Approximately half (51%) of the 6.6 million pregnancies in the US each year are unintended and half of those pregnancies (54%) occur among women not using contraception. Many women discontinue their contraceptives due to method dissatisfaction. Bothersome unscheduled bleeding is one of the main reasons cited by women for stopping a birth control method. Improving counseling and management of these side effects will aide in increasing satisfaction with contraceptive methods. The following review will discuss the bleeding profiles associated with the contraceptive options available in the US. A valuable resource from the Centers for Disease Control and Prevention, the US Selected Practice Recommendations for Contraceptive Use, will be introduced. Definitions of the types of unscheduled bleeding are included, as well as strategies for treatment for each contraceptive method. The evidence whether or not anticipatory counseling increases continuation rates will also be reviewed.
The United States maternal mortality rate has been rising for many years putting the US out of step with peer countries. There are many complex reasons for the rise in maternal deaths and recent data has demonstrated that there is a disproportionate risk for women of color. This article provides an overview of current policy and policy issues aimed at improving the maternal mortality rate in the United States.
Disclaimer: Dr Dhruva is a member of the Teachable Moments editorial team and Dr Redberg is the Editor for JAMA Internal Medicine, but they were not involved in any of the decisions regarding review of the manuscript or its acceptance.
To fully understand the landscape of access to sexual and reproductive health care services in the United States, the context in which religiosity is associated with the delivery of health care must be understood. Drake et al 1 provide data on the geographic concentration of Catholic health care systems through the proportionate market share of Catholic hospitals in each county in the United States and the role that health insurance plays in driving access to Catholic and non-Catholic hospital networks within markets.
OBJECTIVE: To evaluate the effects of buffered lidocaine on pain scores during vulvar biopsy. METHODS: We conducted a double-blind, randomized controlled trial, using prefilled, sequentially numbered, randomized syringes to infiltrate either 3 mL of buffered or nonbuffered lidocaine before vulvar biopsy. The primary outcome was a pain score marked on a 100-mm visual analog scale during infiltration. Secondary outcomes included pain scores after the procedure and change from baseline to infiltration. Participants were recruited to detect a clinically meaningful 15-mm difference in pain scores between groups. Sample size was calculated based on the null hypothesis that the mean pain score would be the same in women treated with buffered lidocaine as in those treated with nonbuffered placebo based on prior studies. Categorical data were compared by Fisher exact test, and continuous data were compared between groups by t-test or Wilcoxon rank sum test. RESULTS: From July 2015 to April 2018, 129 participants were randomized to one of two groups: nonbuffered lidocaine or buffered lidocaine. One hundred twenty-five were analyzed (nonbuffered n=62, buffered n=63). Four patients were excluded. The majority of participants were non-Hispanic white women with a mean age of 59 years. There was no difference in the primary outcome of pain during infiltration with a mean pain score of 35.8 mm in the buffered lidocaine group compared with 42.2 in the nonbuffered lidocaine group (mean difference −6.4; 95% CI −18.4 to 5.6; P=.3 by Wilcoxon rank sum test). There was also no difference in secondary outcomes of pain over the entire procedure (mean difference −0.3, 95% CI −9.7 to 9.2; P=.7) or change in pain from baseline to infiltration (mean difference −6.9, 95% CI −18.4 to 4.7; P=.2). CONCLUSION: There was no difference in pain scores during vulvar biopsy infiltration between the buffered and nonbuffered lidocaine groups. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02698527.
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