Differences in knowledge and attitudes toward the intrauterine device: Do age and race matter?

AIM: The intrauterine device (IUD) is highly effective birth control, but US IUD usage lags. Barriers to usage, including patient attitudes and lack of knowledge, are not well-characterized. This study sought to investigate how attitudes and knowledge about IUD vary by age and race. METHODS: A survey was distributed to all women in the outpatient obstetrics and gynecology office of a large, urban, academic medical center in Philadelphia. Exclusion criteria included inability to read English or age less than 14 years. Surveys queried participant demographics, knowledge about and opinions of IUD. The authors performed exploratory bi-variable analysis using t tests and chi-square testing to determine which outcomes differed by age and race. For those differing significantly, the authors performed regression analysis to assess for confounding by other factors. RESULTS: Of 1366 women approached, 521 completed the survey (38% response rate). After controlling for confounding, only responses to the statement 'Hormonal birth control is safe and effective' differed significantly by age. Knowledge about IUD did not differ significantly by race, but black women were significantly more likely to perceive that they had insufficient knowledge about IUD compared to white women (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.06-3.46). Black women had a more negative opinion of IUD safety (OR: 5.0; 95% CI: 2.35-10.66) and reliability (OR: 5.5; 95% CI: 2.20-14.13) than white women. CONCLUSION: Attitudes and knowledge about IUD do not differ significantly by age. While knowledge about IUD is similar between races, black women may have more negative opinions of IUD.

Anticipated Pain During Intrauterine Device Insertion.

STUDY OBJECTIVE: To identify predictors of anticipated pain with intrauterine device (IUD) insertion in adolescents and young women. DESIGN: We performed linear regression to identify demographic, sexual/gynecologic history, and mood covariates associated with anticipated pain using a visual analogue scale pain score collected as part of a single-blind randomized trial of women who received a 13.5-mg levonorgestrel IUD. SETTING: Three academic family planning clinics in Philadelphia Pennsylvania. PARTICIPANTS: Ninety-three adolescents and young adult women aged 14-22 years. INTERVENTION: Participants received either a 1% lidocaine or sham paracervical block. MAIN OUTCOME MEASURES: Anticipated pain measured using a visual analogue scale before and perceived pain at 6 time points during the IUD insertion procedure. RESULTS: Black or African American participants had a median anticipated pain score of 68 (interquartile range [IQR], 52-83), White participants had a median anticipated pain of 51 (IQR, 35-68), whereas participants of other races had a median anticipated pain score of 64 (IQR, 36-73); P = .012. In multivariate analysis, race was the only covariate that significantly predicted anticipated pain at IUD insertion. Women with anticipated pain scores above the median had significantly higher perceived pain during all timepoints of the IUD insertion procedure. CONCLUSION: Increased anticipated pain is associated with increased perceived pain with IUD insertion. Black adolescent women experience greater anticipated pain with IUD insertion. This population might benefit from counseling and clinical measures to reduce this barrier to IUD use.

Expedited Scheduling of Interval Tubal Ligation: A Randomized Controlled Trial.

OBJECTIVE: To assess whether expedited scheduling for permanent contraception increases the proportion of patients completing interval tubal ligation within 6 months of delivery. METHODS: We randomly assigned patients with unfulfilled immediate postpartum tubal ligation requests to standard scheduling after a postpartum office visit or an expedited process in which we scheduled the interval tubal ligation surgery before discharge from the hospital. The primary outcome was proportion of participants undergoing tubal contraceptive procedures within 6 months of delivery. Secondary outcomes included patient satisfaction with the scheduling process, repeat pregnancy rates, and surgical outcomes. We estimated that 122 patients (61 per group) would provide greater than 80% power to identify a 25% difference favoring expedited scheduling in the primary outcome (one-sided α of 0.05). RESULTS: Between September 2016 and June 2018, 239 patients requested tubal ligation at the time of delivery; 155 were not completed. Of these, 126 patients were eligible for the study. We stopped the study at the prespecified 50% enrollment point after 67 patients enrolled, with 34 and 33 assigned to the standard and expedited arms, respectively. Fifteen participants in the expedited group, and two in the standard group completed tubal ligation within 6 months (50% vs 9%; odds ratio 10.0, CI 2.0-50.2). Delivery-to-surgery interval was 49 days in the expedited group, compared with 121 days in the standard group (P=.05). Seventeen participants in the expedited group and three in the standard group reported being very satisfied with the scheduling process (57% vs 13%, P=.03). The only two interim pregnancies both occurred in the standard group (P=.09). There were no surgical complications in any of the 17 completed tubal procedures. CONCLUSION: Expedited scheduling significantly improves tubal contraceptive surgery completion and patient satisfaction. Laparoscopic or hysteroscopic tubal ligation or salpingectomy can be performed 4-6 weeks after delivery with minimal interval outpatient follow-up. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02875483.

Intrauterine Device Insertion Procedure Duration in Adolescent and Young Adult Women.

STUDY OBJECTIVE: Intrauterine device (IUD) utilization in the United States is low among adolescent and young adult women. Longer procedure duration has been proposed as one potential barrier to IUD insertion in this population. We hypothesized that procedure duration would be longer in adolescents compared to young adult women. DESIGN, SETTING, AND PARTICIPANTS: This study was a secondary analysis of a randomized clinical trial comparing the effectiveness of a lidocaine vs sham paracervical nerve block for pain control during levonorgestrel 13.5 mg IUD insertion. Adolescent and young adult women ages 14-22 years were recruited from 3 outpatient academic sites in Philadelphia, Pennsylvania. INTERVENTIONS AND MAIN OUTCOME MEASURES: Pain scores were recorded at 7 steps during the procedure from speculum insertion through removal. Time stamps associated with each step were used to calculate the overall procedure duration. Cumulative IUD insertion procedure duration was estimated using the Kaplan-Meier method. RESULTS: Ninety-five women enrolled. Nineteen (19/95, 20%) were ages 14-17 and 76 (76/95, 80%) were ages 18-22 years. The median procedure duration (seconds ± interquartile range) was longer for adolescents than for young adults (555 ± 428 seconds vs 383 ± 196 seconds; P = .008). After adjusting for study site, the difference in expected median procedure duration between age groups was not significant (P = .3832). CONCLUSION: The difference in duration of IUD insertion procedures in adolescent and young adult women is not clinically or statistically significant. Providers should not withhold IUDs from appropriate adolescent and young adult women on the basis of age alone.

Incidence of uterine rupture in second-trimester abortion with gemeprost alone compared to mifepristone and gemeprost.

OBJECTIVES: To compare uterine rupture rates in women having a medical abortion receiving gemeprost alone to those receiving mifepristone plus gemeprost. STUDY DESIGN: We reviewed the records of women undergoing medical abortion at 13 0/7-23 6/7 weeks from January 2007 to December 2014 at a single center in Italy. Prior to January 2011, we used gemeprost 1 mg vaginally every 3 h up to a maximum of five doses. After January 2011, we added mifepristone 200 mg orally 24 h prior to the same gemeprost protocol. The primary outcome of the study was the incidence of uterine rupture. We compared the outcome between women receiving gemeprost alone with the combination of gemeprost and mifepristone. RESULTS: One thousand and sixty-one (58.5%) and 753 (41.5%) women underwent medical abortion in the gemeprost-alone and the gemeprost/mifepristone groups, respectively. Five (0.47%) uterine ruptures occurred in the gemeprost and four uterine ruptures occurred in the gemeprost/mifepristone groups, respectively (0.53%) (p=.89). All uterine ruptures occurred in women with prior cesarean delivery. CONCLUSIONS: We rep orted no difference in the incidence of uterine rupture between the gemeprost-alone and gemeprost and mifepristone groups. IMPLICATIONS: Uterine rupture is a rare complication of second-trimester medical abortion with gemeprost. Use of mifepristone prior to gemeprost does not affect this risk.

Do women want to talk about birth control at the time of a first-trimester abortion?

OBJECTIVE: To investigate if women desire talking to a counselor or physician about contraception when seeking first-trimester medical or surgical abortion. STUDY DESIGN: We conducted a cross-sectional study by distributing self-administered anonymous surveys to women at three clinics in Sacramento, California; Chicago, Illinois; and Cleveland, Ohio, from October 2014 to February 2015. Participants completed surveys after registration and before any in-office counseling. We asked whether women want to discuss contraception, specific topics they want to discuss, reasons why they may not want to talk about contraception and whether they want to receive contraception services as part of their abortion care. We conducted regression analyses to assess associations between patient characteristics and the desire for counseling. RESULTS: Among 3041 eligible women, 1959 (64.4%) completed surveys. Overall, 1208 (61.7%) did not want to discuss contraception prior to having an abortion, primarily citing that they already know which method they want. We found no association between the desire to discuss contraception and age, race, planned abortion method, clinic site and number of unplanned pregnancies. Among those who desired to talk about contraception, subjects preferred to discuss which contraceptive methods are easier to use and more effective as compared to previously used methods. Regardless of their desire for a discussion about contraception, 1386 (70.8%) of subjects wanted to leave the clinic with a specific method, including a long-acting reversible method [intrauterine device or implant (190, 13.7%)] or other hormonal method [pills, patch, ring or injectable (680, 49.1%)]. CONCLUSIONS: The majority of women seeking first-trimester abortion do not come to the clinic wanting to discuss contraception, most commonly because they have a preferred method in mind. IMPLICATIONS: Providers should ask women presenting for abortion if they want to discuss contraception and not assume that they need or desire such information. Focused discussions, starting with the preferred method if known, may better satisfy women's preferences. Providers should account for such desires when allocating resources for contraception services during abortion care.

Satisfaction With the Intrauterine Device Insertion Procedure Among Adolescent and Young Adult Women.

OBJECTIVE: To evaluate satisfaction with intrauterine device (IUD) insertion procedures among adolescent and young adult women. METHODS: This secondary analysis of data from a multisite, single-blind, sham-controlled randomized trial of women having a levonorgestrel 13.5-mg IUD inserted enrolled participants from March 2015 through July 2016 at three family planning clinics in Philadelphia, Pennsylvania. Eligible participants were 14-22 years of age, nulliparous, not pregnant, and English-speaking. Randomization was computer-generated allocation in block sizes of four to a 1% lidocaine paracervical or sham block. Only patients were blinded. Satisfaction was measured with three items that assessed overall satisfaction with the procedure, whether participants would recommend the IUD to a friend, and the perception that the IUD was worth the discomfort. Predictors included demographics, sexual and reproductive history, pain after IUD insertion, and treatment group. RESULTS: Ninety-five women enrolled; 93 (97.9%) were included in the analysis. Forty-five (47.4%) were white, 34 (36.0%) were black, 62 (66.0%) were privately insured, and 75 (79.0%) had used contraception previously. Most (n=73 [76.8%]) reported high overall satisfaction with the procedure, 64 (67.4%) would recommend an IUD to a friend, and 79 (83.2%) perceived the IUD was worth the discomfort. The odds of reporting high overall satisfaction were lower among adolescents compared with young adults (odds ratio [OR] 0.07, 95% CI 0.008-0.68); those who never had a gynecologic examination compared with those who had (OR 0.26, 95% CI 0.07-0.99); and decreased as pain score increased (OR 0.96, 95% CI 0.94-0.99). Higher pain scores were negatively correlated with the odds of recommending an IUD to a friend and perceiving the IUD was worth the discomfort. CONCLUSION: Adolescent and young adult women report high levels of satisfaction after the IUD insertion procedure. Young age, lack of experience with gynecologic examinations, and high pain were inversely related to satisfaction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02352714.

Reducing Pain During Intrauterine Device Insertion: A Randomized Controlled Trial in Adolescents and Young Women.

OBJECTIVE: To estimate the effect of a 1% lidocaine paracervical nerve block on pain during intrauterine device (IUD) insertion compared with a sham block in adolescents and young women. METHODS: We conducted a multisite, single-blind, sham-controlled randomized trial in adolescents and young women having a 13.5-mg levonorgestrel IUD inserted. Enrollment occurred at three family planning clinics in Philadelphia, Pennsylvania. Eligible adolescents and young women were aged 14-22 years, nulliparous, not currently or recently pregnant, and English-speaking. Participants were randomized using computer-generated allocation in block sizes of four to receive a 10-mL 1% lidocaine paracervical block or a sham block (1 cm depression of the vaginal epithelium at paracervical block sites with a wooden cotton-tipped applicator). Only patients were blinded. The primary outcome was pain after IUD insertion measured with a 100-mm visual analog scale. Using a two-sided t test and assuming a 20-mm difference in visual analog scale scores, a SD of 28 mm, an α of 0.05, and 90% power, a sample of 43 participants per group was estimated. RESULTS: Between March 2015 and July 2016, 95 participants enrolled (47 lidocaine block group; 48 sham block group). All were included in the analysis. Forty-four percent were white, 36% black, 65% privately insured, and 79% previously used contraception. The median visual analog scale score after IUD insertion was 30.0 (95% CI 20.0-58.0) in the lidocaine block group and 71.5 (95% CI 66.0-82.0) in the sham block (P<.001). CONCLUSION: A 10-mL 1% lidocaine paracervical nerve block reduces pain during IUD insertion in adolescents and young women compared with a sham block with pressure on the vaginal epithelium. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02352714.

Placenta praevia and the risk of adverse outcomes during second trimester abortion: A retrospective cohort study.

BACKGROUND: There are few reports in the literature of the risks associated with second trimester abortion in women with placenta praevia (PP). We hypothesise that PP increases the risk of complications. AIMS: We sought to determine if PP is associated with a higher risk of blood loss and blood transfusion at the time of dilation and evacuation (D&E). MATERIALS AND METHODS: The records of 612 consecutive women undergoing abortion at 15-24 weeks of gestation were reviewed. Participant characteristics, need for blood transfusion, estimated blood loss (EBL) during the abortion and other complications were compared between women with and without ultrasound-documented PP. RESULTS: Eighty-seven of 612 (14.2%, 95% CI 11.5-17.2%) women had ultrasound-documented PP. The rate of blood transfusion was 3.4 and 1.3% in the group with PP and without PP, respectively (adjusted relative risk (RR = 2.8, 95% CI 0.7-11.3). An estimated blood loss of 500 cc or greater during the D&E procedure was observed in 12.6% of women in the PP group compared with 4.2% of women in the group without PP (adjusted RR 3.1, 95% CI 1.4-6.8, P = 0.004). CONCLUSIONS: Second-trimester abortion in women with PP is associated with a higher risk of blood loss of 500 cc or greater. Our study represents a larger sample size of patients with PP undergoing second-trimester abortion than previously reported in the literature. Women with PP may have a higher estimated blood loss and may require access to blood transfusion.

Association of Postpartum Predischarge Depot-Medroxyprogesterone Acetate with In-Hospital Breastfeeding Initiation.

OBJECTIVE: The primary aim of this study was to examine the association between postpartum predischarge depot-medroxyprogesterone acetate (ppDMPA) and in-hospital breastfeeding initiation, and the secondary exploratory aim was to determine if any racial disparities are associated with ppDMPA receipt or its relationship to breastfeeding initiation. MATERIALS AND METHODS: We conducted a cross-sectional retrospective chart review of maternal and newborn records at a large urban academic medical center. Variables extracted included in-hospital feeding choice, obstetrical and sociodemographic variables, infant characteristics, and ppDMPA receipt. The association of ppDMPA and maternal-child characteristics with breastfeeding initiation was examined using logistic regression analysis. RESULTS: Among singleton live births of 919 mother-infant pairs (76.5% African American [AA]), 67% initiated breastfeeding (34% exclusive and 33% mixed) and 31.4% received ppDMPA. Breastfeeding rates differed significantly between AA (60.7%) and non-AA mothers (86.6%), and ppDMPA also differed significantly between AA (37.6%) and non-AA mothers (11.6%). Adjusting for other independent predictors, mothers who received ppDMPA were 1.5 times more likely not to initiate breastfeeding if AA, and 5.2 times more likely not to initiate breastfeeding if non-AA. CONCLUSIONS: ppDMPA receipt was independently associated with decreased rates of breastfeeding initiation. Although more AA mothers received ppDMPA than non-AA, the association of ppDMPA with breastfeeding noninitiation was stronger in non-AA than in AA mothers. Future research should examine this question prospectively to ascertain if there is a cause-effect relationship and should address both physiological effects and social perceptions.

Home or office etonogestrel implant insertion after pregnancy: a randomized trial.

OBJECTIVES: To evaluate whether home visits for contraceptive implant insertion result in an increase in postpartum uptake compared to clinic insertion and to assess the feasibility of home insertions. STUDY DESIGN: We randomized women within 10 weeks of a birth or dilation and curettage (D&C) for abortion or miscarriage to home or standard office insertion. The primary outcome was successful insertion of the implant. To achieve 80% power to detect a 40% difference in visit attendance, 20 women were assigned to each group. The secondary outcome was attendance of the 4-week postpartum visit. RESULTS: From June 2013 through February 2014, we screened 45 women and 40 were randomly assigned to home and office insertion visits. We enrolled 37 postpartum women and 3 women post-D&C. Because of the significant under enrollment of the latter, we chose to report results of only the postpartum women. The results were similar whether we included or excluded post-abortion women. A majority of women desired a home visit for their implant insertion appointment at time of enrollment. Postpartum appointment attendance rates were similar between home and office visits at 53% and 50% (p=1.00), respectively. Home visits resulted in a trend toward increased implant uptake [12/19 (63%) vs 6/18 (33%), p=.10]. CONCLUSION: Home insertion of the contraceptive implant may be a feasible option. Future studies that examine the feasibility and uptake in both postpartum and post-D&C women are warranted. IMPLICATIONS: Women reported preference for home insertion visits in this pilot study. We also showed that a greater proportion of women received the etonogestrel implant at a home visit compared to the current standard of care, which may warrant larger studies that would have sufficient power to evaluate smaller differences.

Intravenous Sedation Without Intubation and the Risk of Anesthesia Complications for Obese and Non-Obese Women Undergoing Surgical Abortion: A Retrospective Cohort Study.

BACKGROUND: The primary objective of this study was to assess the risk of perioperative anesthesia-related complications in a cohort of obese and non-obese women undergoing outpatient surgical abortion under IV sedation without tracheal intubation. METHODS: We performed a retrospective cohort study of all surgical abortions through 22 6/7 weeks' gestation at an outpatient clinic from 2012 to 2013. Women receiving IV sedation were included. Obesity status was defined by the World Health Organization criteria. The primary outcome was the rate of perioperative anesthesia complications defined as tracheal intubation, pulmonary aspiration, hospital transfer for an anesthesia indication, or anesthesia-related adverse events (persistent hypoxemia and allergic reaction). The use of opioid reversal (naloxone) was assessed as a secondary outcome measure. Multivariate analysis for the secondary outcome measure was performed with adjustment for confounding factors. RESULTS: During the study period, 9348 abortions were performed. Of the 5579 patients who received IV sedation, 1438 (25.8%) were obese, 1707 (30.6%) were in the second trimester, and 851 (15.3%) were ≥17 weeks' gestation. No patients experienced a primary outcome measure. Based on the upper 95% confidence interval (CI) for the sample size, the maximal risk of an anesthesia-related complication is 1 in 1860 procedures. Naloxone use occurred in 13 (0.2%) patients and was not more frequent among obese patients (0.14% vs 0.27%; 95% CI of odds ratio [OR], 0.12-2.36; P = 0.54) or procedures at ≥17 weeks' gestation (0.47% vs 0.19%; 95% CI of OR, 0.76-8.06; P = 0.12). These negative findings should be interpreted with caution, given the limitations of the sample size to assess these secondary outcome measures. Naloxone use was associated with fentanyl doses >200 µg (0.82% vs 0.13%; P = 0.002), an association that remained significant when we controlled for confounding factors (adjusted OR, 5.51; 95% CI, 1.61-18.91). Further analysis revealed that fentanyl dose >200 µg was associated with naloxone use for procedures in the first trimester (incident rate ratio, 9.02; 95% CI, 3.73-21.80) but not in the second trimester (incident rate ratio, 0.92; 95% CI, 0.23-3.70). CONCLUSIONS: Among women receiving IV sedation without tracheal intubation for surgical abortion, anesthesia complications are rare and may not be greater for obese women or procedures at gestational age ≥17 weeks. IV sedation without tracheal intubation may be considered for women undergoing first- and second-trimester surgical abortion; however, the rarity of anesthesia-related complications in our cohort precludes a definitive conclusion regarding the overall safety of IV sedation without tracheal intubation.

Prior uterine evacuation of pregnancy as independent risk factor for preterm birth: a systematic review and metaanalysis.

BACKGROUND: Preterm birth (PTB) is the number one cause of perinatal mortality. Prior surgery on the cervix is associated with an increased risk of PTB. History of uterine evacuation, by either induced termination of pregnancy (I-TOP) or spontaneous abortion (SAB), which involve mechanical and/or osmotic dilatation of the cervix, has been associated with an increased risk of PTB in some studies but not in others. OBJECTIVE: The objective of the study was to evaluate the risk of PTB among women with a history of uterine evacuation for I-TOP or SAB. DATA SOURCES: Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, and Sciencedirect) were searched from their inception until January 2015 with no limit for language. STUDY ELIGIBILITY CRITERIA: We included all studies of women with prior uterine evacuation for either I-TOP or SAB, compared with a control group without a history of uterine evacuation, which reported data about the subsequent pregnancy. STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcome was the incidence of PTB < 37 weeks. Secondary outcomes were incidence of low birthweight (LBW) and small for gestational age (SGA). We planned to assess the primary and the secondary outcomes in the overall population as well as in studies on I-TOP and SAB separately. The pooled results were reported as odds ratio (OR) with 95% confidence interval (CI). RESULTS: We included 36 studies in this metaanalysis (1,047,683 women). Thirty-one studies reported data about prior uterine evacuation for I-TOP, whereas 5 studies reported data for SAB. In the overall population, women with a history of uterine evacuation for either I-TOP or SAB had a significantly higher risk of PTB (5.7% vs 5.0%; OR, 1.44, 95% CI, 1.09-1.90), LBW (7.3% vs 5.9%; OR, 1.41, 95% CI, 1.22-1.62), and SGA (10.2% vs 9.0%; OR, 1.19, 95% CI, 1.01-1.42) compared with controls. Of the 31 studies on I-TOP, 28 included 913,297 women with a history of surgical I-TOP, whereas 3 included 10,253 women with a prior medical I-TOP. Women with a prior surgical I-TOP had a significantly higher risk of PTB (5.4% vs 4.4%; OR, 1.52, 95% CI, 1.08-2.16), LBW (7.3% vs 5.9%; OR, 1.41, 95% CI, 1.22-1.62), and SGA (10.2% vs 9.0%; OR, 1.19, 95% CI, 1.01-1.42) compared with controls. Women with a prior medical I-TOP had a similar risk of PTB compared with those who did not have a history of I-TOP (28.2% vs 29.5%; OR, 1.50, 95% CI, 1.00-2.25). Five studies, including 124,133 women, reported data about a subsequent pregnancy in women with a prior SAB. In all of the included studies, the SAB was surgically managed. Women with a prior surgical SAB had a higher risk of PTB compared with those who did not have a history of SAB (9.4% vs 8.6%; OR, 1.19, 95% CI, 1.03-1.37). CONCLUSION: Prior surgical uterine evacuation for either I-TOP or SAB is an independent risk factor for PTB. These data warrant caution in the use of surgical uterine evacuation and should encourage safer surgical techniques as well as medical methods.

Teaching Trainees to Deliver Adolescent Reproductive Health Services.

STUDY OBJECTIVE: Delivery of reproductive services to adolescents varies according to specialty and has been linked to differences in clinical training. Few studies have explored how different specialties' graduate medical education (GME) programs prepare providers to deliver adolescent reproductive services. We explored the perceptions of resident physicians regarding their training in delivering adolescent reproductive health services. DESIGN: Between November 2008 and February 2009, 9 focus groups were conducted with graduate medical trainees in 3 specialties that routinely care for adolescents. The semistructured discussions were audio-recorded, transcribed, and analyzed using an inductive approach to content analysis. SETTING: Large, urban academic medical center in Pittsburgh, Pennsylvania. PARTICIPANTS: Fifty-four resident trainees in pediatrics, family medicine, and obstetrics/gynecology. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Trainees' perspectives regarding the didactic teaching and clinical training in providing adolescent reproductive services. RESULTS: Five themes emerged, reflecting trainees' beliefs regarding the best practices in which GME programs can engage to ensure that trainees graduate with the belief that they are competent and will be comfortable delivering adolescent reproductive services. Trainees believed programs need to: (1) provide didactic lectures and diverse inpatient and outpatient clinical experiences; (2) have faculty preceptors skilled in providing and supervising adolescent reproductive services; (3) teach skills for engaging adolescents in clinical assessments and decision-making; (4) train providers to navigate confidentiality issues with adolescents and caregivers; and (5) provide infrastructure and resources for delivering adolescent reproductive services. CONCLUSION: The 3 specialties differed in how well each of the 5 best practices were reportedly addressed during GME training. Policy recommendations are provided.

Hormonal contraception as treatment for heavy menstrual bleeding: a systematic review.

A systematic review to compare the effectiveness of contraceptives to treat heavy menstrual bleeding (HMB). PubMed was searched for studies using hormonal contraceptive methods to treat HMB. Two reviewers screened 734 citations and extracted eligible trials based on rigid inclusion and exclusion criteria. Fourteen articles met inclusion criteria. The evidence was good to poor quality and suggested that all contraceptives tested were effective in the treatment of HMB, but the levonorgestrel intrauterine system was the most effective method. Hormonal contraceptives effectively treat HMB. The levonorgestel intrauterine system is the superior method.