The Book

… there can be a disconnect between the priorities of a caring provider and the priorities of the patient.

…even with the ubiquity of STIs…most people (even health care providers) simply don’t feel comfortable discussing them. For most of us, having sex is much easier than talking about sex, especially its least pleasant consequences.

…the majority of sexual activity during the reproductive years occurs during times when patients wish to avoid pregnancy.

For individuals with chronic medical conditions, risks of pregnancy complications such as VTE, uncontrolled blood pressure, or stroke are increased.

Sex shouldn’t hurt.

Vulvodynia can affect sexual identify, relationships with partners, and quality of life.

“…if pain with sex is a reason for the choice of abstinence, it is the provider’s role to identify the source of pain and to try to resolve the symptoms.

Patients’ serious mental illnesses (SMIs) have important implications for [their] family planning.

Findings about whether adherence is improved with the ring compared with the pill are mixed.

…it’s incredibly important overall that we have different points of access as a way to protect reproductive health and rights in the current very challenging policy environment we face.

Watch the “QuickStart Guide” video on the ASCCP website at https://www.asccp.org/quickstart.

Reproductive health providers, whose focus is often on patients’ health promotion and disease prevention, are uniquely well-suited to broach holistic discussions about patients’ overall health and psychological well-being as it influences sexual and reproductive health.

You are your safest sex partner.

For many of us, the moral importance of our work is its most compelling appeal, and it helps sustain us in the face of political and economic challenges.

Although abstinence has become associated with saying “no,” viewed from another perspective, abstinence can mean saying “yes” to a number of other sexual activities and personal priorities.

Penile-vaginal intercourse is much more strongly associated with satisfying orgasm for the person with the penis than for the person with the vagina.

After having taken at least 7 COCs at the correct time, patients are at little risk for ovulation until they subsequently miss 7 consecutive pills.

Health care providers can assist our patients … by starting with a clear understanding of our role, which we propose is to help our patients figure out what they want and then help them get it.

Digital health resources have “transformed the provider-patient relationship such that HCPs are today not only responsible for providing information but also for guiding their patients’ search for and use of digital information.

Family planning providers, who are often the sole source of healthcare for reproductive-aged women, are uniquely well-suited to address interrelated mental and reproductive health needs.

While natural, sexuality is also cultural. Physiologic aspects of sexuality (for example, libido and arousal) are strongly linked with social and psychological factors.

Nearly 90% of cycling women experience some discomfort with their menses.

Technology fails people just as people fail technology…Contraceptive methods are imperfect and can fail even the most diligent user.

In younger individuals, the most common cause [of postcoital bleeding] is chlamydia cervicitis. In older individuals, benign lesions such as cervical polyps and more serious problems, such as cervical carcinoma, classically present with this type of bleeding.

Fluctuations in gonadotropins and estrogens seen during [perimenopause] are so dramatic that they have been described as “hormonal chaos.

The fact that the hypothalamus is affected by an array of neurotransmitters and other factors described above can help explain why stress, obesity, and medications can disrupt ovulatory cycling.

More than 80% of Fertility Awareness-Based methods (FABM) use in recent NSFG surveys is self-reported use of “rhythm.” So “lumped” estimates of effectiveness may not apply to individual FABMs.

The fact that the hypothalamus is affected by an array of neurotransmitters and other factors…can help explain why stress, obesity, and medications can disrupt ovulatory cycling.

Because implants and IUDs are highly effective, they are excellent choices for the short-term, too, and the fact that an implant or an IUD is good for “up to” 3 to 20 years is an added advantage but not always relevant.

Given that the increase in maternal morbidity and mortality in the United States is due in part to chronic maternal conditions, providing appropriate contraceptive care is critical.

Many of the resources listed in Contraceptive Technology represent sources that we believe will continue to be maintained by professional organizations and thus be updated to reflect the most current knowledge.

Ring use does not appear to have adverse effects on the cervico-vaginal epithelium or on cervical cytology

Once a pregnancy is visualized on ultrasound examination, then human chorionic gonadotropin hormone (hCG) testing is rarely useful.

The failure rate of every contraceptive method is lower in users over the age of 40 compared to younger individuals.

Placement of a copper IUD within 5 (or 7 or even 10) days after unprotected intercourse reduces the risk of pregnancy by more than 99%.

Overall, the full range of available contraceptive methods is appropriate for the majority of patients with depression and related conditions, including those taking SSRIs or SNRIs or using adjunct therapies.

COCs reduce the risk of ectopic pregnancy by 90%, a leading cause of maternal mortality in early pregnancy, because they substantially reduce the risk of pregnancy.

There are three national guidelines; each one says something different. All three agree that there is no evidence that the [screening pelvic exam] is beneficial. There is evidence of harms, including false alarms.

The Centers for Disease Control and Prevention’s Medical Eligibility Criteria and Selective Practice Recommendations website and mobile app … will have answers to most contraceptive questions healthcare providers might have when initiating contraceptives with their patients. These resources are also maintained regularly.

No contraceptive method is contraindicated on the basis of age alone.

Cumulatively, evidence supports the conclusion that once the implant is in place, it provides convenient, “forgettable,” ongoing pregnancy protection that is not affected by BMI.

 All patients should be offered counseling and voluntary HIV testing, and those at risk should be linked to services that provide HIV PrEP. A useful resource is the PrEP in Family Planning Tool Kit, available at https://www.hiveonline.org/prep4familyplanning/.

Although abstinence has become associated with saying “no,” viewed from another perspective, abstinence can mean saying “yes” to a number of other sexual activities and personal priorities.

As more than 75% of patients will begin their search for health information by using popular search engines such as Google, Bing, or Yahoo, they may face difficulty in parsing out the most appropriate sources for their queries.

In a review of [the] literature, IUDs were placed up to 7 days after unprotected intercourse (UPI) in three studies, up to 10 days after UPI in one study, and up to 10+ days after UPI in one study; there were 0 pregnancies.

User instructions for progestin-only pills: “If you vomit within 4 hours after taking a pill, or if you have diarrhea…Keep taking the pills on schedule, but use a back-up method until 48 hours after vomiting or diarrhea are over.

…approximately 15% of clinical recognized pregnancies end spontaneously in early pregnancy…a prospective observational trial of 30 women having spontaneous abortion found success rates for expectant management are 82.1% at 2 weeks and 100% by 30 days…as long as the woman is stable.

When we counsel patients about birth control, help patients make decisions about an unintended pregnancy, help women plan for pregnancy and safely traverse its nine months…whether or not we are aware of it, we are engaged in a critically important and deeply moral undertaking.

Women with osteopenia have twice the risk for hip fracture…and women with osteoporosis have a nearly 9-fold increased risk.

Tubal infertility per PID episode: 8% after first episode; 20% after second episode; 40% after third episode.

The difference between pregnancy rates during typical use and pregnancy rates during perfect use reveals the consequences of imperfect use; this difference depends both on how unforgiving of imperfect use a method is and on how hard it is to use that method perfectly.

Although abstinence has become associated with saying “no,” viewed from another perspective, abstinence can mean saying “yes” to a number of other sexual activities…an abstinent person does not lose his or her sexuality…

The best approach to reducing the impact of [bleeding changes associated with using contraceptive implants] is to forewarn women about it emphasizing that it is generally not dangerous.

Low levels of hCG (5 to 30 mIU) may be associated with tumors of the pancreas, ovaries, breast, and many other sites. some normal postmenopausal women also have low levels of circulating hCG-like substance of pituitary origin.

… double-blind placebo-controlled trials have shown no difference in the incidence of any of the major side effects in COC users compared to pill users; similar percentages…developed headaches, nausea, vomiting, mastalgia excessive weight gain, etc. However, some women may be more sensitive to exogenous hormones, so counsel all potential hormonal contraceptive users that side effects may be possible but not necessarily to be expected.

Milk expression, such as by hand or pump, is not a substitute for breastfeeding in terms of its fertility-inhibiting effect.

When a woman has had unprotected sex, we can offer her an intrauterine contraceptive rather than emergency contraceptive pills. Placement of the IUD within several days of unprotected sex reduces a woman’s risk of pregnancy to about 1 in 1,000 and providers her with 10 to 20 years of highly effective, fully reversible contraception…

… severe diarrhea can decrease your body’s ability to absorb the pill’s hormone. If you have vomiting or diarrhea, treat it as if you had missed pills.

Breastfeeding has a major protective effect against premenopausal cancers of the ovary, endometrium, and breast and protects against type 2 diabetes.

For some areas of clinical medicine, the why seems hardly to need articulating…The value of work as a heart disease clinician [for example] is not likely to be attacked as immoral…Unfortunately, tis is not true for clinicians working in the field of family planning services and reproductive health.

More frequently, women with [heavy menstrual bleeding] have functional problems with excessive endometrial fibrinolysis, a prostaglandin imbalance, vessel instability, or inhibition of matrix metalloproteinase activity. only about half of women with heavy menstrual bleeding have an anatomical pathology…

The conditions that cause secondary amenorrhea…also commonly cause infrequent menses. Once pregnancy is ruled out, most cases are round to be associated with estrogen production but with a lack of progesterone.

“IUC use appears safe and effective for women who are immunosuppressed due to organ transplantation, autoimmune disease, or infection with HIV. IUC use has not been shown to increase viral shedding, and clinical HIV disease progression was slower among women using the TCU380A than among women using hormonal contraception.

Ovulation can occur even though the breastfeeding mother has not yet resumed menstruation…33-45% during the first 3 months postpartum; 64-71% during months 4 through 12; 87-100% after 12 months.

…the risk of infection and infertility among IUC users is very low. …the placement process, and not the device or its thread, poses a small transient risk of infection… However, antibiotic prophylaxis should not be routinely used before placement.

…insulin resistance in women with polycystic ovarian syndrome does not predictably worsen with COC use.

Risk of death (per year). Using combined oral contraceptives (and presumably the path and ring) for nonsmokers aged 15-34: 1 in 1,667,000 / From an automobile accidents: 1 in 5,000 / From a fire: 1 in 20,000 / In an airplane crash: 1 in 250,00.

Most studies show that during vaginal sex, condoms break approximately 2 percent of the time during intercourse or withdrawal and a similar proportion slip off completely…advise users to have several condoms available in case a condom is torn or put on incorrectly…

The risk of VTE [venous thromboembolism] with COCs [and other hormonal contraceptives] is greatest in the first 3 to 12 months of use and declines thereafter.

COC use increases bone mineral density (BMD) in … anorexic teenagers. COC use by women with osteopenia due to anorexia nervosa is not sufficient to completely protect bone, but when added to anabolic agents such as insulin growth factor, COC use significantly improves that agent’s effectiveness.

Preventing pregnancy is generally safer than pregnancy. Compare the risk of death associated with using combined hormonal contraceptives with the risk of death associated with pregnancy:

• Pregnancy: 1 in 6,700
• Nonsmokers: the risk for women aged 15-34 is 1 in 1,667,000 and for women aged 35-44 it is 1 in 33,000.

Smokers: the risk for women aged 15-34 is 1 in 57,800 and for women aged 35-44 it is 1 in 5,200.

Women using ACE inhibitors, angiotensin-II antagonists, potassium-sparing diuretics, heparin, aldosterone antagonists, and NSAIDS on a chronic daily basis to treat chronic conditions or diseases should have their serum potassium checked during the first cycle of drospirenone use (usually about 14 days after pill initiation). If those levels are normal, no future testing is necessary.

In a study of high-school students who consider themselves virgins, 30% had engaged in heterosexual masturbation of or by a partner, 9% had engaged in fellatio (oral-penile contact) with ejaculation, and 10% had engaged in cunnilingus (oral-female genital contact).

Women with continued spotting or bleeding following their scheduled bleeding may need more estrogen to proliferate the endometrium. Increase the estrogen to proliferate the endometrium. increase the estrogen in the first pills in the pack or decrease the progestin content of those first pills.

…probabilities of pregnancy cumulate over time. For example, suppose that each year the typical proportion of women becoming pregnant while taking the pill is 8%…Within 5 years [of pill use], 34%…will become pregnant.

In terms of contraceptive service delivery, routine adherence to the 6-week convention does not seem appropriate…Although nearly all contraceptive methods can be used postpartum, the methods vary in terms of when in postpartum period they should be initiated. 6 weeks is too late to begin contraceptive for nonbreastfeeding mothers who wish to start using [hormonal methods]; 3 weeks is too soon for inserting an IUC…

Unintended pregnancy/coital act: 17%-30% midcycle, <1% during menses.

Among nonmarried women, 32% reported they had not had sex in the past year, 25% reported only a few times in the past year, 26% reported a few times in the past month, and 26% reported two or more times per week.

Most women wish to discuss sexual concerns but report that most providers neither inquire about nor follow up on sexual issues…

While there is considerable variation in cycle length, less than 1% of women have a regular cycle length of less than 21 days or more than 35 days.

Leiomyoma (uterine fibroids) contain both estrogen and progesterone receptors…However, clinical studies with low-dose COCs have found no impact on the risk of developing new fibroids or on increasing the size of pre-existing fibroids, except in women who used COCs early in life.

While chronic daily use of some drugs may increase serum potassium in some women using drospirenone-containing contraceptive pills, note that intermittent use of NSAIDS does not pose any problems. If a woman is using other potassium-sparing drugs, test her potassium about 14 days after starting her first pack; if that value is normal, no further testing is needed for potassium.

The typical woman who uses reversible methods of contraception continuously from age 15 to age 45 would experience 1.8 contraceptive failures.

The protective effect of transabdominal tubal sterilization on ovarian cancer persists over many years…The risk remained low up to 25 years after surgery and was irrespective of sterilization technique.

What about new contraceptives for men? Except for gossypol, no method has been developed sufficiently for clinical studies.

…we need to convey not only the science of reproductive health, but also why it is of vital importance in people’s lives…If we fail to do so, we are abdicating the moral high ground to those who oppose efforts to provide reproductive health care.

IUCs [intrauterine contraceptives] protect women from ectopic pregnancy…However when a woman does conceive with an IUC in place she is at increased risk of having an ectopic pregnancy…6% to 50% of pregnancies are ectopic.

…antibiotic prophylaxis should not be routinely used before placement [of an intrauterine device].

Spermatozoa appear in the pre-ejaculatory fluid of some men and could cause pregnancy even if the man withdraws prior to ejaculation.

…a women’s blood loss is excessive when she says it is excessive…the key factor in making a diagnosis of [heavy menstrual bleeding] is not the amount of blood a woman loses, which is difficult to ascertain, but how a woman’s HMB disrupts her life.

“Reproductive health care enables individuals and couples to make and implement some of the most important decisions that shape their lives, and that also shape society.”