Oestrogen component of COCs: have we finally found a replacement for ethinyl estradiol?

PURPOSE OF REVIEW: Combined oral contraceptive pills are among the most widely used contraceptive methods globally. Despite their popularity, the potential risks and side effects can lead to both high discontinuation rates and adverse outcomes including thromboembolic events. The quest for a safer alternative to the traditional ethinyl estradiol/progestin combination has led to the use of newer oestrogens. Ethinyl oestradiol alternatives will be reviewed including the newest option, estetrol, as it enters clinical use. RECENT FINDINGS: Oestradiol, when combined with a progestin with strong endometrial activity, is a viable alternative to ethinyl estradiol in the form of oestradiol valerate and estradiol, which have been available since 2008 and 2011, respectively. Estetrol is the newest oestrogen available and is found naturally in the foetal liver. Estetrol was approved for use in 2021. All three of these alternatives have high contraceptive efficacy, similar if not improved cycle control and decreased impact on haemostatic factors as compared to ethinyl estradiol. SUMMARY: Alternatives to ethinyl oestradiol, including the newest option of estetrol, show promise in providing comparable contraceptive efficacy with potentially lower risk of side effects and thromboembolic events.

A Comparison of Paracervical Block Volumes Before Osmotic Dilator Placement: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether a 12-mL paracervical block is noninferior to a 20-mL block in reducing pain with osmotic dilator insertion. METHODS: In this single-blinded noninferiority trial, we randomized individuals undergoing insertion of osmotic dilators before second-trimester abortion to receive either a 12-mL or 20-mL 1% lidocaine paracervical block. The primary outcome was pain immediately after insertion of osmotic dilators. Prespecified secondary outcomes included pain with paracervical block administration, overall pain, and side effects, with 88 participants being required for a noninferiority margin of 15 mm on a 100-mm visual analog scale assuming an SD of 28. We analyzed data using Wilcoxon rank sum, χ2, and t tests and performed analysis of variance to account for repeated measures. Secondary analysis included multivariable regression to explore potential confounders. RESULTS: From January 2018 to October 2020, of 232 eligible individuals, 174 were approached and 96 randomized (48 participants to each group); 91 were available for analysis (45: 12 mL, 46: 20 mL). Group demographics were similar, with a mean gestation of 21 weeks and four osmotic dilators placed. The 12-mL paracervical block was noninferior to the 20-mL paracervical block for pain with osmotic dilator insertion with a difference in means of -1.36 (95% CI -12.56 to 9.85) favoring 12 mL. Median pain scores after dilator placement were 47 mm (interquartile range 22-68) and 50 mm (interquartile range 27-67) in 12-mL compared with 20-mL paracervical block, respectively (P=.81). No difference was seen in median pain at baseline, with paracervical block administration, postprocedure or with overall pain or experience. At least one lidocaine-related side effect occurred in 4% of participants in the 12-mL group compared with 13% for those receiving 20 mL (P=.15), with metallic taste, ringing in ears, and lightheadedness being most common. CONCLUSION: A 12-mL paracervical block is noninferior to a 20-mL block for pain reduction with osmotic dilator insertion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03356145.

Comparison of two home pregnancy tests for self-confirmation of medication abortion status: A randomized trial.

OBJECTIVES: To evaluate individuals' ability to perform and comprehend low-sensitivity and multilevel urine pregnancy tests during medication abortion follow-up. STUDY DESIGN: We conducted a pilot study of individuals using mifepristone and misoprostol for medication abortion through 63-days gestation. We randomly assigned participants to use a 1000 mIU/mL low-sensitivity pregnancy test or a five-level multilevel pregnancy test. Seven days after mifepristone, participants performed their test and completed a questionnaire. One week later, participants performed another test if day 7 low-sensitivity test had been positive or day 7 multilevel test had not shown a one-level drop. We assessed comprehension of abortion status based on participants' final test interpretation, and defined correct comprehension when patient report of pregnancy status was consistent with pregnancy test result. We also assessed usability with a 100-mm Visual Analogue Scale (0 'very easy'; 100 'very difficult') and satisfaction. RESULTS: We enrolled and randomized 88 participants to low-sensitivity (n = 43) and multilevel (n = 45) test groups. Comprehension was correct in 38/39 (97%) and 41/45 (91%) of low-sensitivity and multilevel test users, respectively (p = 0.37). When the test indicated a possible ongoing pregnancy, all three low-sensitivity test users and two of three multilevel test users accurately comprehended their results. Participants rated ease of use as 7.5 (range 0-68) for low-sensitivity and 9.0 (range 0-52) for multilevel (p = 0.24) tests. Most participants were likely or very likely to recommend use of their test (32/36 [89%] low-sensitivity and 42/44 [95%] multilevel test users, p = 0.66). CONCLUSIONS: Patients could comprehend and use low-sensitivity and multilevel tests during medication abortion follow-up with similar satisfaction. IMPLICATIONS: Individuals are able to independently use both the low-sensitivity and multilevel tests for medication abortion follow-up. Both are acceptable for medication abortion follow-up without in-person contact, but future, larger studies to compare comprehension of both tests may be necessary.

Mobile technology for family planning.

PURPOSE OF REVIEW: To evaluate the recent literature on mobile health applications available to patients for contraception and abortion care. RECENT FINDINGS: Women are increasingly interested in contraceptive tools utilizing mobile technology, and a majority of women expect them to be science-based. The largest number of available mobile apps supports natural family planning methods, which is recognized as the least effective contraceptive method. Many available apps cannot be relied on for accurate, science-based pregnancy prevention methods. Further, there is a paucity of data regarding use of mobile technology for women seeking or receiving abortion. SUMMARY: Further research is needed to evaluate mobile health apps and how they can best provide patient consumers with accurate, evidence-based information to support the prevention of unintended pregnancy.

Abortion through telemedicine.

PURPOSE OF REVIEW: Medical abortion offers a well tolerated and effective method to terminate early pregnancy, but remains underutilized in the United States. Over the last decade, 'telemedicine' has been studied as an option for medical abortion to improve access when patients and providers are not together. A number of studies have explored various practice models and their feasibility as an alternative to in-person service provision. RECENT FINDINGS: A direct-to-clinic model of telemedicine medical abortion has similar efficacy with no increased risk of significant adverse events when compared with in-person abortion. A direct-to-consumer model is currently being studied in the United States. International models of direct-to-consumer medical abortion have shown promising results. SUMMARY: The introduction of telemedicine into abortion care has been met with early success. Currently, there are limitations to the reach of telemedicine because of specific restrictions on mifepristone in the United States as well as laws that specifically prohibit telemedicine for abortion. If these barriers are removed, telemedicine can potentially increase abortion access.

HIV and contraception.

PURPOSE OF REVIEW: Contraception is a vital component of medical care for women with HIV or at high risk of acquiring HIV. Over the last several years, there has been emerging evidence regarding the safety and effectiveness of various contraceptive methods, ultimately leading to a revision in the WHO Medical Eligibility Criteria for contraceptive use. RECENT FINDINGS: Progestogen-only injectables may be associated with an increased risk of HIV acquisition and its use has been revised to category 2 from category 1. Etonogestrel and levonorgestrel levels are lower in women who concurrently use contraceptive implant and efavirenz-based antiretroviral therapy. Multipurpose technology, aimed at providing antiretroviral medication and contraception, is an area of ongoing research but is not yet clinically available. SUMMARY: It is important for providers who care for women with HIV or at high risk of HIV to inquire about pregnancy intentions. If contraception is desired, these women should be offered all available methods, with counseling regarding possible risks of contraceptive failure or HIV acquisition.

Update on emergency contraception.

PURPOSE OF REVIEW: Emergency contraception provides a critical and time-sensitive opportunity for women to prevent undesired pregnancy after intercourse. Both access and available options for emergency contraception have changed over the last several years. RECENT FINDINGS: Emergency contraceptive pills can be less effective in obese women. The maximum achieved serum concentration of levonorgestrel (LNG) is lower in obese women than women of normal BMI, and doubling the dose of LNG (3 mg) increases its concentration maximum, approximating the level in normal BMI women receiving one dose of LNG. Repeated use of both LNG and ulipristal acetate (UPA) is well tolerated. Hormonal contraception can be immediately started following LNG use, but should be delayed for 5 days after UPA use to avoid dampening the efficacy of UPA. The copper intrauterine device (IUD) is the only IUD approved for emergency contraception (and the most effective method of emergency contraception), but use of LNG IUD as emergency contraception is currently being investigated. Accurate knowledge about emergency contraception remains low both for patients and healthcare providers. SUMMARY: Emergency contraception is an important yet underutilized tool available to women to prevent pregnancy. Current options including copper IUD and emergency contraceptive pills are safe and well tolerated. Significant gaps in knowledge of emergency contraception on both the provider and user level exist, as do barriers to expedient access of emergency contraception.

Chronic Stroke Outcome Measures for Motor Function Intervention Trials: Expert Panel Recommendations.

BACKGROUND: About half of survivors with stroke experience severe and significant long-term disability. The purpose of this article is to review the state of the science and to make recommendations for measuring patient-centric outcomes in interventions for motor improvement in the chronic stroke phase. METHODS AND RESULTS: A 9-member expert panel reviewed evidence to identify measures of upper and lower extremity function used to date as outcomes in trials with patients who experienced a stroke ≥6 months before assessment. Outcome measures were screened using StrokEDGE consensus panel recommendations, and evaluated for availability of a published minimal clinically important difference. Measures meeting these criteria were further evaluated with regard to their level of measurement, psychometric properties, and ability of minimal clinically important difference to capture gains associated with improved function and clinical relevance to patients, to arrive at recommendations. A systematic literature review yielded 115 clinical trials of upper and lower extremity function in chronic stroke that used a total of 34 outcome measures. Seven of these had published minimal clinically important differences and were recommended or highly recommended by StrokEDGE. Those are the Fugl-Meyer Upper Extremity and Lower Extremity scales, Wolf Motor Function Test, Action Research Arm Test, Ten-Meter and Six-Minute Walk Tests, and the Stroke Impact Scale. All had evidence for their psychometric performance, although the strength of evidence for validity varied, especially in populations with chronic stroke Fugl-Meyer Upper and Lower Extremity scales showing the strongest evidence for validity. CONCLUSIONS: The panel recommends that the Fugl-Meyer Upper and Lower Extremity scales be used as primary outcomes in intervention trials targeting motor function in populations with chronic stroke. The other 6 measures are recommended as secondary outcomes.

Review of therapeutic electrical stimulation for dorsiflexion assist and orthotic substitution from the American Congress of Rehabilitation Medicine stroke movement interventions subcommittee.

Ankle dorsiflexion weakness that impedes walking affects some 30% of people after a stroke, which increases the risk of falls and mortality. Recent advances in functional electrical stimulation or electrical stimulation orthotic substitute walking devices facilitate the use of surface electrode stimulation during therapeutic gait training and as an orthotic substitute. However, many therapists who could promote the use of these electrical stimulation orthotic substitute devices are not doing so, possibly because of a lack of knowledge about the devices and uncertainty about which patients could benefit from the devices but also because of a lack of reimbursement by some insurance providers. In addition, there is limited evidence about the efficacy of electrical stimulation orthotic substitute devices for therapeutic use or as a substitute for a traditional ankle-foot orthosis (AFO). This article provides clinicians with information to guide them in the use of electrical stimulation orthotic substitute devices, discusses current research about the use of electrical stimulation orthotic substitute devices for therapeutic and orthotic purposes, and compares the use of electrical stimulation orthotic substitute devices and AFOs. There is insufficient evidence thus far to conclude that walking with an electrical stimulation orthotic substitute device is superior to walking with an AFO, but electrical stimulation orthotic substitute devices may be the optimal choice for some patients.

Debulking metastatic pelvic nodes before radiotherapy in cervical cancer patients: a long-term follow-up result.

BACKGROUND: Enlarged pelvic nodes are commonly found during preoperative imaging studies in cervical cancer patients and may represent tumor metastasis. It remains controversial whether debulking of these enlarged nodes prior to definitive radiotherapy offers any survival benefit to the patient. METHODS: Enlarged suspicious pelvic nodes identified by imaging studies in stage 1B to stage IIA (early-stage) cervical cancer patients prior to scheduled radical hysterectomy and in stage 1B2 or above (advanced-stage) cervical cancer patients destined for radiotherapy were debulked. Patients with confirmed nodal metastasis (node-positive) were primarily treated by radiotherapy and patients with no evidence of nodal metastasis (node-negative) were treated as planned. Clinical outcomes of these two groups of patients are reported after a long-term follow-up. RESULTS: Sixteen of 110 early-stage and 37 of 97 advanced-stage cervical cancer patients had their enlarged metastatic nodes removed before they were treated by radiotherapy. Microscopic metastatic pelvic nodes were found in six additional patients after the radical hysterectomy and four of them received postoperative adjuvant radiotherapy. After a median follow-up of 62 months, the rates of recurrence inside the pelvis are not significantly different between node-positive and node-negative patients with both early-stage and advanced-stage disease. Recurrences outside the pelvis occurred in 59.1% early-stage and 44.8% advanced-stage node-positive patients, and were the primary cause of poor survival. CONCLUSIONS: Debulking enlarged metastatic pelvic nodes may help reducing pelvic recurrence but does not seem to benefit survival.

Whole-body intensive rehabilitation is feasible and effective in chronic stroke survivors: a retrospective data analysis.

PURPOSE: Upper extremity (UE) intensive repetitive training, locomotor training, and functional strength training, delivered in isolation, promote neural plasticity and functional recovery after stroke. However, the effectiveness of a comprehensive whole-body approach combining these interventions has not been thoroughly investigated. The purpose of this retrospective data analysis was to evaluate the efficacy and feasibility of intensive, comprehensive rehabilitation for a heterogeneous population of chronic stroke survivors in a community clinic setting. METHOD: Whole-body intensive rehabilitation (3-6 hours/day, 4-5 days/week, >or= 2 weeks) consisted of locomotor, balance, and transfer training; progressive resistive strengthening exercise; and repetitive task-specific UE practice. Outcome measures were collected from all patients participating in the program between March 2003 and January 2008 who were diagnosed with a stroke >or= 12 months prior to treatment initiation (N = 35). RESULTS: Significant improvements in function were observed as measured by the Fugl-Meyer Assessment, Wolf Motor Function Test (WMFT), Box and Block test, Berg Balance Scale, Timed Up & Go Test (TUG), and 6-minute walk test. CONCLUSION: Whole-body intensive rehabilitation is an effective and feasible approach to promote recovery in chronic stroke survivors with moderate to severe deficits. Further research is necessary to confirm these results in a more controlled environment.

Clinical correlates of the caregiving experience for Chinese caregivers of patients with schizophrenia.

OBJECTIVE: To assess the correlation between clinical characteristics and the caregiving experience of caregivers of patients with schizophrenia. PATIENTS AND METHODS: Two hundred and one patients with schizophrenia and their caregivers were recruited from a psychiatric clinic. The involvement evaluation questionnaire (IEQ) and the general health questionnaire (GHQ) were administered to the caregivers. The patients were assessed by the Structured Clinical Interview, the positive and negative syndrome scale (PANSS) and the global assessment of functioning scale (GAF). Correlation analysis and regression analysis was performed to identify the best predictors of caregiver stress. RESULTS: The most important clinical predictor of caregiver stress as assessed using IEQ was the GAF, followed by PANSS-Pos and Neg scores and admission. Positive symptoms contributed more to overall caregiver stress than negative symptoms. DISCUSSION: Both symptom severity and patient function were important factors in the caregiver experience. Treatment should aim not only to reduce symptoms but also maximize function. Service planning should include psychosocial intervention involving caregivers.

Endoscopic hemostasis for bleeding gastric stromal tumors by application of hemoclip.

In the past, numerous reports have advocated primary surgical resection as a treatment of choice for bleeding gastric stromal tumors (GIST). There were scarce reports on primary hemostasis with endoscopic therapy. We encountered two patients who presented to our unit with acute bleeding from gastric fundal stromal tumor, in whom we were able to achieved successful endoscopic hemostasis with hemoclip therapy. We describe the management of these cases and reviewed the current management strategies in bleeding gastric stromal tumor.

Becoming a role model: the breastfeeding trajectory of Hong Kong women breastfeeding longer than 6 months.

While a substantial proportion of breastfeeding women stop early in the postpartum period, some women are able to breastfeed for longer periods. The aim of this research was to explore the experience of breastfeeding with a subsample of Hong Kong women who have breastfed for longer than 6 months. Participants (n=17) were recruited from a larger infant-feeding study (n=360) conducted in tertiary-care hospitals in Hong Kong. In-depth qualitative interviews were conducted and content analysis was used to analyse the data. Data analysis revealed four themes that encompassed the women's experiences: (1) making the decision, (2) maintaining family harmony, (3) overcoming barriers, and (4) sustaining lactation. Antenatally, participants anticipated that breastfeeding would be very 'difficult' and described how the practice did not fit with the image of a professional woman in Hong Kong. Despite family opposition, frequently from their mother-in-law, and lack of societal acceptance, difficulties were overcome by what the Chinese people call hung-sum or determination. This study highlights unique cultural and social findings affecting breastfeeding women in Hong Kong which may be useful to health-care providers working with Chinese women locally and internationally.