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- contraceptive devices
- early detection of cancer
- intrauterine devices
- long-acting reversible contraception
Transmission of coronaviruses in utero appears minimal
The effect of the novel coronavirus SARS-CoV-2 (COVID-19) on pregnant women and infants has been a source of anxiety and confusion during the pandemic, with much conflicting evidence. A systematic review and meta-analysis, which includes data from 39 trials examining several types of coronavirus and associated syndromes (COVID-19, MERS, SARS), found a mortality rate of 2.7% among mothers and one-third admitted to the intensive care unit peripartum. The review also found no evidence of vertical (in utero) transmission to babies. However, as this review pooled data from studies examining COVID-19, MERS and SARS, its findings may not be directly applicable to the COVID-19 pandemic.
Eur J Med Res 2020;25:39. https://eurjmedres.biomedcentral.com/articles/10.1186/s40001-020-00439-w
Approximately 1-in-10 PrEP users purchase antibiotics to prevent STIs
Pre-exposure and postexposure prophylaxis (PrEP and PEP) for sexually transmitted infections (STIs) is a strategy that has had limited success in clinical trials and raises concerns of antimicrobial resistance. In recent years there has been growing awareness among clinicians that some patients are self-sourcing antibiotics to prevent STIs. This epidemiological study using an electronic survey among HIV PrEP users in the UK found that 9% reported purchasing antibiotics with the intention of preventing STIs. This behaviour was not limited geographically and was associated with five or more condomless anal sex partners in the previous 6 months and chemsex use. Clinicians should ask patients using HIV PrEP about antibiotic use and discuss the risks of antimicrobial resistance with them.
Sex Transm Infect 2020; http://dx.doi.org/10.1136/sextrans-2020-054592
Testing for HR-HPV is more sensitive than liquid-based cytology for detecting CIN2 or higher in women aged >50 years
In the UK, high-risk human papilloma virus (HR-HPV) testing has been incorporated into the cervical screening programme in the last 5 years. The use of HR-HPV testing alone has been considered as it has a very high sensitivity, but there are concerns about lower specificity leading to unnecessary intervention. This large prospective cohort study in Denmark performed liquid-based cytology and HR-HPV testing in more than 4000 women and compared sensitivity and specificity of these tests alone or as each other’s triage for cervical intraepithelial neoplasia stage 2 (CIN2) or higher. It found that HR-HPV testing alone had the highest sensitivity but the lowest specificity. The study found that liquid-based cytology also detected five cancers that were HPV-negative and so ‘missed’ by HR-HPV testing. The authors recommend primary HPV testing as a triage followed by liquid-based cytology as this raised sensitivity while maintaining high specificity.
Int J Gynecol Cancer 2020;30:1678–1683. http://dx.doi.org/10.1136/ijgc-2020-001457
Levonorgestrel IUDs more likely to expel than copper IUDs when inserted immediately following vaginal birth
Postpartum intrauterine contraception (PPIUC) is an expanding field as several studies have shown its safety, efficacy and acceptability to women, including facilitating access for women who would otherwise have been unable to attend their general practitioner (GP) or sexual health centre for interval insertion. However, there have been concerns about higher expulsion rates when initiating PPIUC compared with interval insertion. This systematic review and meta-analysis identified 48 studies that collectively showed a higher risk of expulsion when PPIUC was inserted after vaginal birth compared with caesarean, and when PPIUC was inserted up to 72 hours after delivery compared with after 72 hours. Copper intrauterine devices (IUDs) were half as likely to expel than levonorgestrel IUDs overall. This information can be used to help women decide when to commence IUD use after having a baby, as many may prefer the convenience of immediate PPIUC and be willing to accept the risk of expulsion, particularly if they would be unable to access the method otherwise.
Am J Obstet Gynecol 2020;223:177–188. https://doi.org/10.1016/j.ajog.2020.02.045
Mifepristone and misoprostol combined are more effective for the treatment of missed miscarriage than misoprostol alone
In many centres, medical management of missed miscarriage typically involves only the use of misoprostol without mifepristone pretreatment. This placebo-controlled randomised trial compared misoprostol with and without mifepristone with regard to expulsion of gestation sac within 7 days of administration for women with missed miscarriage of gestations less than 14 weeks. The trial found an approximately 25% reduction in treatment failure and need for surgical intervention when mifepristone pretreatment was used. Combined treatment should become the mainstay of medical management of missed miscarriage.
Lancet 2020;396:770–778. https://doi.org/10.1016/S0140-6736(20)31788-8
Myomectomy may lead to better QoL scores than uterine artery embolisation for the treatment of uterine fibroids
Uterine fibroids can affect quality of life (QoL) for many women, leading to heavy bleeding and pressure symptoms on surrounding organs. For women wishing to avoid hysterectomy, myomectomy (removal of individual fibroids from the uterus) and uterine artery embolisation (UAE; percutaneous occlusion of arteries supplying the fibroid) are both options to consider. This unblinded randomised controlled trial recruited women to receive one of the treatments and evaluated their QoL scores using a specialised questionnaire at 2 years after treatment. Myomectomy had marginally better scores than UAE; however, confidence intervals were wide, and myomectomy was associated with a higher frequency of adverse events than UAE. Both methods should be discussed alongside other medical treatments depending on the woman’s symptom profile and fertility desires.
N Engl J Med 2020;383:440–451. https://www.nejm.org/doi/full/10.1056/NEJMoa1914735
Fertility returns rapidly after IUS discontinuation
A concern for many women using long-acting reversible contraception (LARC) is that the method may negatively affect their future fertility. This substudy of a phase 3, single-arm, open-label clinical trial of a levonorgestrel intrauterine system (IUS) in the USA evaluated conception rates in the 12 months after IUS removal. More than 85% of the women attempting to conceive did so within 12 months of IUS removal with a median time to conception of 92 days. There was no difference between nulliparous and parous women in conception rates and age did not affect conception rates (although the study only included women aged between 16 and 35 years). This information is helpful in the counselling of women who may be considering the IUS but may have received conflicting information about its effect on future fertility.
Contraception 2020; https://doi.org/10.1016/j.contraception.2020.09.005
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Commissioned; internally peer reviewed.