, varied by whether they had disclosed their status intentionally or inadvertently. Approximately one-third (37%) of survey respondents thought a healthcare provider would scold them if they became pregnant; however, all who had been pregnant in the past while on methadone (n = 11) reported disclosing methadone treatment during pregnancy to their provider. Under a quarter of all women (22%) said having a healthy pregnancy while on methadone was likely or very likely. These perceptions were reinforced by negative experiences with providers, or, in many cases, women in the survey reported that they had never discussed the recommendations for a healthy pregnancy while on methadone with a healthcare provider. DISCUSSION: Women experience and anticipate experiencing negative interactions with their healthcare providers if and when they disclose their methadone treatment. These perceptions and experiences impact subsequent treatment seeking and disclosure. The majority of women did not discuss pregnancy with healthcare providers. To improve quality of care, healthcare providers can provide a safe space for women to disclose methadone treatment through nonjudgmental communication that intentionally alleviates stigma. Additionally, healthcare providers should understand medical guidelines and laws/policies around methadone during pregnancy and communicate this understanding to all patients who may wish to become pregnant or who are at risk for unintended pregnancy.

Perceptions of Pregnancy and Contraceptive Use: An In-Depth Study of Women in Los Angeles Methadone Clinics.

INTRODUCTION: In 2016, 2.1 million people in the United States were estimated to have an opioid use disorder. Although the disorder can be safely and effectively treated with prescription methadone, treatment is potentially long term and may span women's peak childbearing ages. Little is known about women's reproductive health needs while on methadone. METHODS: We interviewed 22 sexually active, nonpregnant women ages 21-39 years at two Los Angeles methadone clinics in 2016. The interviews were transcribed and coded by four researchers using thematic and open coding techniques. RESULTS: One-half of the women were nulliparous and 17 were in stable, monogamous relationships with men. Women reported a range of feelings and perceptions about pregnancy, but nearly all wanted to delay pregnancy until discontinuing methadone. However, many women indicated limited interest in preventing pregnancy because of the relative stability of their relationships, fear of infertility, and low perceived risk of pregnancy. These factors influenced contraceptive use. DISCUSSION: Women described mixed feelings about pregnancy and many ultimately felt that an unplanned pregnancy would be acceptable in the context of their relationships and uncertain fertility. These findings provide context for previous quantitative findings that women in methadone treatment have higher rates of unintended pregnancy and lower rates of contraceptive use than the general population. CONCLUSIONS: Accurate information about pregnancy in the context of methadone treatment may help women to make proactive family planning decisions. Health care providers should discuss the guidelines for pregnancy on methadone and offer a range of options to help women achieve their reproductive goals.

Diagnostic imaging modalities for Müllerian anomalies: the case for a new gold standard.

Female reproductive tract anomalies are difficult to number in the general population but are often discovered in evaluations of menstrual complications or fertility disorders. Traditionally, assessment of the reproductive tract entailed hysterosalpingography to image the uterine cavity with the final diagnosis provided by combined hysteroscopy/laparoscopy. These approaches, while providing important information, were uncomfortable and invasive and for HSG, involved radiation exposure. Magnetic resonance imaging (MIR) allowed for the avoidance of these issues while offering accuracy, thus becoming the gold standard diagnostic imaging modality but entailing cost, patient discomfort, and inconvenience. Current advances in ultrasound technology, specifically 3-dimensional ultrasound, achieve the same benefits of MRI in being accurate and noninvasive but also offer the following advantages: they are available in the office, they are cost-effective, and they provide immediate results. As 3-dimensional technology continues to become more accessible and more providers become proficient in using it, ultrasound may replace MRI as the new gold imaging standard in diagnosing müllerian anomalies.

Clitoral avulsion successfully repaired with 2-octylcyanoacrylate.

INTRODUCTION: Clitoral piercing is becoming more popular in the general populace, playing an aesthetic as well as likely sexual role. However, potential for injury also impacts future clitoral sexual function, thus highlighting the importance of proper repair. AIM: To report a 29-year-old woman presented to the emergency department after a clitoral piercing injury. Examination revealed avulsion of most of the clitoral body. After the patient refused expectant and surgical management, reapproximation was performed using 2-octylcyanoacrylate. METHODS: 2-Octylcyanoacrylate, commonly known as Dermabond(®) (Ethicon Inc., Somerville, NJ, USA), was used to reapproximate the clitoral laceration for this patient. It is a cyanoacrylate tissue adhesive, forming a strong bond between wound edges to allow for normal healing to occur below. Benefits of use are decreased time of repair, water-resistant flexible coating, and no need for suture removal. RESULTS: The laceration was successfully reapproximated with 2-octylcyanoacrylate. The tissue held together satisfactorily and the patient was discharged to home. She was seen as an outpatient 3 days later, with a moderately tender and swollen clitoris, but with an intact repair and improved pain. A visit 8 weeks later showed a well-healed clitoris, and the patient reported resolution of pain and return of sexual function, with successful orgasms. CONCLUSIONS: The delicacy of clitoral anatomy and the potential impact of its injury on future sexual function make it an intimidating area of repair for the general physician. The method of repair must be tailored to the injury, patient, and physician; however, 2-octylcyanoacrylate is a viable alternative to traditional surgical or expectant management, offering strength and flexibility while avoiding further trauma with suture.