Background The Centers for Disease Control’s U.S. Medical Eligibility Criteria for Contraceptive Use recommends that combined hormonal contraceptives (i.e., birth control pills, contraceptive patch, vaginal ring) should be avoided in women with specific medical conditions due to increased risk of cardiovascular events associated with estrogen use. Whether women with category 3 (theoretical or proven risk usually outweigh the advantages) or category 4 (unacceptable health risk) contraindications are appropriately avoiding estrogen-containing combined hormonal contraceptives is unknown. Objective We describe the prevalence of combined hormonal contraceptive use among a sample of reproductive age women with medical contraindications to estrogen use. Our hypothesis was that women with category 3 and 4 contraindications would use estrogen-containing contraception less often than women without medical contraindications. We also explore whether inappropriate estrogen-containing contraceptive use is related to contraceptive provider characteristics. Study Design Data are from the baseline survey of the MyNewOptions study, which included privately-insured women residing in Pennsylvania aged 18–40, who were sexually active and not intending pregnancy in the next year. Women were surveyed about their medical conditions, contraceptive use, and characteristics of their contraceptive provider. Women were considered to have a contraindication to combined hormonal contraceptives if they reported a category 3 or category 4 contraindication—hypertension, smokers over age 35, history of venous thromboembolism, diabetes with complications, coronary artery disease, systemic lupus erythematosus with antiphospholipid antibodies, breast cancer, or migraine headaches with aura. Chi-square tests for general association were used to compare combined hormonal contraceptives use, contraceptive health provider characteristics, and sociodemographic data in women with and without contraindications to estrogen use. Results The MyNewOptions baseline study sample included 987 adult women who were mostly young (46% were 18–25 years), white (94%), employed (70%), and married or cohabiting (54%). Thirteen percent (n=130) of the sample had a medical contraindication to estrogen-containing contraceptive use—migraine with aura (81%) was the most common contraindication, followed by smokers over age 35 (7%), hypertension (11%), history of venous thromboembolism (4%), and diabetes with complications (2%). High use of combined hormonal contraceptives was reported among the women with medical contraindications to estrogen at 39% (n=51). This was not statistically different from women without a medical contraindication (47%, p=0.1). Among the 130 women with a contraindication, whether they did or did not use an estrogen-containing contraceptive did not vary by education level, income, or weight category. With respect to their contraceptive prescribers, there were no differences in prescriber specialty, provider type, or clinic type comparing women us...
(Abstracted from J Minim Invasive Gynecol 2019;26:71–77) The primary sequelae of endometriosis are infertility and chronic pelvic pain (CPP). Nearly 40% of women with endometriosis are infertile, and 71% to 87% have CPP.
Chronic pelvic pain is a complex condition with peripheral and central mechanisms of pain. Successful nonsurgical management typically relies on a multimodal approach, with integration of both pharmacologic and nonpharmacologic interventions. This article reviews nonpharmacologic therapies including pelvic floor physical therapy, dietary modifications, psychotherapy, and acupuncture. These interventions are low risk and should be incorporated into treatment for chronic pelvic pain, as they show promise for successful symptom relief in many overlapping chronic pain conditions. Common nonopioid medications for pelvic are also reviewed, including analgesics, hormone modulating agents, antidepressants, and anticonvulsants. Guidelines for cautious and responsible opioid use are also summarized. While data specific to chronic pelvic pain management remain limited, evidence supporting treatment of other chronic pain conditions is reviewed to help guide management.
Women with high self-efficacy for contraception had an increased use of prescription contraceptive methods compared with nonprescription methods. Strategies for encouraging effective contraceptive choices in women with low contraceptive self-efficacy should be further studied.
Objective To compare the operative time between robot-assisted laparoscopic hysterectomies and standard laparoscopic hysterectomies. Methods A prospective, randomized controlled trial enrolled women aged 18–80 years attending Penn State Hershey Medical Center between April 23 and October 20, 2014 to undergo hysterectomy. Participants were randomized using a random number generator to undergo either robot-assisted or standard laparoscopic hysterectomy. The primary outcome was the total operative time (surgeon incision to surgeon stop, including robot docking time, if applicable). Intention-to-treat analyses were performed and the operative time was compared between the two treatments for non-inferiority, defined as a difference in operative time of no longer than 15 minutes. Results There were 72 patients randomized to each treatment arm. The mean operative time was 73.9 minutes (median 67.0 minutes; interquartile range 59.0–83.0 minutes) in the robot-assisted hysterectomy group and 74.9 minutes (median 65.5 minutes; interquartile range 57.0–90.5 minutes) in the standard laparoscopic hysterectomy group. The upper bound of the 95% confidence interval of the difference in operative time was 6.6 minutes, below the 15-minute measure of non-inferiority. Conclusion When performed by a surgeon experienced in both techniques, the operative time for robot-assisted laparoscopic hysterectomy was non-inferior to that achieved with standard laparoscopic hysterectomy.
Purpose of review To review the current literature on the diagnosis and management of cesarean scar pregnancies Recent findings The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or ‘on the scar’ from those that are exogenic or ‘in the niche’. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required. Summary Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.
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