BMJ Sexual & Reproductive Health最新文献

Objectives: This systematic review aimed to update a 2016 review and answer two questions: (1) Among breastfeeding women, does the use of progestogen-only contraception (POC) (ie, pills, injectables, implants, hormonal intrauterine devices) increase the risk of poor breastfeeding or infant outcomes compared with those not using POC? (2) Among breastfeeding women, does the initiation of POC before 6 weeks postpartum increase the risk of poor breastfeeding or infant outcomes compared with the initiation of POC at 6 weeks or later?

Methods: We searched multiple databases (MEDLINE, EMBASE, Cochrane, ClinicalTrials.gov and CINAHL) from inception to 6 September 2023. We extracted data and assessed risk of bias (RoB) for each study and certainty of evidence for each outcome.

Results: Sixty-one articles met the inclusion criteria; 11 were newly identified since the previous review, most with high RoB. Nine new randomised and non-randomised studies assessing breastfeeding and/or infant outcomes met the inclusion criteria for Question 1. Two new randomised studies assessing breastfeeding and/or infant outcomes met the inclusion criteria for Question 2, examining early versus late initiation of the implant. One new article for each objective included preterm infants. For both questions, studies continue to find no significant adverse effects on breastfeeding (eg, continuation, supplementation, duration) or infant (eg, growth, illness) outcomes. The certainty of evidence ranged from very low to moderate across outcomes.

Conclusions: This updated systematic review provides additional evidence for the safety of POC use during breastfeeding. Newly identified studies are consistent with the prior review in suggesting no consistent findings of adverse effects, while adding evidence for preterm infants.

Objective: To systematically review the evidence on the effectiveness of non-pharmacologic techniques for interval intrauterine device (IUD) placement.

Methods: We searched various databases from database inception to 15 December 2023 for randomised controlled trials (RCTs) examining non-pharmacologic techniques for IUD placement compared with placebo or pharmacologic techniques. Outcomes of interest were pain experienced with IUD placement, provider ease of placement, need for adjunctive placement measures, placement success, patient satisfaction, side effects and adverse events. We extracted data from included articles, assessed risk of bias, and determined certainty of evidence for all outcomes.

Results: Eleven RCTs met the inclusion criteria, examining 10 different non-pharmacologic techniques. The risk of bias was high in 10 trials and low in 1 trial. Of 11 RCTs that examined patient pain, two found reduced pain with the Valsalva breathing technique (where women inhaled deeply and held their breath during IUD placement), without tenaculum placement compared with routine care (i.e., use of a tenaculum) (OR 0.04; 95% CI 0.01 to 0.15) or acupuncture compared with routine care (mean difference -1.88; 95% CI -2.72 to -1.04). None of the four trials that assessed ease of IUD placement found differences between study groups. Across nine RCTs, most had high rates of placement success. One study each examined need for cervical dilation and patient satisfaction; the findings were similar between study groups. Overall, few side effects and no adverse events were reported across the studies.

Conclusions: Non-pharmacologic techniques like the Valsalva manoeuvre and acupuncture may reduce patient pain with IUD placement (certainty of evidence ranging from moderate to low). However, evidence is limited, and more high-quality trials with larger sample sizes are needed.

Prospero registration number: CRD42024507788.

Background: Emergency contraception refers to contraceptive methods used following unprotected sexual intercourse.

Objective: To review the literature on safety of repeated use of emergency contraceptive pills (ECPs) in the same menstrual cycle.

Methods: We searched multiple databases from inception through February 2024 for articles on repeated ECP use. We assessed the risk of bias for each study and certainty of evidence for all outcomes.

Results: From 4565 articles identified, six met the inclusion criteria. Four studies of repeated levonorgestrel (LNG)-ECP use provided very low certainty evidence. Among women who became pregnant after at least one use of LNG-ECP in the conception cycle, women with ectopic pregnancy had increased odds of repeated LNG-ECP use in the conception cycle compared with women with intrauterine pregnancy (adjusted OR (aOR) 2.5, 95% CI 1.0 to 6.2). One non-comparative study reported few serious adverse events with repeated pericoital use of LNG-ECP, and two cohort studies of LNG-ECP failure found no differences in pregnancy, fetal/neonatal, infant or child outcomes comparing higher (2.25-9 mg LNG) and lower (0.75-1.5 mg LNG) doses in the conception cycle. Two studies of repeated ulipristal acetate (UPA) use provided very low certainty evidence. One non-comparative study observed no serious adverse events, no abnormal laboratory results and normal endometrial biopsies with UPA (30 mg, 4-6 doses/month). One randomised controlled trial in a clinical setting observed no serious adverse events with UPA (10 mg, 20 mg or 50 mg for 10 days) compared with placebo.

Conclusion: Evidence on the safety of repeated ECP use is limited and of very low certainty, but overall does not suggest safety concerns.

Background: This narrative review examines the time to return to fertility after discontinuation of subcutaneous depot medroxyprogesterone acetate (DMPA SC) 104 mg among women of reproductive age.

Methods: The review was conducted using multiple data sources including PubMed, CINAHL, Web of Science, The Cochrane Library, Google Scholar, Ovid Medline, EMBASE, POPLINE, Global Health/EBSCO, Scopus, WHO Global Index Medicus, International Clinical Trials Registry Platform (ICTRP), Global Index Medicus - WHO, African Index Medicus (AIM), ScienceDirect, Public Library of Science (PLOS), BioMed Central, Dryad and JSTOR. Search terms included DMPA, SC-DMPA, depot medroxyprogesterone acetate, ovulation, pregnancy, Depo Provera, return to ovulation, fertility, return to fertility, subcutaneous and SubQ. We included studies that used the standard and not experimental dosing of DMPA SC.

Results: Four of the 31 articles met the inclusion criteria. The trials compared DMPA SC 104 mg with intramuscular DMPA (DMPA IM) at various dosages and routes. Follow-up varied from 7.5 to 18 months after the last injection. Median time to ovulation for DMPA SC was 212 days and was not statistically significantly different from DMPA IM 150 mg (183 days). There were no differences in time to ovulation by region, body mass index or age. No studies reported on time to pregnancy, effect of duration or frequency of dosing.

Conclusions: Median time to ovulation for DMPA SC 104 mg of 212 days was similar to that of DMPA IM 150 mg of 183 days, suggesting that choice of formulation (SC vs IM) does not impact the timeline for return to fertility.

Objectives: To update a 2016 review and answer three questions: (1) Among women using an intrauterine device (IUD), does breastfeeding increase the risk of adverse events? (2) Among breastfeeding women, does IUD use increase the risk of adverse events? (3) Among breastfeeding women, does copper (Cu)-IUD use increase risk of adverse breastfeeding or infant outcomes?

Methods: We searched multiple databases from inception to August 2023. We extracted prespecified data and assessed risk of bias (RoB) for each article and certainty of evidence for each outcome.

Results: Thirty-eight articles met the inclusion criteria; 16 were newly identified since the previous review, most with high RoB. Evidence suggested no effect of breastfeeding on IUD-related adverse events (ie, expulsion, bleeding, pain and infection) compared with not breastfeeding; however, an increased relative risk of perforation was observed with breastfeeding at the time of IUD insertion compared with not breastfeeding. For perforation, relative measures of association ranged from 1.4 to 10.1, and absolute rates varied (eg, 0.6-7% or 6.8 per 1000). Evidence suggested no effect of IUD use on risk of adverse events (ie, bleeding, pain and infection) among breastfeeding women compared with no IUD use. Evidence suggested no effect of Cu-IUD use on breastfeeding or infant outcomes among breastfeeding women compared with no Cu-IUD use.

Conclusions: We continued to find an increased relative risk of IUD perforation among breastfeeding women compared with no breastfeeding; however, the absolute risk is low. No other adverse effects with IUD use and breastfeeding were observed. The certainty of evidence for all outcomes was very low.

Background: Clinical diagnosis of heavy menstrual bleeding (HMB) is dependent on patient report of menstrual product usage of pads and tampons, but it is unknown if newer reusable menstrual products (cup and underwear) are similarly diagnostic.

Methods: We enrolled 20 regularly menstruating individuals with HMB for two menstrual cycles. Participants completed a retrospective baseline Pictorial Blood loss Assessment Chart (PBAC) at the time of enrolment (eligibility PBAC score ≥100) as well as several different measures with each study cycle. In cycle 1, participants used study-provided disposable pads and tampons. For cycle 2, participants were randomised to menstrual cup or underwear and collected their menstrual fluid on their heaviest 2 days. We compared the two cycles with respect to the weight of menstrual fluid collected and the frequency of product changes and leaks during the heaviest days in cycles 1 and 2, as well as questionnaire responses.

Results: Overall, the mean rate of product changes per heaviest day were 5.5 disposable product changes (range 1.5-11), 3.6 cup changes (range 1.3-6.2), and 3.5 underwear changes (range 2.7-6.9). Both groups (cup users and underwear users) reported a median 3.5 leaks (range 1-5) per heaviest day in cycle 2, while using the menstrual cup or underwear.

Discussion: Participants reported fewer daily changes of reusable products compared with disposable ones, but more leaks, suggesting that 'rate of product change' with reusable products may result in missed diagnoses of HMB.