As women approach menopause, fertility declines but pregnancy can still occur. Maternal and infant risks are increased among women of older reproductive age compared with younger women. A high proportion of pregnancies among women of older reproductive age are unintended and these pregnancies can also be associated with negative maternal and infant consequences. However, women and their healthcare providers may have concerns about risks associated with contraceptive use, particularly combined hormonal contraceptives, among women of older reproductive age who already may be at increased risk for conditions such as cardiovascular disease and breast cancer. Nonetheless, available evidence does not suggest that hormonal contraceptive use among women of older reproductive age substantially increases age-related risks of cardiovascular events or breast cancer. CDC recommends that contraception is still needed for women older than 44 years who have not reached menopause and wish to avoid pregnancy, and that based on age alone, all contraceptive methods are considered safe or generally safe for use by women of older reproductive age.

The US Medical Eligibility Criteria for Contraceptive Use (US MEC) and US Selected Practice Recommendations for Contraceptive Use (US SPR) provide evidence-based guidance to safely provide contraception counseling and services. Both documents were updated in 2016 and are endorsed by the North American Society for Pediatric and Adolescent Gynecology. The purpose of this mini-review is to highlight updates to the US MEC and US SPR that are most relevant to health care providers of adolescents in order to support dissemination and implementation of these evidence-based best practices. This document is intended to highlight these changes and to complement, not replace, the detailed practice guidance within the US MEC and US SPR.

BACKGROUND: Little is known about unintended pregnancy (UIP) risk and current contraceptive use among women aged 45 years and over in the United States (US). OBJECTIVES: To describe the prevalence of women aged 45-50 years at risk for UIP and their current contraceptive use and to compare these findings to those of women in younger age groups. STUDY DESIGN: We analyzed 2006, 2008 and 2010 Massachusetts Behavioral Risk Factor Surveillance System data, the only US state to routinely collect contraceptive data from women beyond age 44 years. Women aged 18-50 years (n=4,930) were considered at risk for UIP unless they reported current pregnancy, past hysterectomy, not being sexually active in the past year, having a same sex partner, or wanting to become pregnant. Among women considered at risk (n=3,605), we estimated the prevalence of current contraceptive use by age group. Among women considered at risk and aged 45-50 years (n=940), we examined characteristics associated with current method use. Analyses were conducted on weighted data using SUDAAN. RESULTS: Among women aged 45-50 years, 77.6% were at risk for UIP, which was similar to other age groups. As age increased, hormonal contraceptive use (shots, pills, patch, or ring) decreased, while permanent contraception (tubal ligation or vasectomy) increased as did non-use of contraception. Of women aged 45-50 years at risk for UIP, 66.9% reported using some contraceptive method; permanent contraception was the leading method reported by 44.0% and contraceptive non-use was reported by 16.8%. CONCLUSION: A substantial proportion of women aged 45-50 years were considered at risk for UIP. Permanent contraception was most commonly used by women in this age group. Compared with other age groups, more women aged 45-50 years were not using any contraception. Population-based surveillance efforts are needed to follow trends among this age group and better meet their family planning needs. Although expanding surveillance systems to include women through age 50 years requires additional resources, fertility trends showing increasingly delayed childbearing, uncertain end of fecundity, and potential adverse consequences of unplanned pregnancy in older age may justify these expenditures.

The provision of family planning services has important health benefits for the U.S. POPULATION: Approximately 25 million women in the U.S. receive contraceptive services annually and 44 million make at least one family planning-related clinical visit each year. These services are provided by private clinicians, as well as publicly funded clinics, including specialty family planning clinics, health departments, Planned Parenthoods, community health centers, and primary care clinics. Recommendations for providing quality family planning services have been published by CDC and the Office of Population Affairs of the DHHS. This paper describes the process used to develop the women's clinical services portion of the new recommendations and the rationale underpinning them. The recommendations define family planning services as contraceptive care, pregnancy testing and counseling, achieving pregnancy, basic infertility care, sexually transmitted disease services, and preconception health. Because many women who seek family planning services have no other source of care, the recommendations also include additional screening services related to women's health, such as cervical cancer screening. These clinical guidelines are aimed at providing the highest-quality care and are designed to establish a national standard for family planning in the U.S.

BACKGROUND: Nausea and vomiting are side effects of emergency contraception pill (ECP) use. Different ECP regimens and the use of antinausea drugs may prevent these side effects. METHODS: We conducted two searches to identify data pertaining to the prevention of nausea and vomiting with ECP use and management of emesis with ECP use. Both searches queried the PubMed and Cochrane databases for peer-reviewed articles, in any language, published on January 1966-February 2012. Types of ECP included in our searches were levonorgestrel (LNG), Yuzpe regimens or ulipristal acetate (UA). Our search strategy for data on management of emesis with ECP use also included the gray literature. The gray literature includes materials such as reports, patent claims, prescribing information and package labels that are not published commercially. RESULTS: Eleven articles met the inclusion criteria. Split dose or two doses of LNG caused less nausea than UA and standard two-dose Yuzpe regimen in one study. Four studies demonstrated no difference between split-dose versus single-dose LNG. In two trials, meclizine and metoclopramide, given before Yuzpe ECPs, reduced nausea, but only meclizine reduced vomiting. CONCLUSION: The evidence does not support routine use of antiemetics with ECP use. Data to guide management of emesis with ECP are limited to expert opinion and package labeling.

BACKGROUND: Bleeding irregularities, such as intermenstrual spotting or heavy or prolonged menstrual bleeding, are common among copper-containing intrauterine device (Cu-IUD) users and are one of the leading reasons for method discontinuation. This review evaluates the evidence for effective therapeutic and preventive treatments for bleeding irregularities during Cu-IUD use. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles that were published in any language from inception of the database through March 2012 and were relevant to treatments for irregular bleeding during Cu-IUD use. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: From 1470 articles, we identified 17 articles that met our inclusion criteria. Evidence from two studies of poor quality demonstrated that antifibrinolytic agents or nonsteroidal anti-inflammatory drugs (NSAIDs) have been used for intermenstrual bleeding or spotting among a small number of Cu-IUD users with mixed results. Evidence from 10 studies of fair to poor quality suggested that some NSAIDs may significantly reduce menstrual blood loss or bleeding duration among Cu-IUD users with heavy or prolonged menstrual bleeding. Antifibrinolytic drugs or antidiuretics may also help reduce blood loss. High-dose aspirin was shown to increase blood loss among those with baseline menorrhagia. Evidence from five studies of fair to poor quality suggested that bleeding irregularities among new Cu-IUD users may be prevented with NSAIDs, although one large study of good quality suggested that prophylactic treatment with ibuprofen does not affect continuation of Cu-IUD use. Evidence from two studies of fair to poor quality suggested that antifibrinolytic agents might be helpful in preventing heavy or prolonged menstrual bleeding among new Cu-IUD users. CONCLUSIONS: Limited evidence suggests that NSAIDs may be effective treatments for bleeding irregularities associated with Cu-IUD use; antifibrinolytic agents and antidiuretics have also been studied as possible treatments in a small number of subjects, but their safety has not been well documented. NSAIDs and antifibrinolytics may also prevent bleeding irregularities among new CU-IUD users. Preventive NSAID use, however, does not impact Cu-IUD continuation.

The Centers for Disease Control and Prevention (CDC) is developing the US Selected Practice Recommendations (US SPR) for Contraceptive Use, an adaptation of the World Health Organization’s (WHO’s) evidence-based SPR guidance addressing contraceptive management issues that, while common, may also be complex or controversial [1]. | The recommendations in the US SPR will be based on the best available existing scientific evidence and expert guidance on such issues. The evidence was reviewed at an expert meeting held by the CDC in October 2011. In addition to informing development of recommendations for the US SPR, the meeting also served to identify research gaps for which additional evidence is needed to address or further clarify some common questions on contraceptive management and use. These research gaps are listed in Table 1, categorized by general area of interest. In this paper, we discuss three of the research gaps for purposes of illustration: (a) What are the most effective approaches to improve patient and provider understanding of and adherence to instructions for actions to take following dosing errors with oral contraceptive pills (OCPs) (missed pills), the transdermal contraceptive patch and the contraceptive ring? (b) What are the most effective and feasible approaches for prevention and management of bleeding irregularities among women using hormonal or intrauterine contraception? (c) What are the long-term effectiveness and safety of, and patient satisfaction with, hysteroscopic sterilization? For each of these questions, we discuss the significance of the issue, the type of evidence that is needed and the methodological challenges for conducting the needed research.

BACKGROUND: Unscheduled uterine bleeding is common among women who choose extended or continuous combined hormonal contraception and may subsequently lead to method discontinuation. This systematic review evaluates the evidence on treatments for unscheduled bleeding for women using continuous or extended combined hormonal contraception. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles that were published in any language from inception of the database through January 2012 and were relevant to therapeutic or prophylactic treatments for unscheduled uterine bleeding during extended or continuous combined hormonal contraception use. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: Four articles met the inclusion criteria. Evidence from two randomized controlled trials, both of fair quality, suggested that a short hormone-free interval of 3 or 4 days improved a current unscheduled bleeding episode. Evidence from one randomized controlled trial of fair quality suggested that oral doxycycline (100 mg twice daily) did not improve a current unscheduled bleeding episode. One good quality randomized controlled trial suggested that prophylactic treatment with a daily low dose of oral doxycycline (40 mg) caused earlier onset of amenorrhea in new extended combined oral contraceptive users. CONCLUSIONS: Limited evidence suggests that introducing a short hormone-free interval when unscheduled bleeding occurs during continuous or extended hormonal contraceptive use may reduce unscheduled bleeding days; one study suggests that twice-daily oral doxycycline initiated at the time of unscheduled bleeding is an ineffective treatment. Limited data suggest that prophylactic low-dose daily oral doxycycline may induce earlier amenorrhea among new extended combined hormonal contraceptive users.