Diagnosis and Management of an Intramyometrial Ectopic Pregnancy Within a Septate Uterus.

BACKGROUND: An intramyometrial pregnancy is a rare form of ectopic pregnancy, making up an estimated 1% of all ectopic pregnancies. Previously described management options have included surgical excision in the emergency setting. CASE: A 32-year-old woman, gravida 4 para 0, at 6 0/7 weeks of gestation by last menstrual period, was noted to have a gestational sac implanted entirely within the uterine myometrium. Ultrasonography and magnetic resonance imaging confirmed the presence of an intramyometrial ectopic pregnancy within a septate uterus. The patient's abnormal pregnancy was successfully treated with multidose methotrexate. CONCLUSION: Intramyometrial pregnancy is a rare entity that should be considered when it is suggested by ultrasonography or if an intrauterine pregnancy is surgically inaccessible from the endometrial cavity. In a stable patient, multidose systemic methotrexate may be a feasible management strategy.

Lifestyle modifications alone or combined with hormonal contraceptives improve sexual dysfunction in women with polycystic ovary syndrome.

OBJECTIVE: To describe the prevalence of female sexual dysfunction in a well-defined polycystic ovary syndrome (PCOS) population, and to assess the impact of common PCOS treatments on sexual function. DESIGN: Secondary analysis of a randomized controlled trial, oral contraceptive pills and weight loss in PCOS. SETTING: Two academic medical centers. PATIENTS: Women with PCOS (N = 114) defined by the Rotterdam criteria. INTERVENTIONS: Continuous oral contraceptive pill (OCP) or intensive lifestyle modification (Lifestyle) or the combination (Combined) for 16 weeks. MAIN OUTCOME MEASURES: Change in Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R) scores after 16 weeks. RESULTS: There was no change in total FSFI or FSDS-R score in any treatment group; however, an increase in the FSFI desire domain subscore was observed in the Lifestyle and Combined treatments, indicating improved sexual desire over the 16-week period. Overall, 33 participants (28.9%) met criteria for sexual dysfunction by FSFI criteria (baseline score ≤26.55). Among this group, FSFI score improved after 16 weeks of Lifestyle and Combined treatments. There was no change in prevalence of sexual dysfunction in treatment groups at 16 weeks. Use of OCPs did not alter FSFI scores. CONCLUSION(S): Female sexual dysfunction is highly prevalent among women with PCOS. Our findings suggest that common treatments for PCOS, including intensive lifestyle modification and the combination of intensive lifestyle modification and OCPs, have the potential to improve sexual function in these women; the mechanism for these improvements is likely multifactorial. CLINICAL TRIAL REGISTRATION NUMBER: NCT00704912.

Prevalence and predictors of initiation of intrauterine devices and subdermal implants immediately after surgical abortion.

OBJECTIVES: To estimate uptake of long-acting reversible contraception (LARC) methods immediately after surgical abortion in a system that makes these methods readily available, and to determine demographic, medical, social, and visit-specific predictors of immediate post-abortion intrauterine device (IUD) and implant initiation. STUDY DESIGN: We performed a retrospective cohort study of LARC (levonorgestrel intrauterine system [IUS], copper IUD, and subdermal implant) initiation at the time of surgical abortion up to 21w0d gestation at Planned Parenthood League of Massachusetts from 2012 through 2017. We calculated proportions of IUD and implant initiation and used mixed effect logistic regression to estimate predictors of each outcome. RESULTS: Among 26,858 surgical abortion patients, 25.4% received immediate post-abortion LARC: 14.2%, 4.2%, and 7.0% received a levonorgestrel IUS, copper IUD, and implant, respectively. Compared to White women, Black women had lower odds of initiating an IUD (aOR 0.81, 95% CI 0.74-0.89). Multiparous women had greater odds than nulliparous women of initiating an IUD (aOR 1.69, 95% CI 1.57-1.82) or implant (aOR 1.36, 95% 1.20-1.53). We found age was the strongest predictor of implant initiation (<18 versus≥35: aOR 3.26, 95% CI 2.26-4.71), but was not associated with IUD uptake. Gestational age was not associated with IUD or implant uptake. Implant uptake increased from 2.4% (2012) to 8.7% (2017) (aOR 3.65, 95% CI 2.36-5.65) while IUD uptake remained fairly constant. CONCLUSION: About 25% of women chose to initiate intrauterine or implantable contraception immediately after surgical abortion when these methods are readily available. Implant uptake has increased significantly in recent years. Women who initiated IUDs and implants differed in their demographic and social profiles. IMPLICATIONS: Women seeking surgical abortion should have same-day access to IUDs and implants. Clinicians and researchers should analyze IUD and implant initiation separately.

Society of Family Planning clinical recommendations: contraception after surgical abortion.

These recommendations present an evidence-based assessment of provision of contraceptives at the time of surgical abortion. Most methods of contraception, including the intrauterine devices (IUD), implant, depot medroxyprogesterone injection, oral contraceptive pill, contraceptive patch, monthly vaginal ring, barrier methods and some permanent methods, can be safely initiated immediately after first- or second-trimester surgical abortion. Provision of postabortion contraceptives, particularly IUDs and implants, substantially reduces subsequent unintended pregnancy. IUD insertion immediately following uterine aspiration is safe. While this may be associated with a higher risk of device expulsion than with interval placement, expulsion rates remain low, and this risk must be weighed against the fact that patients often do not receive their desired IUD at an interval insertion and therefore experience higher rates of subsequent unintended pregnancy. Many patients experience barriers that prevent access to the full spectrum of postabortion contraceptive options, particularly IUDs and implants. Advancements in health-systems-based point-of-care provision and policies are needed to improve comprehensive contraceptive availability following surgical abortion. These recommendations will address clinical considerations for postabortion contraceptive provision and recommend interventions to improve contraceptive access following uterine evacuation.

Contraception After Surgical and Medical Abortion: A Review.

IMPORTANCE: To prevent subsequent unintended pregnancy, contraception should be initiated soon after surgical and medical abortion. Evidence regarding the safety of postabortion contraception, especially for longacting reversible methods, has accumulated in recent years. OBJECTIVE: This review seeks to provide up-to-date recommendations about the provision and timing of contraception after surgical and medical abortion. EVIDENCE ACQUISITION: Recommendations are based on the US Medical Eligibility Criteria (MEC) or on the authors' review of the current literature for topics that the MEC does not address. RESULTS: Contraceptive counseling at the time of abortion should be collaborative. All reversible contraceptive methods are safe to begin immediately after surgical abortion, barring concern for surgical complications or underlying medical contraindications. After medical abortion, the implant may be initiated immediately, combined hormonal contraception may be initiated shortly thereafter, and the intrauterine device may be placed once the abortion is complete. Further research is needed to determine the optimal timing of depot medroxyprogesterone acetate initiation after medical abortion. CONCLUSIONS AND RELEVANCE: Abortion is an important opportunity for contraceptive counseling and provision. Clinic policies and insurance coverage should maximize access to all contraceptive methods, including long-acting reversible methods.

Contraceptive choices and preferences in a cohort of women with cystic fibrosis.

OBJECTIVES: As life expectancy for women with cystic fibrosis (CF) improves, reproductive decision-making is becoming increasingly relevant. We sought to characterize fertility intentions, contraceptive use, and preferences among adult females with CF. STUDY DESIGN: We conducted a cross-sectional survey of contraceptive use and preferences in reproductive-aged women with CF. Subjects were recruited via an electronic mailing list from the Penn Adult Cystic Fibrosis Program. RESULTS: Fifty-three women with CF responded and met eligibility criteria. Most (83%) were sexually active, however only 49% used contraception. Condoms and the oral contraceptive pill were the most commonly used methods. Compared to the national contraceptive use among Caucasian women (65%), use in our cohort was significantly lower (p = 0.01). Participants prioritized effectiveness and ease of use in their contraceptive method; they wanted to avoid side effects and interference with sexual enjoyment. Although these priorities are similar to Caucasian women in the literature, additional contraceptive priorities differed significantly between the groups. CONCLUSIONS: This CF cohort is sexually active but contraceptive utilization was low, and women with CF identify specific contraceptive preferences. There is a significant unmet need for contraception among women with CF.

Contraception in women with cystic fibrosis: a systematic review of the literature.

OBJECTIVE: To perform a systematic review of the literature to examine original research on contraception in women with cystic fibrosis (CF) with a specific focus on safety, efficacy, non-contraceptive benefits, and utilization patterns in this population. STUDY DESIGN: We searched PubMed and Embase databases for any peer-reviewed original research in English on the use of contraception in women with CF. RESULTS: We identified 241 unique citations. After title review and exclusion of articles not reporting original data, 18 publications were included in the final review, with at least two articles for each area of focus. Limited evidence indicates that oral contraceptive pills are likely safe and efficacious in women with CF. Hormonal contraception may reduce pulmonary exacerbation rates and decrease need for antibiotics, suggesting non-contraceptive benefits. Women with CF utilize birth control at similar rates as the general population, and oral contraceptive pills and condoms are the most commonly used methods. CONCLUSIONS: Data on the safety, efficacy, and non-contraceptive benefits of hormonal contraception in women with CF are scant. Based on the limited data, hormonal contraception seems to be safe and efficacious and may provide noncontraceptive benefits. Further high-quality data from disease-specific research are required to better inform contraceptive decision-making among women with CF.

Using the androgen excess-PCOS society criteria to diagnose polycystic ovary syndrome and the risk of metabolic syndrome in adolescents.

OBJECTIVES: To use the Androgen Excess-PCOS Society (AE-PCOS) criteria in adolescents to diagnose polycystic ovary syndrome (PCOS) and identify the prevalence of metabolic risk factors. STUDY DESIGN: Retrospective chart review of adolescents (>2 years postmenarche) presenting at a specialty clinic from 2008 through 2010 with complete evaluation for PCOS and metabolic risk were reviewed. Metabolic risk in adolescents with PCOS was compared with those with ≤ 1 AE-PCOS criteria. RESULTS: Of the 205 adolescents evaluated, 66% were found to have PCOS based on the AE-PCOS criteria. The most common presenting symptom was menstrual irregularity, followed by acne, hirsutism, and weight gain. Adolescents with PCOS had a significantly higher prevalence of obesity, hypertension, and low level of high-density lipoprotein cholesterol. Subjects with PCOS had ≥ 1 metabolic risk factor compared with the subjects without PCOS (63.6% vs 33.3%, P = .002). More adolescents with PCOS had ≥ 2 abnormal metabolic risk factors excluding body mass index compared with those without PCOS (P < .02). The prevalence of metabolic syndrome (≥ 3 risk factors) was 10.8% in adolescents with PCOS compared with 1.7% in those without PCOS (P < .04). CONCLUSIONS: Adolescents diagnosed with PCOS based on the AE-PCOS criteria are at a significantly increased risk of ≥ 1 metabolic abnormality. Our data underscore the need to accurately diagnose PCOS in the adolescent population instead of delaying the diagnosis to adulthood. Further, using similar criteria for the diagnosis of PCOS in adolescents (>2 years postmenarche) and adults will be more convenient for the clinician.

The diagnosis of polycystic ovary syndrome in adolescents.

Polycystic ovary syndrome (PCOS) is recognized as the most common endocrinopathy in reproductive-aged women. The symptoms of PCOS vary with age, race, weight, and medications, adding to the challenges of accurate diagnosis. Adolescent patients pose particular diagnostic problems because characteristics of normal puberty often overlap with signs and symptoms of PCOS. This article reviews the diagnosis of PCOS in adolescents.