Position Paper: SGIM Sex- and Gender-Based Women's Health Core Competencies.

Women's health care has evolved significantly since it was first acknowledged as an integral part of internal medicine training more than two decades ago. To update and clarify core competencies in sex- and gender-based women's health for general internists, the Society of General Internal Medicine (SGIM) Women and Medicine Commission prepared the following Position Paper, approved by the SGIM council in 2023. Competencies were developed using several sources, including the 2021 Accreditation Council for Graduate Medical Education Program Requirements for Internal Medicine and the 2023 American Board of Internal Medicine Certification Examination Blueprint. These competencies are relevant to the care of patients who identify as women, as well as gender-diverse individuals to whom these principles apply. They align with pivotal advances in women's health and acknowledge the changing context of patients' lives, reaffirming the role of general internal medicine physicians in providing comprehensive care to women.

Future Pregnancy Considerations after Premature Birth of an Infant Requiring Intensive Care: A Qualitative Study.

BACKGROUND: Postpartum contraception counseling and method use vary widely among patients who had a preterm birth. We performed this study to explore what issues and concerns individuals with preterm infants requiring intensive care describe as influencing their postpartum contraceptive choices. METHODS: We conducted a qualitative study using semi-structured interviews with participants who gave birth to a singleton preterm infant admitted to the neonatal intensive care unit (NICU). We explored pregnancy, childbirth, postpartum care, and NICU experiences, as well as future reproductive plans and postpartum contraceptive choices. Two coders used a constant-comparative approach to code transcripts and identify themes. RESULTS: We interviewed 26 participants: 4 (15%) gave birth at less than 26, 6 (23%) at 26 to 27 6/7, 8 (31%) at 28 to 31 6/7, and 8 (31%) at 32 to 36 6/7 weeks of gestation. We identified three main themes related to future pregnancy plans and contraception choice. First, participants frequently described their preterm birth and their infants' NICU hospitalization as traumatic experiences that affected plans for future pregnancies. The loss of control in predicting or preventing a future preterm birth and uncertainty about their premature child's future medical needs resulted in participants wanting to avoid going through the same experience with another child. Second, participants chose contraception based on previous personal experiences, desired method features, and advice from others. Last, having a preterm birth did not result in any ambivalence among those who desired permanent contraception. CONCLUSIONS: Preterm birth influences future pregnancy plans. When discussing reproductive goals with patients, clinicians should be aware of potential trauma associated with a premature birth, assess for whether patients want to discuss contraception, and center the conversation around individual needs if patients do desire contraceptive counseling.

Development and Pilot Testing of a Patient-Centered Web-Based Reproductive Decision Support Tool for Primary Care.

BACKGROUND: Patient-centered counseling to help women achieve their reproductive goals is an essential yet often absent component of primary care. OBJECTIVE: We developed and piloted MyPath, a novel web-based decision support tool integrating reproductive goals assessment, information about optimizing health before pregnancy, and contraceptive decision support, for use prior to primary care visits in the Veterans Administration (VA). DESIGN: We created MyPath using best practices for decision tool development, including a conceptual framework informed by theory and user-centered design with input from patients, providers, and scientific experts. We conducted a non-randomized pilot in two VA Women's Health primary care clinics. A control group (n = 28) was recruited prior to and intervention group (n = 30) recruited after introduction of MyPath into clinics. PARTICIPANTS: Women Veterans ages 18-44 with an upcoming visit scheduled with one of eight providers. INTERVENTIONS: After recruitment of controls, providers and staff received a brief introduction to MyPath. Patients scheduled to see providers in the intervention phase used MyPath on an iPad in the waiting room prior to their visit. MAIN MEASURES: Acceptability, feasibility, discussions about pregnancy and/or contraceptive needs, and contraceptive decision quality by a survey of participants and providers. KEY RESULTS: Nearly all participants who used MyPath reported they learned new information (97%) and would recommend it to other Veterans (93%). No providers reported that MyPath significantly increased workload. A greater proportion of intervention participants reported having discussions about reproductive needs in their visit compared to controls (93% vs 68%; p = 0.02). Intervention participants also experienced greater increases in pre-/post-visit knowledge and communication self-efficacy and a trend towards greater reduction in contraceptive decision conflict compared to controls. CONCLUSIONS: MyPath was highly acceptable to women, increased the proportion of primary care visits addressing reproductive needs, and improved decision quality without increasing providers' perceived workload. A larger randomized evaluation of effectiveness is warranted.

Copper intrauterine device placement 6-14 days after unprotected sex.

OBJECTIVE: To evaluate pregnancy risk following copper (CuT380A) intrauterine device (IUD) placement 6-14 days after unprotected intercourse. STUDY DESIGN: We used a combined dataset from four protocols in which participants had received a CuT380A IUD regardless of recent unprotected intercourse. At entry, participants had negative point of care urine pregnancy testing and reported all acts of unprotected intercourse in the two weeks prior to IUD placement. We identified a subset of women who had placement 6-14 days after unprotected intercourse and provided follow-up information on pregnancy status 2-4 weeks after IUD insertion. This follow-up within the four protocols included self -administered home urine pregnancy test (UPT) results 2-4 weeks after IUD placement or continued contact for up to 6 months. RESULTS: We identified 134 women who had a CuT380A IUD placed 6-14 days after unprotected intercourse and provided follow-up information on pregnancy status. Ninety-five (71%) participants reported UPT results 2-4 weeks after placement and the other 39 women were followed for 6 months after IUD placement to assess pregnancy status. Zero (97.5% CI 0-2.7%) participants reported a pregnancy within four weeks of CuT380A IUD placement. CONCLUSION: In these collected data, no women with recent unprotected intercourse became pregnant within 1 month of CuT380A IUD placement. IMPLICATION: These data indicate a low likelihood of pregnancy among women who reported unprotected intercourse 6-14 days preceding IUD insertion. For many women and their providers, these data may be sufficient to support same-day placement of a copper IUD rather than delaying IUD placement until the next menses.

Unintended Pregnancy and Contraceptive Use Among Women Veterans: The ECUUN Study.

BACKGROUND: Little is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system. OBJECTIVE: To determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy among reproductive-aged women veterans. DESIGN AND PARTICIPANTS: We conducted a cross-sectional, telephone-based survey with a national sample of 2302 women veterans aged 18-44 years who had received primary care in the VA within the prior 12 months. MAIN MEASURES: Descriptive statistics were used to estimate rates of contraceptive use and unintended pregnancy in the total sample. We also estimated the unmet need for prescription contraception in the subset of women at risk for unintended pregnancy. For comparison, we calculated age-adjusted US population estimates using data from the 2011-2013 National Survey of Family Growth (NSFG). KEY RESULTS: Overall, 62% of women veterans reported current use of contraception, compared to 68% of women in the age-adjusted US population. Among the subset of women at risk for unintended pregnancy, 27% of women veterans were not using prescription contraception, compared to 30% in the US population. Among women veterans, the annual unintended pregnancy rate was 26 per 1000 women; 37% of pregnancies were unintended. In the age-adjusted US population, the annual rate of unintended pregnancy was 34 per 1000 women; 35% of pregnancies were unintended. CONCLUSIONS: While rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women veterans served by the VA are similar to those in the US population, these rates are suboptimal in both populations, with over a quarter of women who are at risk for unintended pregnancy not using prescription contraception, and unintended pregnancies accounting for over a third of all pregnancies. Efforts to improve contraceptive service delivery and to reduce unintended pregnancy are needed for both veteran and civilian populations.

Racial and ethnic disparities in contraceptive knowledge among women veterans in the ECUUN study.

OBJECTIVE: To assess whether racial/ethnic disparities in contraceptive knowledge observed in the general US population are also seen among women Veterans served by the Veterans Affairs (VA) healthcare system. STUDY DESIGN: We analyzed data from a national telephone survey of 2302 women Veterans aged 18-44 who had received care within VA in the prior 12 months. Twenty survey items assessed women's knowledge about various contraceptive methods. Multivariable logistic regression was used to examine racial/ethnic variation in contraceptive knowledge items, adjusting for age, marital status, education, income, parity, and branch of military service. RESULTS: Contraceptive knowledge was low among all participants, but black and Hispanic women had lower knowledge scores than whites in almost all knowledge domains. Compared to white women, black women were significantly less likely to answer correctly 15 of the 20 knowledge items, with the greatest adjusted difference observed in the item assessing knowledge about the reversibility of tubal sterilization (adjusted percentage point difference (PPD): -23.0; 95% CI: -27.8, -18.3). Compared to white women, Hispanic women were significantly less likely to answer correctly 11 of the 20 knowledge items, with the greatest adjusted difference also in the item assessing tubal sterilization reversibility (PPD: -13.1; 95% CI: -19.5, -6.6). CONCLUSION: Contraceptive knowledge among women Veterans served by VA is suboptimal, especially among racial/ethnic minority women. Improving women's knowledge about important aspects of available contraceptive methods may help women better select and effectively use contraception. IMPLICATIONS: Providers in the VA healthcare system should assess and address contraceptive knowledge gaps as part of high-quality, patient-centered reproductive health care.

Self-Administered Lidocaine Gel for Intrauterine Device Insertion in Nulliparous Women: A Randomized Controlled Trial.

OBJECTIVE: To evaluate self-administration of vaginal lidocaine gel to decrease pain with intrauterine device (IUD) insertion in nulliparous women. METHODS: In this randomized, double-blind, placebo-controlled trial, women self-administered 2% lidocaine or placebo vaginal gel 5 minutes before IUD insertion. The primary outcome was change in pain from baseline to IUD insertion on a 100-mm visual analog scale. We also assessed pain after speculum insertion, tenaculum placement, uterine sounding, and 5 minutes after IUD insertion. Secondary outcomes included patient acceptability, ease of IUD insertion, and need for pain medication for up to 7 days. RESULTS: From July 2012 to May 2013, 59 women were randomized; 30 received lidocaine gel and 29 placebo. Baseline demographics, including age, race, and body mass index, were similar. There was no difference in median change in pain during IUD insertion in women receiving lidocaine (61 mm [interquartile range 53-71]) compared with placebo (69 mm [interquartile range 63-80], P=.06). Women receiving lidocaine experienced less pain with tenaculum placement (32 mm [interquartile range 18-54]) compared with placebo (56 mm [interquartile range 26-75], P=.02). Most (76%) women were satisfied with their IUD insertion experience and 86% would probably or definitely recommend an IUD to a friend. Thirty-four percent of women required pain medication for at least 3 days after IUD insertion. CONCLUSION: For nulliparous women, self-administered vaginal lidocaine gel does not reduce pain with IUD insertion, but does decrease pain with tenaculum placement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, http://clinicaltrials.gov, NCT01534520.

Unprotected intercourse in the 2 weeks prior to requesting emergency intrauterine contraception.

BACKGROUND: Previous emergency contraception studies have excluded women who report >1 episode of unprotected or underprotected intercourse. Thus, clinical recommendations are based on exposure to a single episode of underprotected intercourse. OBJECTIVE: We sought to assess the prevalence and timing of underprotected intercourse episodes among women requesting emergency contraception and to examine the probability of pregnancy following an emergency contraception regimen including placement of either a copper intrauterine device or a levonorgestrel intrauterine device with simultaneous administration of an oral levonorgestrel pill in women reporting multiple underprotected intercourse episodes, including episodes beyond the Food and Drug Administration-approved emergency contraception time frame (6-14 days). STUDY DESIGN: Women seeking emergency contraception who had a negative pregnancy test and desired either a copper intrauterine device or levonorgestrel emergency contraception regimen enrolled in this prospective observational study. At enrollment, participants reported the number and timing of underprotected intercourse episodes in the previous 14 days. Two weeks later, participants reported the results of a self-administered home pregnancy test. RESULTS: Of the 176 women who presented for emergency contraception and received a same-day intrauterine device, 43% (n = 76) reported multiple underprotected intercourse episodes in the 14 days prior to presenting for emergency contraception. Women with multiple underprotected intercourse episodes reported a median of 3 events (range 2-20). Two-week pregnancy data were available for 172 (98%) participants. Only 1 participant had a positive pregnancy test. Pregnancy occurred in 0 of 97 (0%; 95% confidence interval, 0-3.7%) women with a single underprotected intercourse episode and 1 of 75 (1.3%; 95% confidence interval, 0-7.2%) women reporting multiple underprotected intercourse episodes; this includes 1 of 40 (2.5%; 95% confidence interval, 0-13.2%) women reporting underprotected intercourse 6-14 days prior to intrauterine device insertion. CONCLUSION: Women seeking emergency contraception from clinics commonly reported multiple recent underprotected intercourse episodes, including episodes occurring beyond the Food and Drug Administration-approved emergency contraception time frame. However, the probability of pregnancy was low following same-day intrauterine device placement.

Racial and ethnic differences in contraceptive use among women who desire no future children, 2006-2010 National Survey of Family Growth.

OBJECTIVE: To evaluate racial/ethnic differences in contraceptive use among women who do not desire future pregnancy. STUDY DESIGN: We used the 2006-2010 National Survey of Family Growth to examine the associations between race/ethnicity and 1) use of any contraceptive method at last heterosexual intercourse and 2) effectiveness of contraceptive method used among women who stated that they did not desire any (more) children. We conducted multivariable logistic regression to assess the independent effect of race/ethnicity on these outcomes, adjusting for socio-demographic factors, reproductive characteristics, and indicators of healthcare access and utilization. RESULTS: The study sample consisted of 2900 women, aged 15-44 years. The vast majority of women (91.2%) used contraception at last sex, although this varied significantly by race/ethnicity (p<.01). In the fully adjusted model controlling for demographic and reproductive characteristics as well as healthcare access, compared to whites, black women were significantly less likely to use any contraception at last sex (OR: 0.43; 95% CI: 0.27-0.73), while there was no significant difference for Hispanic women (OR: 0.95; 95% CI: 0.52-1.72). Among women who used a method at last sex, the type of contraceptive method varied significantly by race/ethnicity in bivariate analysis (p<.01), although most women (59%) used a highly effective method. In the fully adjusted model, racial/ethnic differences were no longer significant. CONCLUSIONS: In this nationally representative cohort of women who report that they do not desire (more) children, black women were significantly less likely than white women to use any contraception at last intercourse; this difference did not appear to be due to differential access to health care. IMPLICATIONS: Significant racial/ethnic differences exist in contraceptive use among women who have completed childbearing, which do not appear to be explained by differential socioeconomic status, reproductive characteristics or utilization of healthcare. Other factors, including social mobility and locus of reproductive control, that may contribute to these variations should be further explored.

A checklist approach to caring for women seeking pregnancy testing: effects on contraceptive knowledge and use.

OBJECTIVE: To assess how a checklist reminding clinicians to deliver a bundled intervention affects contraceptive knowledge and use 3 months after women seek walk-in pregnancy testing. METHODS: Pre-intervention, an inner-city family planning clinic provided unstructured care; during the intervention period, clinic staff used a checklist to ensure women received needed services. Women seeking walk-in pregnancy testing who wished to avoid pregnancy for at least 6 months were asked to complete surveys about their contraceptive knowledge and use immediately after and 3-months after visiting the study clinic. To assess the significance of changes over time, we used logistic regression models. RESULTS: Between January 2011 and May 2013, over 1500 women sought pregnancy testing from the study clinic; 323 completed surveys (95 pre-intervention and 228 during the intervention period). With this checklist intervention, participants were more likely to receive emergency contraception (EC) (22% vs. 5%, [aOR 4.66 (1.76-12.35)], [corrected] have an intrauterine device or implant placed at the time of their clinic visit (5% vs. 0%, p=0.02), or receive a contraceptive prescription (23% vs. 10%, p<0.001). Three months after visiting the study clinic, participants from the intervention period were more knowledgeable about intrauterine and subdermal contraception and were more likely to report at 3-month follow-up a method of contraception more effective than the method they used prior to seeking pregnancy testing from the study clinic (aOR=2.02, 95% CI=1.03-3.96). The authors would like to apologize for any inconvenience caused. [corrected]. CONCLUSIONS: Women seeking walk-in pregnancy testing appear more likely to receive EC and to have switched to a more effective form of birth control in the 3 months following their visit when clinic staff used a 3-item checklist and provided scripted counseling. IMPLICATIONS: A checklist reminding clinic staff to assess pregnancy intentions, provide scripted counseling about both emergency and highly-effective reversible contraception, and offer same-day contraceptive initiation to women seeking walk-in pregnancy testing appears to increase use of more effective contraception.

Routine counseling about intrauterine contraception for women seeking emergency contraception.

OBJECTIVE: To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an inner-city clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC. STUDY DESIGN: For 8 months before and 21 months after this change in clinic policy, women aged 15-45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n=328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data. RESULTS: Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, p<0.01; EMR: 32% vs. 68%, p<0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months. CONCLUSIONS: Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC. IMPLICATIONS: Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement.

Women's information-seeking behavior after receiving contraceptive versus noncontraceptive prescriptions.

BACKGROUND: Contraceptives are among the most commonly prescribed medications used by women of reproductive age, but little is known about women's information-seeking behavior after receiving prescriptions for medication. STUDY DESIGN: All reproductive-age women who visited one of four primary care clinics in Western Pennsylvania between October 2008 and April 2010 were invited to complete a follow-up survey after their visit which included questions regarding medications prescribed, information-seeking after their visit and their perceptions of the quality of the information they found. RESULTS: Of the 218 women prescribed contraceptives, 49% sought additional information after their visit. In models adjusted for sociodemographic and reproductive characteristics of the respondents, women who received a contraceptive prescription were twice as likely to seek additional information about their medication as women who received noncontraceptive prescriptions [odds ratio (OR)=2.06, 95% confidence interval (CI) 1.47-2.90]. Women who received a contraceptive prescription were more likely to seek information from the Internet (OR=1.84, 95% CI 1.26-2.70) and from the package insert (OR=1.55, 95% CI 1.02-2.36) than women who received noncontraceptive prescriptions. CONCLUSIONS: Women frequently sought additional information on contraceptive prescriptions. Efforts are needed to increase the quantity and improve the quality of contraceptive counseling provided by primary care providers and the quality of the information provided by package inserts and the Internet.

Cancer and contraception. Release date May 2012. SFP Guideline #20121.

As a result of advances in cancer diagnosis and treatment, young women within the reproductive-aged group are now more likely to survive cancer. Reproductive-aged women with cancer may be interested in deferring pregnancy either temporarily or permanently at cancer diagnosis, during therapy or after treatment. Currently, there are limited guidelines to aide clinicians in managing the contraceptive needs in this special population. After reviewing the evidence regarding the safety and efficacy of available methods of contraception for women who have been diagnosed with cancer, the Society of Family Planning recommends that women of childbearing age who are being treated for cancer avoid combined hormonal contraceptive methods (containing estrogen and progestin) when possible because they may further increase the risk of venous thromboembolism (VTE) (Level A). The copper T380A intrauterine device, a highly effective, reversible, long-acting, hormone-free method, should be considered the first-line contraceptive option for women with a history of breast cancer (Level A), although for women being treated with tamoxifen, the levonorgestrel-containing intrauterine system (IUS) which decreases endometrial proliferation may be preferable (Level B). Women who develop anemia may benefit from use of a progestin-containing contraceptive (Level A). Women who develop osteopenia or osteoporosis following chemotherapy should avoid the progestin-only contraceptive injection (Level B). More information is needed in many areas. There are insufficient data to evaluate the risk of VTE when progestin-only contraceptives are used by women at high risk of VTE. Information is also needed on whether the levonorgestrel-containing IUS affects the risk of breast cancer recurrence and whether hormonal contraceptives affect the risk of breast cancer among women who have received chest wall, or "mantle field," radiation. Finally, studies of the safety and effectiveness of IUS use by women who are immunosuppressed and studies of whether progestin-only contraceptives affect the risk of fracture among cancer survivors or, more generally, women with osteopenia would be useful.

Associations between recent contraceptive use and quality of life among women.

BACKGROUND: Whether contraception affects health-related quality of life (HRQoL) is unclear. STUDY DESIGN: We conducted a cross-sectional analysis of routine intake data collected from women aged 18-50 years, including the RAND-36 (Research and Development Corporation) measure of HRQoL, pregnancy intentions and recent contraceptive use. We used multivariable logistic regression to test the relationship between HRQoL and use of any and specific contraceptives. Physical and mental HRQoLs were dichotomized based on US population averages. Models were adjusted for age, race, marital status, education and pregnancy intentions. RESULTS: Among the 726 women, those using any form of contraception were more likely to have average or better mental HRQoL than women using no contraception [adjusted odds ratio (aOR)=1.60, 95% confidence interval (CI) 1.01-2.53]. Women using injectable contraception were less likely than those using combined hormonal methods to have average or better physical HRQoL (aOR=0.26, 95% CI 0.09-0.80) and mental HRQoL (aOR=0.24, 95% CI 0.06-0.86). CONCLUSIONS: Measures of women's HRQoL differ with contraceptive use.

Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration.

BACKGROUND: The objective of this study was to assess the effect of timing of postpartum levonorgestrel-releasing intrauterine device (IUD) insertion on breast-feeding continuation. STUDY DESIGN: Women interested in using a levonorgestrel IUD postpartum were randomized to immediate postplacental insertion (postplacental group) or insertion 6-8 weeks after vaginal delivery (delayed group). Duration and exclusivity of breast-feeding were assessed at 6-8 weeks, 3 months, and 6 months postpartum. Only women who received an IUD were included in this analysis. RESULTS: Breast-feeding was initiated by 32 (64%) of 50 of women receiving a postplacental IUD and 27 (58.7%) of 46 of women receiving a delayed IUD (p=.59). More women in the delayed group compared with the postplacental group continued to breast-feed at 6-8 weeks (16/46 vs. 15/50, p=.62), 3 months (13/46 vs. 7/50, p=.13), and 6 months postpartum (11/46 vs. 3/50, p=.02). The results did not differ when only women who initiated breast-feeding or only primiparous women with no prior breast-feeding experience were analyzed. CONCLUSIONS: Immediate postplacental insertion of the levonorgestrel IUD is associated with shorter duration of breast-feeding and less exclusive breast-feeding. Further studies on the effects of early initiation of progestin-only methods on women's lactation experience are needed.

Emergency contraception use and counseling after changes in United States prescription status.

Analysis of data from the 2006-2008 National Survey of Family Growth indicates that use of emergency contraception in the United States has increased after changes in its prescription status in 2006. However, clinicians continue to play a pivotal role in ensuring that women have accurate information about emergency contraception.