Archive for the ‘Research & Studies’ Category

February 14, 2014

New Study Raises More Questions About the Value of Mammograms

This chart, published in British Medical Journal, shows that the breast cancer mortality of patients who underwent mammogram screening vs. those who did not is practically equal.

new, long-term study in BMJ provides perhaps the most compelling argument to date that screening mammograms may not be effective in reducing the death rate from cancer and may in fact cause harm from overtreatment in some women.

The study is based on results from the Canadian National Breast Screening Study. For this research, 89,835 women ages 40 to 59 were randomly assigned to receive either annual mammograms for five years, or no mammograms during the study period. All of the women received breast exams by trained nurses. The women were followed for up to 25 years to see which of them died of breast cancer.

Based on the data, the authors report that there was no difference between those who had screening mammography and those who didn’t in terms of their likelihood of dying from breast cancer. The authors conclude:

Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available. Overall, 22% (106/484) of screen detected invasive breast cancers were over-diagnosed, representing one over-diagnosed breast cancer for every 424 women who received mammography screening in the trial.

Put simply, this means that one in five cancers do not pose a deadly threat, yet these women may still undergo treatment, including surgery, chemotherapy and radiation.

A New York Times article this week summarizes the research, and provides some commentary from doctors. Among them, Dr. Russell P. Harris, a screening expert and professor of medicine at the University of North Carolina, Chapel Hill, commented that the results “will make women uncomfortable, and they should be uncomfortable.”

“The decision to have a mammogram,” he added, “should not be a slam dunk.”

New York Times reporter Gina Kolata explains that the number of cancers treated unnecessarily would be even higher if a precancerous condition had been included in the study:

Many cancers, researchers now recognize, grow slowly, or not at all, and do not require treatment. Some cancers even shrink or disappear on their own. But once cancer is detected, it is impossible to know if it is dangerous, so doctors treat them all.

If the researchers also included a precancerous condition called ductal carcinoma in situ, the overdiagnosis rate would be closer to one in three cancers, said Dr. Anthony B. Miller of the University of Toronto, the lead author of the paper. Ductal carcinoma in situ, or D.C.I.S., is found only with mammography, is confined to the milk duct and may or may not break out into the breast. But it is usually treated with surgery, including mastectomy, or removal of the breast.

These findings are unlikely to result in any immediate change in what doctors recommend to women, and are likely to cause controversy among experts.

An accompanying editorial in BMJ, “Too Much Mammography,” explains the strengths and limitations of the study, and notes that it is difficult to make changes around screening mammography practices “because governments, research funders, scientists, and medical practitioners may have vested interests in continuing activities that are well established.”

Indeed, the American College of Radiology — which represents radiologists who perform and interpret mammograms — has issued a statement criticizing the study. This organization also objected to the 2009 recommendations on routine mammography, put forth by the U.S. Preventive Services Task Force, which we discussed here.

The National Partnership for Women and Families also provides a summary of the research, and Breast Cancer Action has issued a response as well, noting that the findings may not apply equally to all women:

The information that we have seen from this study does not let us draw conclusions for specific communities, many of which are most affected by higher morbidity rates. Given the unequal burden that women of color bear when it comes to breast cancer morbidity and mortality, questions remain as to whether there are different findings for difference communities. Absent this evidence, there are no clear answers for women of color. The growing body of evidence, of which this study is part, continues challenge long-standing and commonplace assertions that mammograms are a driving factor in reducing death rates.

What this research makes clear, however, is that we need more effective methods for detecting breast cancer, and new ways of determining which cancers need treatment.

Previous posts on the evidence about mammograms include:


February 7, 2014

U.S. Abortion Rate Drops, But What Do the Numbers Mean?

The U.S. abortion rate has declined to its lowest levels in four decades, according to a new report from the Guttmacher Institute.

As of 2011, the rate had declined to 16.9 abortions per 1,000 women aged 15–44, almost half of what it was in 1981 (29.3 per 1,000 women) and the lowest since 1973 (16.3 per 1,000).

While the record number of abortion restrictions passed in 2011 may come to mind as a possible cause, the data used largely predate those restrictions.

The Guttmacher report also notes that even states that did not implement new restrictions during the study period also saw declines:

It is crucial to note that abortion rates decreased by larger-than-average amounts in several states that did not implement any new restrictions between 2008 and 2010, such as Illinois (18%) and Oregon (15%). So, even in states like Louisiana and Missouri, we cannot assume that the new restrictions were responsible for the decline in abortion incidence.

More plausible explanations, according to the report, might be the increase in long-acting, highly effective methods of contraception such as IUDs; increasing use of birth control among young women in general; and overall declines in the pregnancy and birth rate.

This doesn’t mean, however, that the surge of restrictions enacted over the past several years will not have a negative impact on women’s access to abortions — it just doesn’t show yet in the data.

Judy Norsigian, Our Bodies Ourselves executive director, had this to say about the numbers:

At this point, it is misleading to suggest that restrictions don’t make a difference.  The restrictions that we are seeing now, after this study was done, are of an entirely different order, because they are causing a dramatic rise in the closing of clinics. Just look at the crisis in Texas now. We know that abortion providers in Texas and other impacted states will continue to do their best to meet the needs of the most vulnerable women who can’t afford to travel to places where abortion services are available, but these providers will face huge obstacles.

It is also important to recognize that although there may be a reduction in the abortion rate overall, the rate rose nearly 18 percent among the country’s poorest women — a trend that might reflect the growing economic challenges facing women now. Of the more than 1.2 million legal abortions reported in 2008, women whose family income fell below the national poverty level accounted for 42 percent of these abortions.

For further exploration of Guttmacher’s results and the reasons behind the numbers, see:


February 5, 2014

Does Viewing an Ultrasound Deter Women from Having an Abortion?

ultrasound viewing study

Source: Relationship Between Ultrasound Viewing and Proceeding to Abortion / Obstetrics & Gynecology January 2014

We all know what forcing women to undergo and view ultrasounds prior to an abortion is supposed to do — influence women to carry their pregnancies to term.

That’s why crisis pregnancy centers, which operate with an anti-abortion agenda, offer ultrasounds even though most are not equipped to provide medical services, and anti-abortion mobile buses park near schools and offer free ultrasounds to pregnant women.

But does viewing an ultrasound really deter women from choosing abortion?

According to research findings, bolstered by a new study, the answer is probably no.

Researchers from University of California, San Francisco and Planned Parenthood looked at data for more than 15,000 women seeking abortions at a Los Angeles Planned Parenthood clinic in 2011. All patients underwent a pre-procedure ultrasound, which can be standard in abortion care, and all were offered the opportunity to view the ultrasound screen. (Mandating that women undergo an ultrasound, view it, and listen to a description of the fetus is a whole other issue.)

Less than half, 6,346 women, chose to view it. Almost all of them, regardless of their viewing choice, went on to have abortions (98.8 percent).

Researchers also considered how certain the women felt about their decisions to have an abortion. Women who were highly certain about their decision did not waver, regardless of whether they viewed the ultrasound.

As might be expected, women who were were less certain of their decision to abort the pregnancy and who viewed the ultrasound were slightly less likely to have an abortion than like-minded women who did not view it (95.2 percent of those who viewed it continued with the abortion compared with 97.5 percent of those who did not).

Other factors, such as gestational age, weighed more heavily on the decision. Women who were 17 to 19 weeks pregnant, for example, were almost 20 times more likely to continue the pregnancy than women up to nine weeks pregnant, regardless of whether or not they viewed the ultrasound. The authors suggest that this may have to do with women’s feelings about terminating a pregnancy earlier vs. later.

The authors caution that their findings may be different from situations in which the ultrasound is forced, but they conclude that mandatory viewing should be avoided:

Finally, these results cannot be generalized to women’s experience of ultrasound viewing in settings where it is mandatory, although given the very high percentage of women proceeding with abortion after viewing the ultrasound image, it is unlikely that mandatory viewing would substantially affect the number of abortions performed. It may, however, affect patient satisfaction and health outcomes, which research shows are enhanced when patients feel control over decisions related to their care. Mandating that women view their ultrasound images may have negative psychological and physical effects even on women who wish to view.

The clinical implications of this study are twofold. First, women should be offered the opportunity to voluntarily view their ultrasound images before abortion. However, because fewer than half of women select this option, mandatory viewing should be avoided. Second, health care providers engaged in ultrasound viewing should be sensitive to how patients react to their images but avoid making assumptions about the effect of viewing on patient decision-making. Patients with low decisional certainty about the abortion decision may need more time and support in reaching a decision about whether abortion is the correct decision for them.

For more on the use of ultrasounds in the context of abortion, read this excellent commentary by Tracy Weitz, one of the study’s authors and director of the Advancing New Standards in Reproductive Health (ANSIRH) at UCSF (and a contributor to “Our Bodies, Ourselves”). Written last March, during the height of political battles around mandating transvaginal ultrasounds, Weitz takes a closer look at the weak rationale for anti-abortion activists thinking that ultrasound viewing would reduce the number of abortions.

To date, she notes, “no peer-reviewed empirical data has supported this proposition that viewing an ultrasound image discourages women from abortion. In fact, what limited information does exist suggests that women seeking abortions have a range of experiences associated with viewing their ultrasound and any mind-changing occurs in a complex context that may or may not include ultrasound viewing along with other factors.”

Conversations about mandatory ultrasound, Weitz argues, should be focused on how these laws drive up costs, make providing abortion care more difficult, do not improve health outcomes, and eliminate patient autonomy.

To learn more about situations and states in which ultrasounds are regulated in the context of abortion, view this fact sheet from Guttmacher Institute. Currently, three states mandate that an abortion provider perform an ultrasound and show and describe the image; eight states mandate the ultrasound and require the provider to offer the patient the opportunity to view the image.


January 17, 2014

The Real Danger of the NuvaRing

If you read the recent Vanity Fair article about NuvaRing contraception, “Danger in the Ring,” you could be excused for coming away with the conclusion that NuvaRing is deadly and should be yanked off the market immediately.

But hold on.

NuvaRing, a hormonal birth control that is inserted into the vagina, contains estrogen and etonogestrel, a form of progestin that’s different from what’s in the most common low-dose combined birth control pills. As the Vanity Fair article describes, it is also the subject of ongoing lawsuits about dangerous blood clots.

Marie Brenner’s article focuses heavily those lawsuits alleging harms from the device. What it doesn’t do is put the risk of harms from NuvaRing in the context of other hormonal birth control options, or discuss real magnitude of risk of any of these options.

All hormonal birth control with estrogen carries some risk of blood clots. These are referred to as venous thromboembolism, or VTE, and can be fatal. The risks of the most common combined oral contraceptives are quite small.

The latest FDA safety announcement (2012) estimates that for every 10,000 women taking birth control pills over the course of one year, between three and nine cases of blood clots may occur. In fact, the risks are thought to be higher during pregnancy (five to 20 cases per year for every 10,000 women), and much higher right after birth. By comparison, among non-pregnant women who do not take birth control pills, the number of cases per year ranges from one to five.

Some types of birth control, such as the newer types of pills (like Yasmin and Yaz) containing the progestin drospirenone, are thought to cause a greater risk. These pills have come under more scrutiny in Europe and the United States, with Europe taking a more active role in reviewing the risks. Some women’s health advocates, including Our Bodies Ourselves, have questioned allowing these newer pills to remain on the market because they pose a greater clot risk without offering any major benefits over older types of pills.

The factors to consider when weighing the risks and benefits of NuvaRing or other non-pill alternatives may be different, however, because non-pill alternatives offer more convenience and less chance of missing a dose.

Part of the problem in determining what’s “best” for any individual is the lack of clarity surrounding the increased risk that comes with using NuvaRing. Indeed, different studies have yielded different results: A BMJ study included in the Vanity Fair article found about a 90 percent increase in risk; a FDA paper reports a 56 percent increased risk; other studies have reported “similar” rates of venous thromboembolism between the ring and the regular oral contraceptives.

Looking at the BMJ study, which seems most alarming, lets consider the actual numbers. The researchers explain a 90 percent increased risk would result in 7.8 incidents of VTE per 10,000 exposure years. That means, for example, if 1,000 women each used NuvaRing for 10 years, there would be about 8 incidents of VTE among them in that decade (1,000 women x 10 years = 10,000 exposure years).

So, while different methods of hormonal birth control carry different levels of risk, in general hormonal birth control is very safe for most women. Of great concern, however, is that women aren’t given this information to help in their decision-making.

recent article in Huffington Post describes the FDA approval process for NuvaRing and alleges that Organon — the company that made NuvaRing, which pharmaceutical giant Merck now owns —  maneuvered to keep clot risk information off the product label. To date, the NuvaRing label does not feature the same “black box warning” that the birth control patch carries, which notes a higher risk than the pill. Instead, the NuvaRing product label simply notes that smokers who use the ring may have “serious cardiovascular events.” The NuvaRing website does include some information on comparing the risk to combined oral contraceptives, but the FDA-approved label does not make this as clear by not including it in the black box warning that carries the most important safety information.

Cindy Pearson, executive director of the National Women’s Health Network, and a strong advocate for close review of drug safety, has responded to the concerns:

The most heartbreaking part of the Vanity Fair article are the accounts of women who never knew that the contraceptive ring was delivered a higher dose of hormones and is slightly more risky than pills. No clinician should offer women these products without fully disclosing the risks, and encouraging women to try alternative, safer forms of contraception if they haven’t already done so.

Agreed. While the risk to an individual woman may be low with any of these birth control methods, women must be informed that newer options — including the ring, the patch, and the newer pills — may be more risky than older-style combined oral contraceptives.

In addition, health care providers need to stay on top of the evidence, and should make a point of discussing the benefits and the risks. All women should have the information they need to make good choices for their own health.

Related: Hormonal Contraception and Heart Risks


January 8, 2014

False Alarms Remain a Huge Problem with Mammograms Used for Breast Cancer Screening

Breast cancer detection has become a more controversial subject over the past several years, with routine screening mammograms — the kind many women are encouraged to undergo starting in their 40s — drawing more scrutiny.

More and more, researchers and clinicians are acknowledging that screening mammography has a high rate of false alarms, causing worry along with sometimes unnecessary treatment.

annual mammogram benefit harm tradeoff chartH. Gilbert Welch, a professor at the Dartmouth Institute for Health Policy and Clinical Practice, recently wrote an excellent New York Times op-ed exploring the difficult science around breast cancer screening. Explaining the findings of a study on the benefits and harms of screening mammography that he and Honor J. Passow, also of the Dartmouth Institute, published last month in JAMA Internal Medicine, Welch asks how much overdiagnosis we’re willing to tolerate compared to the possibility of reducing deaths from breast cancer.

Using data from radiologists who perform mammograms, Welch and Passow concluded that among 1,000 40-year-old American women screened annually over the course of a decade, between 0.1 and 1.6 women will avoid dying from breast cancer. (See chart at left; click to view full size.) A staggeringly high number — between 510 and 690 women — will have at least one false alarm (60-80 of whom will undergo a biopsy), and up to 11 women will be overdiagnosed and treated needlessly with chemotherapy or radiation therapy, or surgeries such as lumpectomy or mastectomy.

For 50-year-old women screened annually for 10 years, the numbers are as follows:
* 0.3-3.2 women will avoid dying from breast cancer.
* 490-670 women will have at least one false alarm (70-100 will undergo a biopsy).
* 3-14 women will be overdiagnosed and treated needlessly.

And for 60-year-old women screened annually for 10 years:
* 0.5-4.9 women will avoid dying from breast cancer.
* 390-540 women will have at least one false alarm (50-70 will undergo a biopsy).
* 6-20 women will be overdiagnosed and treated needlessly.

“Overtreatment” sometimes occurs when women receive treatments for cancers that would never have gone on to grow, spread, or cause health problems. In those cases, surgery, chemotherapy, and other treatments don’t provide any health benefit, but there are clear harms. Unfortunately, there is no way to know which cancers would go on to be deadly.

Meanwhile, there is little public awareness that routine screening can lead to both false alarms and overtreatment. A recent online survey of middle-aged Americans, notes Welch, suggests that acceptance of routine screening would diminish if the facts were more readily available.

Welch argues that more research is needed, especially on whether older findings showing that early detection might save lives still matter, now that treatment for breast cancer has changed and improved. He is, however, pessimistic about whether trials will happen that would help answer these questions, or explore outcomes when women choose more or less screening:

Two randomized trials could begin to answer the central question of mammography interpretation: How hard should the radiologist look? Women who view mammography favorably might be willing to be screened under either the current approach or a high-threshold approach — meaning their radiologist would ignore small, likely harmless abnormalities found on a mammogram.Those who view it less favorably might choose that high-threshold approach (knowing that the harms of false alarms and overdiagnosis would be minimized) or forgo mammography completely.

Putting the two trials together, we could finally learn what level of screening minimizes false alarms and overdiagnosis while saving the most lives. Most experts would say that it’s never going to happen. It would cost too much, take too long and need too many subjects.

Maybe they are right. But maybe not. Sure, it would cost millions of dollars. But that’s chicken feed compared with the billions of dollars we spend on breast cancer screening every year. Sure, it would take 10 to 15 years. But it would help our daughters know more. Sure, it would take tens of thousands of women to participate. But maybe they would want to be part of the effort to help sort out the morass surrounding what is one of the most common medical interventions done to American women.

We agree with Welch that more needs to be done — both in terms of research and educating the public about the real risks and benefits of their routine screening decisions.

“A screening program that falsely alarms about half the population is outrageous,” writes Welch, adding:

To be sure, many women are quickly reassured by a second test that their breast is normal. But others — while told they don’t have cancer — are told that their breast is somehow abnormal, that they have dysplasia or atypia, that they are at ‘high risk.’ Whether you blame the doctors or the system or the malpractice lawyers, it’s a problem that needs to be fixed.

Plus: For more information, read our previous posts on breast cancer, including several on what is known about the benefits and risks of routine mammography. Good starting points are: “New Mammogram Guidelines Are Causing Confusion, But Here’s Why They Make Sense,” “Do Screening Mammograms Do More Harm Than Good?“, and “The Benefits and Harms of Routine Mammograms.”


December 17, 2013

When Off-Label is Safer for Women: The Politics of Medication Abortion

Among the numerous tactics used to restrict abortion access, several states have proposed or implemented laws that impose unnecessary restrictions on medication abortion. These restrictions interfere with evidence-based practices that are considered safer for women’s health.

Some states are requiring that medication abortions follow the exact regimen approved by the FDA back in 2000, though research has since proven that lower doses are safer and just as effective. (The FDA has approved updated labeling since 2000, but these updates have not addressed the commonly used lower-dose regimen; it is not clear whether the drug company plans to submit new data and request these changes.)

The FDA protocol calls for a clinician to provide 600 mg of the first drug, mifepristone, for the patient to take orally, followed 48 hours later by 400 mcg of oral misoprostol. More modern, evidence-based regimens call for only 200 mg of mifepristone, followed later by 800 mcg of misoprostol that is held in the cheek until it dissolves instead of swallowed. The newer regimen also allows for the misoprostol dose to be taken at home.

Guttmacher Institute: State Policies on Medication AbortionBut states looking to make abortions more difficult for women to obtain are requiring physicians to administer the second dose in person. This mean women are forced to make an additional clinic visit — a significant hardship for many patients.

It’s common practice for doctors to prescribe drugs “off-label,” which means in a different way or for a different purpose than what the FDA has specifically approved. This allows doctors to use the most current evidence and their own judgment. Indeed, a new study accepted for publication in the journal Contraception illustrates how the practice of medicine can change to improve patient safety after a drug has been approved by the FDA.

The researchers reviewed Planned Parenthood data from the five years prior to 2006 — the year Planned Parenthood clinics changed their protocol for medication abortion from vaginal to oral administration of misoprostol, and added additional steps (such as STI testing and routine antibiotics) to reduce infection risk — and the five years after.

They found three deaths out of 218,928 abortions before the change, and no deaths among 711,556 abortions after the change. The Planned Parenthood study used the common reduced dose regimen of 200 mg mifepristone followed by 800 mcg of misoprostol. Other studies have also demonstrated the safety and effectiveness of the reduced mifepristone dose.

When politicians insist on the outdated FDA-approved regimen, they are prohibiting the use of the safer approaches.

The outdated FDA regimen, says Rachael Phelps, medical director for Planned Parenthood in Rochester and Syracuse, is “dramatically less effective, has more side effects, is harder for women to use, and increases the likelihood of an additional invasive procedure compared to the evidence based regimen. Mandating the FDA regimen forces doctors to provide substandard medical care and is just plain bad medicine.”

A case challenging such a law in Oklahoma had been set to go before the Supreme Court, but was dismissed following a state Supreme Court ruling that the law would effectively ban all medication abortion in the state. Texas’s controversial HB 2 law also requires adherence to the outdated FDA-approved regimen.

For a quick guide to additional states with restrictions requiring the old regimen or barring remote doctors from supervising medication abortion via telemedicine, view this fact sheet from Guttmacher Institute.

The federal Women’s Health Protection Act (S1696 / HR 3471) introduced this year would prohibit such restrictions. Among provisions addressing telemedicine abortion, hospital admitting privileges, and other targets of recent legislation, the bill would forbid any “limitation on an abortion provider’s ability to prescribe or dispense drugs based on her or his good-faith medical judgment, other than a limitation generally applicable to the medical profession.” Contact your senator or representative to support this Act.


December 12, 2013

Cochrane Review: The Safety and Benefits of Midwives Overseeing Maternity Care

Midwife-Led Continuity Models Versus Other Models of Care for Childbearing WomenIf you’re pregnant and living in the United State, it’s likely that an obstetrician will oversee your maternity care and childbirth. In other countries, however, midwives commonly provide care, assuming the pregnancy is low-risk.

An updated Cochrane review aimed to figure out whether patient outcomes vary by who is leading the care team.

Cochrane compiles findings from multiple studies into systematic reviews, considered top-notch for determining the best evidence-based care. In this instance, the authors looked at outcomes for moms and babies of what the authors refer to as “midwife-led continuity models of care” — defined as incorporating a midwifery perspective of minimizing routine intervention during birth, and midwives acting as the lead professionals in organizing and delivering care before, during and after birth.

They considered 13 studies representing 6,242 women in Australia, Canada, Ireland, New Zealand and the United Kingdom that compared the effects of midwife-led continuity models of care with other models: eight studies compared it to a shared model of care (responsibility is shared between different care providers); three studies compared it to medical-led models of care (what we’re most used to in the United States); and two studies compared it to various options of standard care, including midwife-led (with varying levels of continuity), medical-led, and shared care.

All of the studies looked at licensed midwives in hospital birth settings.

In the final review, “Midwife-Led Continuity Models Versus Other Models of Care for Childbearing Women,” the authors report that the midwife-led continuity models of care were associated with some benefits, including a decreased likelihood of episiotomy or instrumental birth, and decreased likelihood of preterm birth or loss of the fetus before 24 weeks’ gestation. Women cared for under this model were more likely to have spontaneous vaginal birth; they also had slightly longer labors and were less likely to use any pain relief.

There were no differences between groups in rates of cesarean birth (although the authors suggest more data may be needed), or overall fetal loss or neonatal death. There were no specific adverse effects attributed to midwife-led continuity of care models.

The Royal College of Obstetricians and Gynaecologists (a UK professional organization) essentially agreed with the message of the review, noting that while other types of specialists should be available for high-risk pregnancies and emergencies, “more women with low-risk pregnancies should be given the option of midwifery-led care.”

While noting that additional research is needed, the Cochrane authors’ recommend what has become standard practice in many parts of the world: “Most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.”

While the midwifery model of care — especially midwife-led continuity care — is not standard practice in the United States, midwives and other health advocates have been working to change that. Some academic medical centers now incorporate midwives into their care teams for hospital births, for example, though not all teams are midwife-led.

In this JAMA News item, nursing professor and American Journal of Nursing Editor Diana Mason argues for increased access to midwives and birth centers for low-risk births to meet consumer choice and to combat the high cost of maternity care. Mason writes:

We need to question the basic framework for designing maternity services: should it be one in which pregnancy and birth are viewed as normal life transitions or as diseases? This is not just a philosophical issue. The midwifery model of care views birthing as a normal physiologic process and involves care that includes the identification of women at risk for complications and in need of management by an obstetrician.

Women’s health advocates are also pushing for broader reform of the maternity care system, including better and increased support of women before, during, and after birth; expanded choice in birth settings; an emphasis on medical evidence; and improved staffing of maternity care teams.

These issues and other concerns are addressed in the 2020 Vision for A High-Quality, High-Value Maternity Care System – prepared for Childbirth Connection’s Transforming Maternity Care symposium — which focuses on woman-centered care that “respects the values, culture, choices, and preferences of the woman, and her family, as relevant, within the context of promoting optimal health outcomes.”

To learn more about the midwifery model of care, check out this excerpt from “Our Bodies, Ourselves,” and the resources from Childbirth Connection. To find a practice with nurse-midwives in your area, try the ACNM’s Find a Midwife search tool.


November 27, 2013

Worried About the Effectiveness of Emergency Contraception Pills? Here’s An Alternative

Emergency contraception is tremendously important for women seeking to prevent pregnancy after unprotected sex. Activists and public health advocates have worked for years to make EC pills more readily available, and have been successful in getting pills such as Plan B available without a prescription or age restrictions.

Emergency contraception pills containing levonorgestrel (including Plan B) may not be right for every woman and situation, however. Though the pills can be taken up to five days after unprotected intercourse, the pills are most effective (95 percent) when taken within 24 hours and become steadily less effective as more time passes. A different type of EC pill — Ella, containing ulipristal — is thought to keep a pretty high level of effectiveness for the full five days.

News this week has raised another issue of emergency contraception effectiveness: EC pills with levonorgestrel seem to be less effective in women weighing more than 165 pounds, and lose their ability to work in women who weigh more 175 than pounds.

This loss of effect happens regardless of whether women are considered overweight or obese according to BMI charts, or are simply tall — despite headlines that almost exclusively focus on “obese women.”

As Linda Prine of the Reproductive Health Access Project said in an interview with NPR: “This is barely overweight. We’re talking about a BMI over 25. So this is probably more than half of American women. This medication would not work for them.”

The Food and Drug administration is reviewing whether makers of levonorgestrel-containing pills (Plan B, Plan B One-Step, Next Choice, My Way) should be required to revise their labels to include a weight warning. In Europe, the label for one identical product (Norlevo) has already been changed to warn about the loss of effectiveness.

The European label change is what prompted news coverage this week, though the study that informed the change was actually published in 2011.

For that study, researchers reviewed results from two prior randomized controlled trials to look for factors that could explain rates of emergency contraception failure. Not only did they find that overweight and obese women had much higher risks of pregnancy than “normal” weight women (anywhere from double the risk to more than four times greater), but women with a “normal weight” BMI women who are tall also have greater risks of pregnancy.

The authors note that additional research is needed to determine whether these women could be given higher doses of the drug for improved efficacy.

The researchers also found that while Ella (ulipristal) worked at higher weights than levonorgestrel-containing pills, it, too, lost some effectiveness with increasing weight. At about 194 pounds, ulipristal appeared to lose all effectiveness.

Women in need of emergency contraception do have another option, however: the copper IUD (Paragard).

IUDs are intrauterine devices that not only are considered 99.9 percent effective for emergency contraception, but they can remain in place for up to 10 years and are one of the most effective forms of contraception overall. While in the past doctors may have been reluctant to provide IUDs for younger women and women who have not had children, more current research suggests that their concerns about side effects were largely unfounded.

Copper IUDs work to prevent pregnancy by inhibiting fertilization, primarily by preventing sperm from reaching an egg. They may also help to prevent implantation of a fertilized egg, but they do not interfere with an established pregnancy. (It is important to remember that IUDs do not protect against HIV or other sexually transmitted infections, so barrier methods may be needed as well for protection.)

For more information, read more about the safety of prescribing the IUD for teenagers, along with this post on the pros and cons of IUDs. You can also read an excerpt from “Our Bodies, Ourselves” on emergency contraception, and visit the excellent Princeton/ARHP emergency contraception website for more on EC and body size.


November 20, 2013

Is There a Connection Between Endometriosis and Environmental Pollutants?

Endometriosis is a painful and puzzling condition in which the tissue that lines the inside of the uterus — the endometrium — grows outside the uterus, often on the ovaries and fallopian tubes. In addition to causing pain, endometriosis can result in heavy bleeding and infertility. One in 10 women of reproductive age is thought to be affected.

One of the most frustrating aspects of endometriosis is that the cause is unknown. A couple of new studies have focused on environmental triggers, with mixed results. Both studies appear in an upcoming issue of the journal Environmental Health Perspectives.

The first study used data from the large Nurses’ Health Study II, involving more than 84,000 female nurses. The researchers identified those who lived near roadways, exposing them to more particulate matter in the air as adults. (Particulate matter is a type of pollution that can come from vehicle exhaust and other sources, such as coal-burning power plants.) The authors report that they did not find any significant association between exposure and the incidence rate of endometriosis, but also note this is the first human study to assess the relationship between particulate matter exposure and endometriosis.

Future research is likely needed to confirm the result, and other factors may need to be considered, such as the amount of exposure to particulate matter where women grew up or where they work. 

The second study did find a link between another type of pollution and endometriosis. Researchers used data from the Women’s Risk of Endometriosis study conducted in Washington state, analyzing blood samples of women with and without endometriosis to gauge their levels of organochlorine pesticides (OCPs). The researchers found associations between levels of two pesticides — β-hexachlorocyclohexane (HCH) and mirex — and a greater chance of having endometriosis.

Organochlorine pesticides, such as DDT, were commonly used in agriculture and for mosquito control during the 20th century. While their use has been greatly restricted in the United States, these pesticides accumulate in bodies and are still often detected in blood studies. The researchers note that most U.S. exposures are now from consumption of fatty foods, fish, and dairy products where the toxins have built up. Global use of OCPs is also a concern, as the contamination may spread.

These pesticides are known to be potential endocrine disruptors, but the exact nature of any link with endometriosis is unclear. The researchers involved in the study also found that the link was stronger when they looked just at ovarian endometriosis, although they don’t speculate on why that may be, except that ovarian cases may differ in some way from other cases of endometriosis.

All of this points to the need for more research.

For more information, visit the Endometriosis Association, which offers free informational packets and other resources. You can also read excerpts from “Our Bodies, Ourselves,” and learn more about both endometriosis and pesticides via the National Library of Medicine.


October 31, 2013

What Percentage of Older Women Are Satisfied with Their Body Image? Survey Says …

Body image is often thought of as a concern for teen girls and younger women, and the abundance of resources on this topic are skewed toward those age groups.

But a new study published in the Journal of Women and Aging illustrates how few of us are happy with how our bodies look, even as we get older: Only 12 percent of women reported being satisfied with their body size.

While the number is pathetically low, it’s not surprising considering how many of us are self-critical about our appearance. Even if we are not actively dieting, our culture — and sometimes our own families and friends — make it impossible to tune out messages that we should be younger, thinner and prettier.

Researchers from UNC Chapel Hill conducted an internet-based survey of 1,789 U.S. women age 50 and older to find out more about their perspectives. Participants were overwhelmingly white (92.3 percent), and the average age was 59. Close to half (42 percent) had a body mass index (BMI) that put them within “normal” weight ranges for their height.

For the study, participants were shown silhouettes of nine bodies of various sizes and asked which silhouette most resembled their own body, and which body size they preferred. Women who preferred the shape closest to their own were considered to be satisfied with their bodies. Women who preferred a different body shape were categorized as dissatisfied.

In discussing their findings, the authors point out that women who are generally satisfied “appear to exert considerable effort to achieve and maintain this satisfaction, and they are not impervious to experiencing dissatisfaction with other aspects of their appearance, particularly those aspects affected by aging.”

For instance, many of the women who fell into the “satisfied” group were unhappy with specific body parts, including their stomach (56.2 percent), face (53.8 percent), and skin (78.8 percent) — although they reported dissatisfaction at lower rates than the women who were dissatisfied overall with their bodies.

And while the majority (88 percent) of women who were satisfied were considered “normal” weight, 40.6 percent said they would be moderately or extremely upset if they gained just 5 pounds.

Satisfaction with one’s body shape/size also does not grant immunity to negative thinking:

- A third (34.1 percent) reported thinking about their weight “daily” or “always.”
- Half (50.7 percent) expressed envy of younger women’s appearance.
- More than three-quarters (77.1 percent) reported that their shape played a primary role in their self-evaluation — about the same percentage of women who were unsatisfied with their appearance.

The women were also asked about their weight, height, ethnicity, symptoms of eating disorders, diet, and weight-control behaviors (like dieting and frequent weighing), concerns about their weight and shape, and quality of life. There was no difference between the satisfied and unsatisfied groups when it came to skipping meals or extreme/disordered weight control measures.

Satisfied women reported somewhat more exercise (average of 5.1 hours vs. 3.8 hours), and the authors note that “exercise may directly (and indirectly) enhance body esteem in women.”

Women who were unsatisfied with their bodies were significantly more likely to report that a physical or medical condition affected their weight or appetite (30.3 percent vs. 9.2 percent). The were also more likely to do frequent body checking, attempt weight loss, spend more than half their time dieting, and report having tried low-calorie diets or diet plans.

The authors were not able to determine whether these activities led to dissatisfaction, or whether body dissatisfaction more often led to these activities. The study also doesn’t address the effect that negative messages and stigma may have on satisfaction rates.

The authors recommend that health-care providers discuss weight, shape, and aging-related concerns with all mature women, and “maintain sensitivity when talking about weight management.”

For a more personal take on these survey results, read Rachel Zimmerman’s post at WBUR’s Common Health. Zimmerman reflects on how she spends an “inordinate, and frankly embarrassing amount of time thinking about food, planning meals and strategizing about how to control [her] weight.”

And for more information, check out Our Bodies Ourselves resources on body image. For help related to eating disorders, see the National Eating Disorders Association.


October 18, 2013

New Study on Youth and Sexual Violence Considers Spectrum of Rape Scenarios

In a new study published in JAMA Pediatrics, nearly 1 in 10 youths in the United States reported committing an act of sexual violence.

As part of a larger Growing Up With Media study on media consumption and exposure, the researchers surveyed 1,058 girls and boys ages 14 to 21 about their experience as perpetrators of sexual violence and their exposure to violent sexual media.

Rather than ask participants if they had ever raped or sexually assaulted anyone, the researchers asked more nuanced questions, including if they had tried to make someone have sex with them when they knew the other person didn’t want to, and if they had succeeded at doing so.

The participants were also asked if they had kissed, touched, or done anything sexual with an unwilling partner. Among the findings:

  • 9 percent of youths surveyed reported some type of sexual violence perpetration in their lifetime;
  • 8 percent kissed, touched, or made someone else do something sexual when they knew the other person did not want to (ie, forced sexual contact);
  • 3 percent got someone to give into sex when he or she knew the other person did not want to have sex (hereafter referred to as coercive sex);
  • 3 percent attempted – but were not able – to force someone to have sex (ie, attempted rape);
  • 2 percent forced someone to have sex with him or her (ie, completed rape).
  • About 3 in 4 victims were a romantic partner.

There was a good amount of overlap: 12 percent reported two different behaviors, 11 percent reported three, and 9 percent reported all four types.

When asked about the most recent time they tried to force or were able to force someone to have sex, tactics were mostly coercive. Arguing or pressuring the person (32 percent) or getting angry or making the person feel guilty (63 percent), were more commonly used than threats (5 percent) or physical force (8 percent). Alcohol was a factor in 15 percent of these situations.

It’s important to keep in mind that survey research like this — even when conducted via the internet — may underestimate true rates of actions like sexual assault, because perpetrators are motivated to avoid reporting their own crimes.

The authors note this as a limitation, adding, “Nonetheless, rates are much higher than the lifetime rate of 0.15% yielded in a national study of adults that was conducted face to face.”

Perpetrators & Victims
Women were much more likely to be the victim of an attempted or completed rape; perpetrators reported that about 80 percent of victims were female. The researchers also found that about 5 percent of victims were transgender.

White youths were more likely than nonwhite youths to report perpetrating coercive sex, and youths living in higher-income households were more likely to report attempted rape.

Perpetrators of any type of sexual violence were significantly more likely to have consumed any type of X-rated material, especially violent materials.

The authors note that while media consumption and violence could not be causally linked by their study, “it seems appropriate to suggest that frequent consumption of sexual and violent material and especially sexually violent material should be a marker for concern for adolescent health care professionals.”

Looking at the gender of assailants, researchers found that boys and young men accounted for almost all rapes and attempted rapes committed before age 18. The study notes that 98 percent of perpetrators whose first act occurred at ages 8 to 15 were male, as were 90 percent of perpetrators involved in an assault at ages 16-17.

Among 18- and 19-year-olds, women accounted for slightly more than half (52 percent) of attempted/completed rape perpetrators (seven women out of 13 total). The authors note that their broad definitions may result in finding an unexpectedly high amount of female perpetrators. They add, however, that it’s important to challenge the widespread notion that women cannot coerce men.

Some may argue that the definitions of rape and sexual assault in our investigation are too broad. Indeed, this may be why the perpetration rate among females is higher than might be posited. Rape includes acts beyond those in which the victim is physically overpowered, however. Restrictive definitions have potentially led to undercounting of sexual assault experiences.

For example, in the National Violence Against Women Survey, respondents were asked whether anyone had ever made them engage in a sexual activity “by using force or threat of force.” Psychological coercion was not clearly specified even though there are multiple coercive strategies other than physical force that can be used in a rape. To ensure that comprehensive rates of sexual assault and rape are identified as well as to begin building the research base on female perpetrators, research needs to include a fuller spectrum of rape scenarios.

Few Criminal Consequences
The findings on attitudes and punishment are chilling.

“Sixty-six percent of perpetrators reported that no one found out about the perpetration. Contact with the justice system was uncommon: 1% of perpetrators reported police contact and 1% an arrest,” note the authors.

They also found that half of perpetrators said that the victim was completely responsible for the incident. Only 1 in 3 said that they, the perpetrator, were completely responsible for the incident.

Recommendations
The authors recommend that more effort should be made on education that avoids victim blaming and emphasizes perpetrators taking responsibility for their own actions. They also suggest further research on factors related to taking responsibility, such as motivations behind the sexual violence and feelings of remorse or regret.

Incidents like this recent one in Maryville, Mo., in which a family moved due to harassment after the daughter was sexually assaulted, highlight the cruelty of victim-blaming and the need for prevention programs that put responsibility on the assailant.

The authors also commend bystander intervention programs, but note that most of that research has been done at the college level, and more work is needed at the high school level.

Plus: To learn more about consent, including essential rules, ways to talk about it, and examples of the enthusiastic consent model, check out Scarleteen’s Driver’s Ed for the Sexual Superhighway: Navigating Consent.


October 9, 2013

Studies Look at Access to Family Planning Services Provided at Federally Qualified Health Centers

A pair of newly published studies in the journal Contraception look at the types and access to family planning services provided at community health clinics that are considered a popular primary care option for low-income women of reproductive age.

The studies, produced by researchers at the George Washington University School of Public Health, examine the services at Federally Qualified Health Centers (FQHCs). These health clinics provide primary and preventive care on a sliding scale, primarily to low-income and uninsured patients. It’s also worth noting that when states attempt to defund Planned Parenthood clinics, these are clinics to which many women may get directed for care.

The authors anticipate that these health centers will become an even more important part of care as the Affordable Care Act is fully implemented and Medicaid is expanded. One of the co-authors is Dr. Susan Wood, who resigned her post as director of the FDA’s Office of Women’s Health in 2005 in protest over delays in approving over-the-counter access to emergency contraception.

In the first study, “Scope of Family Planning Services Available in Federally Qualified Health Centers,” researchers surveyed several hundred FQHCs about on-site care, including approaches to pregnancy prevention and STI/HIV testing and treatment, as well as referrals of patients to other sites, staffing issues, and other aspects of care. While they found that almost all of the FQHCs provided at least one contraceptive method, the type and accessibility of those methods varied.

Slightly more than half of the centers were able to dispense oral contraceptives on site rather than sending patients elsewhere with a prescription. Slightly more than a third (36 percent) offered both oral contraception and longer acting IUDs and/or implants on-site. If a woman has to go to another location, there may be consequences such as incurring lost work time that may make it harder to follow through.

Also, only about a third of the surveyed centers received Title X family planning funding (it’s not clear whether some clinics had not applied, or did apply and were rejected). The researchers found that while pretty much all of the centers provided access to oral contraception, the Title X-funded clinics were more likely to provide the full range of contraceptive options.

A companion paper, “Accessibility of Long Acting Reversible Contraceptives (LARC) in Federally-Qualified Health Centers (FQHCs),” looks specifically at the survey results on long-acting contraceptive options, including intrauterine devices (IUDs) and implants. The study found that slightly more than half of the FQHCs offered IUDs on-site, while about a third offered contraceptive implants on site. For the rest of them, patients would have to be referred elsewhere to receive the devices.

The authors again found that clinics receiving Title X funds were more likely to provide these options.


September 27, 2013

Concerned About the New “Hookup Culture?” It’s No So New, or Worrisome, After All

It seems like every so often, the media and others can’t resist a story about how college students — especially girls — are going wild with lots of meaningless sex. The implication is usually that these young women are destroying both themselves and society.

For example, a 2009 ABC news piece actually uses the word “sluts” in the headline. Almost 15 years ago, Tom Wolfe’s novel “I am Charlotte Simmons” raised some of the same criticism, often focusing specifically on the behavior of young women.

The topic was recently in the news again, thanks to a New York Times article “Sex on Campus: She Can Play That Game, Too.” Like those before it, the article largely looks at “hooking up” as something new, even though that may not be the case.

Following the trend of focusing on the “problem” of women having sex, there’s been a lot of questioning as to whether female college students are missing out on prime husband-finding time — or simply making their own choices during a period when relationships are not high on their to-do lists. Disturbingly, The New York Times story takes a detour to explore drinking and campus rape, as though non-consensual activity is somehow linked to what women enthusiastically consent to.

Given all the hand-wringing, you’d think today’s college women just discovered sex outside of long-term relationships. Yet according to research results released at a recent American Sociological Association meeting, 18- to 25-year-olds are probably not having any more sex or sexual partners than women their age 15 to 25 years ago.

The main researcher commented, “College students overestimate the degree to which their peers are hooking up. It feels like something new, but they might be surprised to know the actual frequency of sex, the number of sexual partners, etc. don’t appear to have increased from their parents’ generation.”

It may also be helpful for students to know that when Guttmacher researchers looked at rates of “premarital” sex in 2002, the percentages of women and men who had sex by age age 20 (74 percent of women, 77 percent of men) was extremely similar to the overall rates for 20-year-olds in the 1970s (72 percent), 1980s (76 percent), and 1990s (74 percent).

As Kate Harding puts it in this column on “hook-up culture’s bad rap,” none of the drama over hook-up culture — which is often based on misogyny and what people want from girls instead of for girls — is really that helpful:

If we encouraged girls and women to place real value on their own desires, then instead of hand-waving about kids these days, we could trust them to seek out what they want and need, and to end relationships, casual or serious, that are unsatisfying or damaging to them, regardless of whether they’d work for anyone else.

She later adds:

[I]f we teach all kids that there’s a wide range of potentially healthy sexual and emotional relationships, and the only real trick (granted, it’s a doozy) is finding partners who are enthusiastic about the same things you want, then there’s room for a lot more people to pursue something personally satisfying at no one else’s expense.

And that’s a fact.

Also see:
Let’s Talk About Casual Sex, Baby” by Jaclyn Friedman
Breaking News: Casual Sex Won’t Ruin Your Life!” by Jessica Wakeman
Thoughts on the ‘Hook-Up Culture,’ or What I Learned From My High School Diary” by Nona Willis Aronowitz


September 16, 2013

Headlines about the “Pullout Generation” Are Premature: Studies Show Multiple Methods of Contraception Use

A recent article in the journal Obstetrics & Gynecology has led to some catchy headlines calling today’s young, straight women “the pullout generation.”

The researchers looked at data from the 2006-2008 National Survey of Family Growth for 2,220 sexually active female respondents ages 15–24 years and found that almost 1 in 3 of those surveyed reported using withdrawal as a method of contraception during at least one month of the study. (It’s not clear how girls who were not having sex with male partners were included or excluded.)

What the study-inspired headlines don’t explain, though, is that very few of these respondents relied only the “pullout” method to prevent pregnancy – maybe even fewer than in older studies.

So it is really accurate to call today’s young women the “Pullout Generation?” Almost 9 out of 10 withdrawal users also used other methods, either simultaneously or at some other point in the study. And let’s not forget that 69 percent of those surveyed always used other methods, such as condoms and the pill.

Those who used withdrawal at any point were more likely to have unintended pregnancies, and more likely to use emergency contraception. While some coverage of the study has noted that those exclusively using withdrawal were “less likely” to get pregnant than women exclusively using other methods, the small mathematical difference isn’t considered meaningful.

When the CDC reported in 2009 on the sexual and reproductive health of young people ages 10-24 (covering the years 2002-2007), about 13 percent of unmarried, sexually active girls and women said they had used withdrawal the last time they had sex. This included those who had used withdrawal alongside another method. Thus, the reporting should have noted fewer than 13 percent were using *only* withdrawal.

In another report of contraception use by adolescents released in 2010, almost 11 percent of sexually active girls in 9th-12th grades reported using only the withdrawal method the last time they had sex. This study uses some data sources that overlap with the CDC’s report.

It’s not clear, then, that increasing use of withdrawal as a main method of contraception is actually “a thing.”

As Ann Friedman suggests in her column on the “Pullout Generation,” that doesn’t mean there isn’t legitimate interest in better and alternate birth control methods. In fact, Global Female Condom Day is today, which makes it the perfect opportunity to learn more about this woman-oriented, non-hormonal method.

For more information on withdrawal, including failure rates and things to think about, see Scarleteen and Bedsider. For more info on female condoms, read this excerpt from “Our Bodies, Ourselves” or our many blog posts on the topic.


August 30, 2013

Want to Reduce Unintended Pregnancies? Provide Health Education & Support

Almost half of all pregnancies in the United States are unintended. These pregnancies can result in worse health outcomes for both women and their babies, due to potentially poor health prior to pregnancy and delays in obtaining prenatal care and making changes such as quitting smoking.

For a new, small study published in the Journal of Midwifery & Women’s Health, researchers spoke to women in three Michigan neighborhoods characterized as low-income, urban, culturally/ethnically diverse, and medically underserved — basically the type of neighborhood where unintended pregnancy rates are higher than average.

The researchers conducted six focus groups with a total of 41 women, ages 18 to 44 years, who were either pregnant or had been pregnant within the last three years. They sought the women’s input on three important questions:

  1. What could be done to encourage women to recognize their pregnancies early (within six weeks from their last menstrual period)?
  2. What should be the primary action to help women recognize their pregnancy early?
  3. What are the most important things that could help women to be sure of their pregnancies early?

The women identified a few main themes and provided numerous suggestions for addressing these issues, including:

  • Promoting knowledge of reproductive changes in the body: Teach women about their female reproductive system and its cyclic changes, such as timing of ovulation, number of days in a cycle, and how to keep a menstrual calendar.
  • Promoting early testing or confirmation of pregnancy: Assist women to know symptoms of pregnancy and to recognize their pregnancies early through the use of home pregnancy test kits or going to the doctor or clinic to confirm a pregnancy.
  • Providing informational support: Provide a list of locally available pregnancy-related resources, such as clinics, prenatal classes, and educational sessions on women’s health.
  • Providing emotional support: Have a friend to talk with or have nurses, midwives, and other health professionals to go to for guidance during the preconception and prenatal periods.

While small, this type of study — and the prison health study we wrote about earlier in the week — are very much needed, because they ask the people most affected about their needs and experiences.

In this instance, community health workers (residents from each neighborhood employed to promote health and access to health care) were already familiar figures in these neighborhoods, and a participatory research model was employed that was sensitive to the residents’ needs. For example, the researchers provided transportation *and* childcare so the women could participate.

In their “implications for practice” section, the study’s authors urge future research along the themes the women identified. Teaching women about the menstrual cycle, along with the signs and symptoms of ovulation and pregnancy, can help women to take more control over their health and their lives.

As one woman in the study said, “I guess just being taught more in an individual sense of how to recognize things in your own body instead of being lumped, that it would be the standard, like I said earlier, 28-32 days. I mean, if women could really have that sense of, like, knowing how they are, it’s much easier to plan around that, or at least to be aware.”

The researchers also urge systemic approaches to reducing unintended pregnancy and the associated health effects, including comprehensive reproductive education (starting even before adolescence), policies that promote access to pregnancy-related resources and facilities, and access to early pregnancy testing.