INTRODUCTION: The association of breast cancer patients’ mortality with estrogen receptor (ER) status (ER + versus ER-) has been well studied. However, little attention has been paid to the relationship between the quantitative measures of ER expression and mortality. METHODS: We evaluated the association between semi-quantitative, immunohistochemical staining of ER in formalin-fixed paraffin-embedded breast carcinomas and breast cancer-specific mortality risk in an observational cohort of invasive breast cancer in 681 white women and 523 black women ages 35-64 years at first diagnosis of invasive breast cancer, who were followed for a median of 10 years. The quantitative measures of ER examined here included the percentage of tumor cell nuclei positively stained for ER, ER Histo (H)-score, and a score based on an adaptation of an equation presented by Cuzick and colleagues, which combines weighted values of ER H-score, percentage of tumor cell nuclei positively stained for the progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) results. This is referred to as the ER/PR/HER2 score. RESULTS: After controlling for age at diagnosis, race, study site, tumor stage, and histologic grade in multivariable Cox proportional hazards regression models, both percentage of tumor cell nuclei positively stained for ER (Ptrend = 0.0003) and the ER H-score (Ptrend = 0.0004) were inversely associated with breast cancer-specific mortality risk. The ER/PR/HER2 score was positively associated with breast cancer-specific mortality risk in women with ER + tumor (Ptrend = 0.001). Analyses by race revealed that ER positivity was associated with reduced risk of breast cancer-specific mortality in white women and black women. The two quantitative measures for ER alone provided additional discrimination in breast cancer-specific mortality risk only among white women with ER + tumors (both Ptrend ≤ 0.01) while the ER/PR/HER2 score provided additional discrimination for both white women (Ptrend = 0.01) and black women (Ptrend = 0.03) with ER + tumors. CONCLUSIONS: Our data support quantitative immunohistochemical measures of ER, especially the ER/PR/HER2 score, as a more precise predictor for breast cancer-specific mortality risk than a simple determination of ER positivity.

OBJECTIVE: The purpose of this study was to characterize age-group specific patterns in the stability of contraceptive use and to evaluate whether factors that are associated with nonuse and sporadic use, compared with stable use, differ by age among women who are at risk for unintended pregnancy. STUDY DESIGN: We used data from the 2006-2010 National Survey of Family Growth to characterize the prevalence of stable and sporadic contraceptive use and nonuse by age over a 1-year period. We used polytomous logistic regression models to assess the odds of contraceptive nonuse and sporadic use vs stable use. Age-stratified models were used to show age-group differences in associated characteristics. RESULTS: Over a 1-year period, stable contraceptive use decreased across age groups from 80% for teens 15-19 years old to 74% for women 20-24 years old, and 70-71% for women 25-34 and 35-44 years old. Contraceptive nonuse increased across age groups from 5% for teens 15-19 years old to 9-20% for older women. By contrast, sporadic use was least common for women 35-44 years old (10% compared with 16-17% for younger women). Among teens 15-19 years old, a history of method discontinuation because of dissatisfaction was associated with nonuse. Among older women, intentions to have children in the future and reported difficulty achieving pregnancy were associated with nonuse and sporadic use. CONCLUSION: Because the stability of contraceptive use and associated factors differ by age, providers may need to consider these differences when talking to women about contraception. To address nonuse, helping teens identify a method that they are comfortable using may be especially important; for older women, discussing the potential for continuing fertility may be more important. To address sporadic use, discussing the benefits of user-independent methods may be helpful, with a particular emphasis on long-acting reversible contraceptives for younger women and teens who are less likely to have completed their desired childbearing and who have tended to rely on methods that are more difficult to use consistently.

OBJECTIVES: To provide updated and more detailed pooled IUD expulsion rates and expulsion risk estimates among women with postpartum IUD placement by timing of insertion, delivery type, and IUD type to inform current IUD insertion practices in the United States. DATA SOURCES: We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019. STUDY ELIGIBILITY CRITERIA: We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or Levonorgestrel (LNG)-containing IUDs that reported counts of expulsion. STUDY APPRAISAL AND SYNTHESIS METHODS: We evaluated IUD expulsion among women receiving postpartum IUDs in the 'immediate' (within 10 minutes), 'early inpatient' (greater than 10 minutes to less than 72 hours), 'early outpatient' (72 hours to less than 4 weeks) and interval (4 weeks or greater) time periods after delivery. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete IUD expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type and IUD type using log-binomial multivariable regression. RESULTS: We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7,661 IUD placements. Complete IUD expulsion rates varied by timing of placement: 10.2% (range 0.0-26.7) for immediate, 13.2% (3.5-46.7) for early inpatient, 0% for early outpatient, and 1.8% (0.0-4.8) for interval placements. Complete IUD expulsion rates also varied by delivery type: 14.8% (range 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for LNG-IUDs was 27.4% (18.8-45.2) and 12.4% (4.8-43.1) for copper IUDs. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsions (adjusted RR (aRR), 8.33; 95% CI, 4.32-16.08 and aRR, 5.27; 95% CI, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (aRR, 4.57; 95% CI, 3.49-5.99). Among immediate placements at the time of vaginal delivery, LNG-IUDs were associated with a greater risk of expulsion compared with copper IUDs (aRR, 1.90; 95% CI, 1.36-2.65). CONCLUSION: While IUD expulsion rates vary by timing of placement, type, and mode of delivery, IUD insertion can take place at any time. Understanding the risk of IUD expulsion at each time period will enable women to make an informed choice about when to initiate an IUD in the postpartum period based on her own goals and preferences.

BACKGROUND: Contraception use among postpartum women is important to prevent unintended pregnancies and optimize birth spacing. Long-acting reversible contraception (LARC), including intrauterine devices and implants, is highly effective, yet compared to less effective methods utilization rates are low. OBJECTIVES: We sought to estimate prevalence of LARC use among postpartum women and examine factors associated with LARC use among those using any reversible contraception. STUDY DESIGN: We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. We included data from 37 sites that achieved the minimum overall response rate threshold for data release. We estimated the prevalence of LARC use in our sample (n=143,335). We examined maternal factors associated with LARC use among women using reversible contraception (n=97,013) using multivariable logistic regression (LARC versus other type of reversible contraception) and multinomial regression (LARC versus other hormonal contraception and LARC versus other non-hormonal contraception). RESULTS: The prevalence of LARC use overall was 15.3%. Among postpartum women using reversible contraception, 22.5% reported LARC use, which varied by site, ranging from 11.2% in New Jersey to 37.6% in Alaska. Factors associated with postpartum LARC use versus use of another reversible contraceptive method included: age </=24 years (adjusted odds ratio [AOR] = 1.43; 95% confidence interval [CI] = 1.33-1.54) and >35 years (AOR = 0.87; 95 % CI = 0.80-0.96) versus 25-34 years; public insurance (AOR = 1.15; 95% CI = 1.08-1.24) and no insurance (AOR = 0.73; 95% CI = 0.55-0.96) versus private insurance at delivery; having a recent unintended pregnancy (AOR = 1.44; 95% CI=1.34-1.54) or being ambivalent about the recent pregnancy (AOR = 1.29; 95% CI=1.18-1.40) versus recent pregnancy intended; having >/=1 previous live birth (AOR = 1.40; 95% CI = 1.31-1.48) and having a postpartum check-up after recent live birth (AOR = 2.70; 95% CI = 2.35-3.11). Hispanic and non-Hispanic black postpartum women had a higher rate of LARC use (26.6% and 23.4% respectively) compared to non-Hispanic white women (21.5%),and there was significant race/ethnicity interaction with educational level. CONCLUSIONS: Nearly one in six (15.3%) postpartum women with a recent live birth and nearly one in four (22.5%) postpartum women using reversible contraception reported LARC use. Our analysis suggests that factors such as age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance may be associated with postpartum LARC use. Ensuring all postpartum women have access to the full range of contraceptive methods, including LARC, is important to prevent unintended pregnancy and optimize birth spacing. Contraceptive access may be improved by public health efforts and programs that address barriers in the postpartum period, including increasing awareness of the availability, effectiveness, and safety of LARC (and other methods), as well as providing full reimbursement for contraceptive services, and removal of administrative and logistic barriers.

OBJECTIVE: To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method. DATA SOURCES: We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018. METHODS OF STUDY SELECTION: We searched databases for any published studies that examined postpartum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model. TABULATION, INTEGRATION, AND RESULTS: We identified 48 level I to II-3 studies of poor to good quality. Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement (adjusted RR 7.63, 95% CI 4.31-13.51; adjusted RR 6.17, 95% CI 3.19-11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85-6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50-2.43) compared with CuT380A. CONCLUSION: Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.

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.

BACKGROUND: Although it has been well-documented that obesity is associated with decreased risk of premenopausal breast cancer and increased risk of postmenopausal breast cancer, it is unclear whether these associations differ among breast cancer subtypes defined by the tumor protein expression status of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). METHODS: We evaluated the associations of body mass index (BMI) at age 18 years and recent BMI in relation to risk of breast cancer overall and ER/PR/HER2-defined subtypes, in 6320 women (3934 case-patient participants, 2386 control participants) aged 35-64 years, who participated in one of three population-based case-control studies. We estimated multivariable-adjusted odd ratios (ORs) and corresponding 95% confidence intervals (CIs) using polychotomous unconditional logistic regression methods for case-control comparisons in premenopausal women and postmenopausal women. RESULTS: BMI at age 18 years was inversely associated with risk of breast cancer, particularly among premenopausal women (>/= 25 vs. < 20 kg/m(2), OR = 0.72, 95% CI = 0.53-0.96; per 5 kg/m(2) increase, OR = 0.83, 95% CI = 0.73-0.95). This inverse association did not differ across ER/PR/HER2-defined subtypes or by race (white women, African-American women). Recent BMI was not associated with risk of premenopausal breast cancer after adjustment for BMI at age 18 years; nevertheless, the analysis for the joint effects of BMI at age 18 years and recent BMI showed that premenopausal women in the highest categories of the two BMI measures (>/= 25 kg/m(2) at age 18 years and >/= 30 kg/m(2) for recent BMI) had 46% lower risk of breast cancer than premenopausal women in the lowest categories of the two BMI measures (< 20 kg/m(2) at age 18 years and < 25 kg/m(2) for recent BMI; OR = 0.54, 95% CI = 0.38-0.78). Neither measure of BMI was statistically significantly associated with risk of postmenopausal breast cancer. CONCLUSION: Our findings indicate that high BMI near the end of adolescence decreases risk of all ER/PR/HER2-defined subtypes of premenopausal breast cancer and also suggest that this benefit could be maximized among premenopausal women who consistently have high BMI during their premenopausal years.

BACKGROUND: Whether providers who regularly provide family planning services consider contraceptive methods as unsafe for women with obesity is unknown. METHODS: We analyzed questionnaire responses received from December 2009 to March 2010 from 635 office-based physicians and 1323 Title X clinic providers delivering family planning services, who were randomly sampled (response rate 65%) before the release of national evidence-based contraception guidelines. We examined provider and clinical setting characteristics and clinic patient demographics for association with provider misconceptions about safety of combined oral contraceptives (COCs), depot medroxyprogesterone acetate (DMPA), or intrauterine devices (IUDs) for women with obesity. If providers considered methods as unsafe or do not know, we categorized those responses as misconceptions. We used multivariable logistic regression to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: A substantial proportion of respondents had misconceptions about the safety of COCs (31%), DMPA (24%), copper (Cu) (18%), and levonorgestrel (LNG)-IUDs (16%) for women with obesity. Provider type was associated with increased odds of misconceptions for all four methods compared with office-based obstetrician/gynecologists. Not having the method available onsite was associated with safety misconceptions of DMPA (aOR 1.90, 95% CI 1.07-3.36), Cu-IUD (aOR 4.19, 95% CI 1.51-11.61), and LNG-IUD (aOR 5.25, 95% CI 1.67-16.49). CONCLUSION: While the majority of providers considered all four contraceptive methods safe for women with obesity, substantial proportions had misconceptions about safety of COCs, DMPA, and IUDs. Provider education, particularly among certain specialties, is needed to increase knowledge regarding moderate and highly effective contraceptive methods among this patient population.

BACKGROUND: Early age at menarche, nulliparity, late age at first completed pregnancy, and never having breastfed, are established breast cancer risk factors. However, among breast cancer subtypes, it remains unclear whether all of these are risk factors for triple-negative breast cancer (TNBC). METHODS: We evaluated the associations of these reproductive factors with TNBC, in 2658 patients with breast cancer (including 554 with TNBC) and 2448 controls aged 20-64 years, who participated in one of the three population-based case-control studies: the Women's Contraceptive and Reproductive Experiences Study, the Women's Breast Carcinoma in situ Study, or the Women's Learning the Influence of Family and Environment Study. We used multivariable polychotomous unconditional logistic regression methods to conduct case-control comparisons among breast cancer subtypes defined by estrogen receptor, progesterone receptor, and human epidermal growth factor receptor-2 expression status. RESULTS: TNBC risk decreased with increasing duration of breastfeeding (P trend = 0.006), but age at menarche, age at first completed pregnancy, and nulliparity were not associated with risk of TNBC. Parous women who breastfed for at least one year had a 31% lower risk of TNBC than parous women who had never breastfed (odds ratio, OR = 0.69; 95% confidence interval, CI = 0.50-0.96). The association between breastfeeding and risk of TNBC was modified by age and race. Parous African-American women aged 20-44 years who breastfed for 6 months or longer had an 82% lower risk of TNBC than their counterparts who had never breastfed (OR = 0.18, 95% CI = 0.07-0.46). CONCLUSIONS: Our data indicate that breastfeeding decreases the risk of TNBC, especially for younger African-American women.

BACKGROUND: Migraine with aura and combined hormonal contraceptives are independently associated with an increased risk of ischemic stroke. However, little is known about whether there are any joint effects of migraine and hormonal contraceptives on risk of stroke. OBJECTIVE: To estimate the incidence of stroke in women of reproductive age and examine the association between combined hormonal contraceptive use, migraine type (with or without aura), and ischemic stroke. STUDY DESIGN: This study used a nationwide health care claims database and employed a nested case control study design. Women ages 15-49 years with first-ever stroke during 2006-2012 were identified using the International Classification of Diseases-9th Revision-Clinical Modifications inpatient services diagnosis codes. Four controls were matched to each case based on age. Migraine headache with and without aura was identified using inpatient or outpatient diagnosis codes. Current combined hormonal contraceptive use was identified using the National Drug Code from the pharmacy database. Conditional logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals of ischemic stroke by migraine type and combined hormonal contraceptive use. RESULTS: Between 2006-2012, there were 25,887 ischemic strokes among women ages 15-49, for a cumulative incidence of 11 strokes per 100,000 women. Compared to women with neither migraine nor combined hormonal contraceptive use, the odds ratio of ischemic stroke was highest among women with migraine with aura using combined hormonal contraceptives (odds ratio 6.1, 95% confidence interval 3.1-12.1); odds ratios were also elevated for migraine with aura without combined hormonal contraceptive use (odds ratio 2.7, 95% confidence interval 1.9-3.7), migraine without aura and combined hormonal contraceptive use (odds ratio 1.8, 95% confidence interval 1.1-2.9), and migraine without aura without combined hormonal contraceptive use (odds ratio 2.2, 95% confidence interval 1.9-2.7). CONCLUSION: The joint effect of combined hormonal contraceptives and migraine with aura was associated with a 6-fold increased risk of ischemic stroke compared with neither risk factor. Use of combined hormonal contraceptives did not substantially further increase risk of ischemic stroke among women with migraine without aura. Determining migraine type is critical in assessing safety of combined hormonal contraceptives among women with migraine.

OBJECTIVE: Immediate postpartum intrauterine devices (IUDs) have been underutilized in the United States despite their known safety. Understanding how providers' attitudes contribute to underutilization is important in improving access. Our objective was to examine healthcare providers' perceptions of the safety of immediate postpartum IUDs before publication of United States contraceptive guidelines. MATERIALS AND METHODS: We analyzed survey data collected from December 2009 to March 2010 from 635 office-based physicians and 1368 Title X clinic providers (overall response rate of 64.8%). Providers were asked how safe they thought copper and levonorgestrel (LNG) IUDs were in postpartum women (very safe, safe, unsafe, very unsafe, and unsure). Multivariable logistic regression was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for characteristics associated with considering immediate and delayed postpartum IUDs to be safe. RESULTS: Less than 40% of respondents considered immediate or delayed IUD insertion to be safe. Providers with <1 day of family planning training had decreased odds of considering immediate postpartum IUD insertion to be safe compared with unsafe/unsure (aOR 0.18, 95% CI 0.04-0.84 for copper IUD and aOR 0.17, 95% CI 0.04-0.81 for LNG-IUD). Providers without training in postpartum or interval copper IUD insertion had decreased odds of considering immediate postpartum copper IUD insertion (aOR 0.40, 95% CI 0.16-0.79) and delayed postpartum insertion for both IUD types to be safe (aOR 0.34, 95% CI 0.18-0.66 for copper IUD and aOR 0.41, 95% CI 0.21-0.77 for LNG-IUD). CONCLUSIONS: Before United States contraceptive guidelines, a majority of providers perceived immediate postpartum IUDs to be unsafe.

BACKGROUND: Contraception is an important consideration for women with multiple sclerosis (MS), however little is known about the possible effects of hormonal contraception on disease progression or other adverse outcomes (e.g., thrombosis, low bone mineral density). OBJECTIVE: To evaluate the evidence on the safety of contraceptive use among women with MS. SEARCH STRATEGY: We searched the PubMed database for peer-reviewed articles published in any language from database inception through July 2015. SELECTION CRITERIA: We included studies that examined health outcomes among women diagnosed with MS initiating or continuing a contraceptive method. We excluded case reports and case series but included all other study designs. RESULTS: From 111 articles, we identified four studies (from 5 articles) that met our inclusion criteria. Evidence from one randomized controlled trial, two retrospective cohort studies, and one cross-sectional study suggests that use of combined oral contraceptives or oral contraceptives (type not specified) among women with MS does not worsen the clinical course of disease, defined as disability level, disease severity or progression, relapse, or number of new brain lesions on magnetic resonance imaging (body of evidence grading Level I, fair to Level II-3, poor). No studies were identified that examined the safety of other contraceptive methods or examined other outcomes of interest (venous thromboembolism, changes in bone mineral density) related to contraceptive use among women with MS. CONCLUSIONS: Limited evidence suggests that COC or OC use after MS onset does not worsen the clinical course of disease.

BACKGROUND: Potential barriers to intrauterine device (IUD) use include provider concern about difficult insertion, particularly for nulliparous women. OBJECTIVE: To evaluate the evidence on the effectiveness of medications to ease IUD insertion on provider outcomes (i.e., ease of insertion, need for adjunctive insertion measures, insertion success). SEARCH STRATEGY: We searched the PubMed database for peer-reviewed articles published in any language from database inception through February 2016. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that examined medications to ease interval insertion of levonorgestrel (LNG) IUDs and copper-T IUDs. RESULTS: From 1855 articles, we identified 15 RCTs that met our inclusion criteria. Most evidence suggested that misoprostol did not improve provider ease of insertion, reduce the need for adjunctive insertion measures, or improve insertion success among general samples of women seeking an IUD (evidence Level I, good to fair). However, 1 RCT found significantly higher insertion success among women receiving misoprostol prior to a second IUD insertion attempt after failed attempt versus placebo (evidence Level I, good). Two RCTs on 2% intracervical lidocaine as a topical gel or injection suggested no positive effect on provider ease of insertion (evidence Level I, good to poor), and one RCT on diclofenac plus 2% intracervical lidocaine as a topical gel suggested no positive effect on provider ease of insertion (evidence Level I, good). Limited evidence from 2 RCTs on nitric oxide donors, specifically nitroprusside or nitroglycerin gel, suggested no positive effect on provider ease of insertion or need for adjunctive insertion measures (evidence Level I, fair). CONCLUSIONS: Overall, most studies found no significant differences between women receiving interventions to ease IUD insertion versus controls. Among women with a recent failed insertion who underwent a second insertion attempt, one RCT found improved insertion success among women using misoprostol versus placebo.

BACKGROUND: Women with medical conditions associated with increased risk for thrombosis generally should not use estrogen-containing contraceptives, however less is known about progestin-only contraceptives (POCs) and thrombosis risk. OBJECTIVES: To identify evidence regarding the risk of venous thromboembolism (VTE) or arterial thromboembolism (stroke or acute myocardial infarction [AMI]) among women using POCs. METHODS: We searched the PubMed database for all articles published from database inception through January 2016 for studies examining thrombosis among women using POCs. We included studies which examined women with medical conditions associated with thrombosis risk, as well as studies of women in the general population (either without these conditions or who were not specified to have these conditions). Hormonal contraceptives of interest included progestin-only pills (POPs), injectables, implants, and levonorgestrel-releasing intrauterine devices (LNG-IUDs). Outcomes of interest included VTE, stroke and AMI. RESULTS: There were 26 articles of good to poor quality that met inclusion criteria; 9 studies examined women with medical conditions and 20 examined women in the general population. Two studies found that among smokers and women with certain thrombogenic mutations, use of depot medroxyprogesterone acetate (DMPA) had elevated odds of VTE compared with non-smokers or those without mutations, although confidence intervals were wide and overlapped with odds among non-users. One study found that among women with previous VTE, use of POCs (including DMPA) was associated with a non-significant increased odds of recurrent VTE (all of which were among DMPA users); two other studies that examined POCs other than DMPA did not observe an association with recurrent VTE. Two studies found that use of DMPA among healthy women was also associated with increased odds of VTE. Two studies found that use of POCs for therapeutic indications was associated with increased odds of VTE. Studies did not find increased odds of VTE with POPs for contraceptive purposes, implants or LNG-IUDs, nor were there increased odds of stroke or AMI with any POCs. CONCLUSION: The majority of evidence identified by this systematic review did not suggest an increase in odds for venous or arterial events with use of most POCs. Limited evidence suggested increased odds of VTE with use of injectables (three studies) and use of POCs for therapeutic indications (two studies, one with POCs unspecified and the other with POPs). Any increase in risk likely translates to a small increase in absolute numbers of thrombotic events at the population level.

BACKGROUND: Migraine is common among women of reproductive age and is associated with an increased risk of ischemic stroke. Combined oral contraceptives (COCs) are also associated with an increased risk of ischemic stroke. Use of hormonal contraception among women with migraine might further elevate the risk of stroke among women of reproductive age. OBJECTIVE: To identify evidence regarding the risk of arterial thromboembolism (stroke or myocardial infarction) among women with migraine who use hormonal contraceptives. METHODS: We searched the PubMed database for all articles published from database inception through January 2016. We included studies that examined women with migraine overall or separated by subtype (with or without aura). Hormonal contraceptives of interest included combined hormonal methods (COCs, patch, and ring) and progestin-only methods (progestin-only pills, injectables, implants, and progestin intrauterine devices). RESULTS: Seven articles met inclusion criteria. All were case-control studies of fair to poor quality reporting on use of COCs or oral contraceptives (OCs) not further described and all reported stroke outcomes. Four studies demonstrated that, among women with migraine (not separated by subtype), COC use was associated with approximately 2-4 times the risk of stroke compared with non-use. The only study to examine specific migraine subtypes found an elevated risk of stroke among women with migraine with aura, and this risk was similar regardless of OC use, although these odds ratios were not reported. Two studies did not report risks among women with migraine and COC use combined, but both found increased risks of stroke with migraine and COC use independently. No evidence was found on other hormonal contraceptives or on risk of myocardial infarction. CONCLUSION: Limited evidence suggests a 2-4 fold increased risk of stroke among women with migraine who use COCs compared with non-use. Additional study is needed on the risks of hormonal contraceptives, including combined and progestin-only methods, among women with different migraine subtypes.

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.

BACKGROUND: Women who use combined hormonal contraceptives and cigarettes have an increased risk for cardiovascular (CV) events. We reviewed the literature to determine whether women who use hormonal contraceptives (HC) and electronic cigarettes (e-cigarettes) also have an increased risk. STUDY DESIGN: Systematic review. METHODS: We searched for articles reporting myocardial infarction (MI), stroke, venous thromboembolism, peripheral arterial disease, or changes to CV markers in women using e-cigarettes and HC. We also searched for indirect evidence, such as CV outcomes among e-cigarette users in the general population and among HC users exposed to nicotine, propylene glycol, or glycerol. RESULTS: No articles reported on outcomes among e-cigarette users using HC. Among the general population, 13 articles reported on heart rate or blood pressure after e-cigarette use. These markers generally remained normal, even when significant changes were observed. In 3 studies, changes were less pronounced after e-cigarette use than cigarette use. One MI was reported among 1,012 people exposed to e-cigarettes in these studies. One article on nicotine and HC exposure found both exposures to be significantly associated with acute changes to heart rate, though mean heart rate remained normal. No articles on propylene glycol or glycerol and HC exposure were identified. CONCLUSION: We identified no evidence on CV outcomes among e-cigarette users using HC. Limited data reporting mostly acute outcomes suggested that CV events are rare among e-cigarettes users in the general population, and that e-cigarettes may affect heart rate and blood pressure less than conventional cigarettes. There is a need for research assessing joint HC and e-cigarette exposure on clinical CV outcomes.

OBJECTIVE: To examine contraceptive use among women with selected medical conditions. METHODS: We used a nationwide health care claims database to identify women aged 15-44 years continuously enrolled in private insurance during 2004-2011 with and without selected medical conditions. We assessed current permanent and reversible prescription contraceptive use during October 1, 2010, to September 30, 2011, with diagnosis, procedure, and pharmacy codes and calculated prevalence by age and condition. We used polytomous logistic regression to calculate odds of female sterilization or reversible prescription methods compared with neither. Among users of reversible methods, we used logistic regression to calculate odds of using long-acting reversible contraceptives compared with shorter acting methods. RESULTS: A low proportion of women with medical conditions were using sterilization or reversible prescription methods (45% and 30% of women aged 15-34 and 35-44 years, respectively), and this proportion was consistently lower among the older age group across all medical conditions. Across both age groups, sterilization and long-acting reversible contraceptives were used less frequently than shorter acting methods (injectable, pill, patch, or ring). The odds of sterilization were higher among women with any compared with no condition for women aged 15-34 years (odds ratio [OR] 4.9, 95% confidence interval [CI], 4.5-5.3) and 35-44 years (OR 1.2, 95% CI, 1.1-1.2). Among women using reversible prescription methods, the odds of using long-acting reversible contraceptives were increased among those with any compared with no condition for women aged 15-34 years (OR 2.2, 95% CI, 2.1-2.5) and 35-44 years (OR 1.1, 95% CI, 1.1-1.2). CONCLUSION: Despite the potential for serious maternal and fetal pregnancy-associated risks, contraceptive use was not optimal among women with medical conditions. LEVEL OF EVIDENCE: III.

Convincing epidemiologic evidence indicates that physical activity is inversely associated with breast cancer risk. Whether this association varies by the tumor protein expression status of the estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), or p53 is unclear. We evaluated the effects of recreational physical activity on risk of invasive breast cancer classified by the four biomarkers, fitting multivariable unconditional logistic regression models to data from 1195 case and 2012 control participants in the population-based Women's Contraceptive and Reproductive Experiences Study. Self-reported recreational physical activity at different life periods was measured as average annual metabolic equivalents of energy expenditure [MET]-hours per week. Our biomarker-specific analyses showed that lifetime recreational physical activity was negatively associated with the risks of ER-positive (ER+) and of HER2-negative (HER2-) subtypes (both Ptrend ≤ 0.04), but not with other subtypes (all Ptrend > 0.10). Analyses using combinations of biomarkers indicated that risk of invasive breast cancer varied only by HER2 status. Risk of HER2-breast cancer decreased with increasing number of MET-hours of recreational physical activity in each specific life period examined, although some trend tests were only marginally statistically significant (all Ptrend ≤ 0.06). The test for homogeneity of trends (HER2- vs. HER2+ ) reached statistical significance only when evaluating physical activity during the first 10 years after menarche (Phomogeneity = 0.03). Our data suggest that physical activity reduces risk of invasive breast cancers that lack HER2 overexpression, increasing our understanding of the biological mechanisms by which physical activity acts.

OBJECTIVE: To examine the associations between hormonal contraceptive use and measures of HIV disease progression and antiretroviral treatment (ART) effectiveness. STUDY DESIGN: A prospective cohort study of women with prevalent HIV infection in St Petersburg, Russia was conducted. After contraceptive counseling, participants chose to use combined oral contraceptives (COCs), depot-medroxyprogesterone acetate (DMPA), a copper intrauterine device (IUD), or male condoms for pregnancy prevention. Among participants not using ART at enrollment, we used multivariate Cox regression to assess the association between current (time-varying) contraceptive use and disease progression, measured by the primary composite outcome of CD4 decline to <350 cells/mm3, ART initiation, or death. Among participants using ART at enrollment, we used linear mixed models to estimate the predicted mean CD4 change at select time points by contraceptive method. RESULTS: During a total of 5,233 months follow-up among participants not using ART with enrollment CD4 ≥350 cells/mm3 (n=315), 97 experienced disease progression. Neither current use of COCs (adjusted hazard ratio [aHR] 0.91, 95% confidence interval [CI] 0.56-1.48) nor DMPA (aHR 1.28, 95% CI 0.71-2.31) was associated with a statistically significant increased risk for disease progression compared with use of non-hormonal methods (IUD or condoms). Among participants using ART at enrollment (n=77), we found no statistically significant differences in the predicted mean changes in CD4 cell count comparing current use of COCs (P=0.1) or DMPA (P=0.3) with non-hormonal methods. CONCLUSION: Hormonal contraceptive use was not significantly associated with measures of HIV disease progression or ART effectiveness among women with prevalent HIV infection. IMPLICATIONS: Hormonal contraceptive use was not significantly associated with measures of HIV disease progression or ART effectiveness among women with prevalent HIV infection.

BACKGROUND: Superficial venous disease, which includes superficial venous thrombosis (SVT) and varicose veins, may be associated with a higher risk of venous thromboembolism (VTE). Use of combined hormonal contraceptives (CHCs) has been associated with an increased risk of VTE compared with non-use. Little is known about whether use of CHCs by women with superficial venous disease may further elevate the risk of VTE. OBJECTIVES: To investigate evidence regarding risk of VTE in women with SVT or varicose veins who use CHCs compared with non-CHC users. METHODS: We searched the PubMed database for all English language articles published from database inception through September 2014. We included primary research studies that examined women with SVT or varicose veins who used CHCs compared to women with these conditions who did not use CHCs. Outcomes of interest included VTE (among women with SVT or varicose veins) and SVT (for those with varicose veins). RESULTS: Two studies were identified that met inclusion criteria. One fair quality case-control study reported an odds ratio (OR) for VTE of 43.0 (95% confidence interval [CI] 15.5-119.3) among women with SVT using oral contraceptives (OCs) compared with non-users without SVT. The OR for VTE was also increased for women with SVT not using OCs (OR 5.1; 95% CI 2.8-9.5) and for women without SVT using OCs (OR 4.0; 95% CI 3.3-4.7), compared with non-users without SVT. One fair quality cohort study demonstrated that women with varicose veins had an increased rate of VTE with use of OCs (1.85 per 1,000 women-years [WY]), compared with users without varicose veins (0.84 per 1,000 WY), non-users with varicose veins (0.31 per 1,000 WY), and non-users without varicose veins (0.19 per 1,000 WY). This study also demonstrated that women with varicose veins had an increased rate of SVT with use of OCs (10.63 per 1,000 WY), compared with non-users with varicose veins (7.59 per 1,000 WY), users without varicose veins (1.89 per 1,000 WY), and non-users without varicose veins (0.77 per 1,000 WY). CONCLUSION: Two studies suggest increased risk of VTE among OC users with superficial venous disease; however, no definitive conclusions can be made due to the limited number of studies and limitations in study quality. Theoretical concerns need to be clarified with further research on whether the risk of significant sequelae from superficial venous disease among CHC users is related to clinical severity of disease and underlying factors.

OBJECTIVE: To examine the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use. STUDY DESIGN: Pregnancy Risk Assessment Monitoring System (PRAMS) 2004-2008 data were analyzed from Missouri, New York State, and New York City (n = 9536). We used multivariable logistic regression to assess the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use, defined as any method and more effective methods (sterilization, intrauterine device, or hormonal methods). RESULTS: The majority of women received prenatal (78%) and postpartum (86%) contraceptive counseling; 72% received both. Compared with those who received no counseling, those counseled during 1 time period (adjusted odds ratio [AOR] 2.10, 95% confidence interval [CI] 1.65-2.67) and both time periods (AOR 2.33, 95% CI 1.87-2.89) had significantly increased odds of postpartum use of a more effective contraceptive method (32% versus 49% and 56%, respectively; P for trend < 0.0001). Results for counseling during both time periods differed by type of health insurance before pregnancy, with greater odds of postpartum use of a more effective method observed for women with no insurance (AOR 3.51, 95% CI 2.18-5.66) and Medicaid insurance (AOR 3.74, 95% CI 1.98-7.06), than for those with private insurance (AOR 1.87, 95% CI 1.44-2.43) before pregnancy. Findings were similar for postpartum use of any contraceptive method, except no differences by insurance status were detected. CONCLUSIONS: The prevalence of postpartum contraceptive use, including use of more effective methods, was highest when contraceptive counseling was provided during both prenatal and postpartum time periods. Women with Medicaid or no health insurance before pregnancy benefited the most.

OBJECTIVE: To calculate incidence of postpartum venous thromboembolism by week after delivery and to examine potential risk factors for venous thromboembolism overall and at different times during the postpartum period. METHODS: A deidentified health care claims information database from employers, health plans, hospitals, and Medicaid programs across the United States was used to identify delivery hospitalizations among women aged 15-44 years during the years 2005-2011. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes were used to identify instances of venous thromboembolism and associated characteristics and conditions among women with recent delivery. Incidence proportions of venous thromboembolism by week postpartum through week 12 were calculated per 10,000 deliveries. Logistic regression was used to calculate odds ratios for selected risk factors among women with postpartum venous thromboembolism and among women with venous thromboembolism during the early or later postpartum periods. RESULTS: The incidence proportion of postpartum venous thromboembolism was highest during the first 3 weeks after delivery, dropping from nine per 10,000 during the first week to one per 10,000 at 4 weeks after delivery and decreasing steadily through the 12th week. Certain obstetric procedures and complications such as cesarean delivery, preeclampsia, hemorrhage, and postpartum infection conferred an increased risk for venous thromboembolism (odds ratios ranging from 1.3 to 6.4), which persisted over the 12-week period compared with women without these risk factors. CONCLUSION: Risk for postpartum venous thromboembolism is highest during the first 3 weeks after delivery. Women with obstetric complications are at highest risk for postpartum venous thromboembolism, and this risk remains elevated throughout the first 12 weeks after delivery. LEVEL OF EVIDENCE: II.

OBJECTIVE: Health care providers should assess pregnancy in women seeking contraceptive services. Although urine pregnancy tests are available in most U.S. settings, their accuracy varies based on timing relative to missed menses, recent intercourse, or recent pregnancy. We examined the performance of a checklist based on criteria recommended in family planning guidance documents to assist health care providers in assessing pregnancy in a sample of U.S. teenagers and young women. METHODS: Study participants were a convenience sample of sexually active black females aged 14-19 years seeking care in an urban family planning clinic. Each participant provided a urine sample for pregnancy testing and was then administered the checklist in two formats, audio computer-assisted self-interview and in-person interview. We estimated measures of the checklist performance compared with urine pregnancy test as the reference standard, including negative predictive value, sensitivity, specificity, and positive predictive value. RESULTS: Of 350 participants, 31 (8.9%) had a positive urine pregnancy test. The audio computer-assisted selfinterview checklist indicated pregnancy was unlikely for 250 participants, of whom 241 had a negative urine pregnancy test (negative predictive value=96.4%). The sensitivity of the audio computer-assisted self-interview checklist was 71%, the specificity was 75.6%, and the positive predictive value was 22%. The in-person checklist yielded similar results. CONCLUSION: The checklist may be a valuable tool to assist in assessing pregnancy in teenagers and young women. Appropriate use of the checklist by family planning providers in combination with discussion and clinically indicated use of urine pregnancy tests may reduce unnecessary barriers to contraception in this population.

PURPOSE: To estimate the prevalence of and factors associated with dual method use (i.e., condom with hormonal contraception or an intrauterine device) among adolescents and young women in the United States. METHODS: We used 2006-2010 National Survey of Family Growth data from 2,093 unmarried females aged 15-24 years and at risk for unintended pregnancy. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to assess the associations between dual method use at last sex and sociodemographic, behavioral, reproductive history, and sexual behavior factors. RESULTS: At last sex, 20.7% of adolescents and young women used dual methods, 34.4% used condoms alone, 29.1% used hormonal contraception or an intrauterine device alone, and 15.8% used another method or no method. Factors associated with decreased odds of dual method use versus dual method nonuse included having a previous pregnancy (aOR = .44, 95% CI .27-.69), not having health insurance coverage over the past 12 months (aOR = .41, 95% CI .19-.91), and having sex prior to age 16 (aOR = .49, 95% CI .30-.78). CONCLUSIONS: The prevalence of dual method use is low among adolescents and young women. Adolescents and young women who may have a higher risk of pregnancy and sexually transmitted infections (e.g., those with a previous pregnancy) were less likely to use dual methods at last sex. Interventions are needed to increase the correct and consistent use of dual methods among adolescents and young women who may be at greater risk for unintended pregnancy and sexually transmitted infections.

BACKGROUND: Black women are more likely than white women to have an aggressive subtype of breast cancer that is associated with higher mortality and this may contribute to the observed black-white difference in mortality. However, few studies have investigated the black-white disparity in mortality risk stratified by breast cancer subtype, defined by estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status. Furthermore, it is not known whether additional consideration of p53 protein status influences black-white differences in mortality risk observed when considering subtypes defined by ER, PR and HER2 status. METHODS: Four biomarkers were assessed by immunohistochemistry in paraffin-embedded breast tumor tissue from 1,204 (523 black, 681 white) women with invasive breast cancer, aged 35-64 years at diagnosis, who accrued a median of 10 years' follow-up. Multivariable Cox proportional hazards regression models were fit to assess subtype-specific black-white differences in mortality risk. RESULTS: No black-white differences in mortality risk were observed for women with triple negative (ER-negative [ER-], PR-, and HER2-) subtype. However, older (50-64 years) black women had greater overall mortality risk than older white women if they had been diagnosed with luminal A (ER-positive [ER+] or PR+ plus HER2-) breast cancer (all-cause hazard ratio, HR, 1.88; 95% confidence interval, CI, 1.18 to 2.99; breast cancer-specific HR, 1.51; 95% CI, 0.83 to 2.74). This black-white difference among older women was further confined to those with luminal A/p53- tumors (all-cause HR, 2.22; 95% CI, 1.30 to 3.79; breast cancer-specific HR, 1.89; 95% CI, 0.93 to 3.86). Tests for homogeneity of race-specific HRs comparing luminal A to triple negative subtype and luminal A/p53- to luminal A/p53+ subtype did not achieve statistical significance, although statistical power was limited. CONCLUSIONS: Our findings suggest that the subtype-specific black-white difference in mortality risk occurs mainly among older women diagnosed with luminal A/p53- breast cancer, which is most likely treatable. These results further suggest that factors other than subtype may be relatively more important in explaining the increased mortality risk seen in older black women.

BACKGROUND: Female sterilization is the second most commonly used form of contraception in the United States. Newer approaches to female sterilization, including hysteroscopic methods, have been approved for use in the United States since 2002. Little is known about the occurrence and timing of pregnancies after these procedures. STUDY DESIGN: The objective of this systematic review was to identify evidence that assesses when and how often pregnancies occur following hysteroscopic sterilization. The PubMed database was searched for all studies published from database inception through March 2012 that reported whether or not pregnancies occurred following hysteroscopic sterilization. RESULTS: Twenty-four original research articles of fair quality met the inclusion criteria: 22 studies of women who underwent Essure(R) placement and 2 studies of women who underwent Adiana(R) placement. Eleven articles that documented bilateral tubal occlusion with hysterosalpingogram (HSG) or placement with X-ray or ultrasound following Essure(R) placement did not report any pregnancies with follow-up ranging from 7 months to 7 years. The remaining 11 articles identified 102 reported pregnancies. Eighteen of these pregnancies occurred prior to the 3-month period required before imaging for contraceptive reliability. Two articles did not report what follow-up imaging was performed among women after Essure(R) placement; one of these articles reported three pregnancies. Two reports from the same study of women who underwent Adiana(R) placement reported six pregnancies during the first year of follow-up, three pregnancies during the second year of follow-up and no pregnancies during the third year of follow-up. CONCLUSIONS: Fair-quality evidence suggests that among women who were followed beyond 3 months after hysteroscopic sterilization, pregnancies were rare and generally occurred among women who had no imaging follow-up or had inadequate confirmation of placement or occlusion. Few pregnancies occurred in women with documented bilateral tubal occlusion by HSG or correct placement at 3 months by ultrasound or X-ray. Only one study reported follow-up past 5 years. Further studies are needed to address the long-term effectiveness of hysteroscopic sterilization.

OBJECTIVE: Little is known about the magnitude and consequences of violence against children for those living outside family care. We sought to estimate the frequency of childhood abuse and examine its association with lifetime pregnancy involvement (LPI) and past year suicide ideation among orphaned youth. METHODS: We analyzed data collected via cross-sectional interviewer-administered surveys completed by 293 orphaned youth aged 16-23 years living outside of family care in St. Petersburg, Russia. We used multivariable logistic regression to estimate adjusted odds ratios (AORs) of LPI and past year suicide ideation associated with childhood physical and sexual abuse. Other risk factors were also examined (e.g., social vulnerability, sexual and substance use behaviors), and characteristics of orphaned youth with LPI and past year suicide ideation were described. RESULTS: The prevalence of childhood abuse was higher among females than among males (23.3% versus 15.6% for physical abuse, and 20.3% versus 5.6% for sexual abuse), as was the prevalence of LPI and past year suicide ideation among those with histories of abuse. Experiences of childhood abuse were strong risk factors for both LPI and past year suicide ideation, with significant variation by gender. While both types of abuse were significantly associated with LPI and past year suicide ideation among females, physical abuse was significantly associated with LPI and sexual abuse was associated with suicide ideation for males. Of the other characteristics examined, strong modifiable risk factors included having no one to turn to for help and no involvement in activities outside of class. Among those with LPI (n=36), nearly 20% had been pregnant or gotten someone pregnant ≥2 times, most (61.8%) reported at least one induced abortion, and current use of effective contraception was nearly non-existent. Among those with past year suicide ideation (n=30), nearly half (44.8%) reported attempting suicide. CONCLUSIONS: There is an urgent need for interventions to prevent and mitigate the negative influence of childhood abuse experiences. Programs providing services to orphaned youth should increase access to sexual education, effective contraceptives, and mental health counseling.

BACKGROUND: After a woman initiates certain methods of contraception [e.g., hormonal methods, intrauterine devices (IUDs)], she is generally asked to return at some interval for a follow-up visit; however, is it unclear whether follow up is needed, what an appropriate follow-up schedule is and what should be done at follow-up visits. METHODS: We conducted four separate searches in the PubMed database for all peer-reviewed articles in any language published from database inception through April 2012 that examined the following health outcomes for combined hormonal contraceptives (CHCs), IUDs or medroxyprogesterone acetate (DMPA): (a) incidence of hypertension among women who began using a CHC compared to women not using a CHC; (b) incidence of migraine among women who began using a CHC compared to women not using a CHC; (c) incidence of pelvic inflammatory disease (PID) among women who began using an IUD compared to women who started another form or used no method of contraception or examined incidence of PID at two or more time periods after IUD insertion and (d) whether initial weight gain predicts future weight gain among women who began using DMPA. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: A total of 15 studies met our inclusion criteria: 5 examined hypertension and combined oral contraceptive (COC) use, 7 examined PID and IUD use and 3 examined weight gain after DMPA initiation. No studies that examined migraine after CHC initiation met our inclusion criteria. Few women developed hypertension after initiating COCs, and studies examining increases in blood pressure after COC initiation found mixed results (Level I, fair to II-2, fair). Among women who had a copper IUD inserted, there was little difference in incidence of PID, or IUD removal for PID, compared with women who initiated DMPA, a hormone-releasing IUD, or COCs (Level I, good to Level II-2, fair). Studies that examined when women were diagnosed with PID after IUD insertion found mixed results. The study with the largest sample size found a much greater incidence of PID in the first 20 days after insertion, with very low rates of PID up to 8 years postinsertion (Level I, good to Level II-3, poor). Studies that examined weight gain after DMPA initiation found that weight gain >5% of baseline weight at 6 months was associated with greater mean change in weight and greater mean change in body mass index at follow-up times ranging from 12 to 36 months (Level II-2, fair to Level II-3, fair). CONCLUSIONS: Evidence on select adverse events associated with initiation of contraceptive use is limited but does not suggest increased risk of hypertension among COC users or increased risk of PID among IUD users. DMPA users who gain >5% of baseline body weight may be at increased risk of future weight gain.

BACKGROUND: Provision of contraception is often linked with physical examination, including clinical breast examination (CBE) and pelvic examination. This review was conducted to evaluate the evidence regarding outcomes among women with and without physical examination prior to initiating hormonal contraceptives. STUDY DESIGN: The PubMed database was searched from database inception through March 2012 for all peer-reviewed articles in any language concerning CBE and pelvic examination prior to initiating hormonal contraceptives. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: The search did not identify any evidence regarding outcomes among women screened versus not screened with CBE prior to initiation of hormonal contraceptives. The search identified two case-control studies of fair quality which compared women who did or did not undergo pelvic examination prior to initiating oral contraceptives (OCs) or depot medroxyprogesterone acetate (DMPA). No differences in risk factors for cervical neoplasia, incidence of sexually transmitted infections, incidence of abnormal Pap smears or incidence of abnormal wet mount findings were observed. CONCLUSIONS: Although women with breast cancer should not use hormonal contraceptives, there is little utility in screening prior to initiation, due to the low incidence of breast cancer and uncertain value of CBE among women of reproductive age. Two fair quality studies demonstrated no differences between women who did or did not undergo pelvic examination prior to initiating OCs or DMPA with respect to risk factors or clinical outcomes. In addition, pelvic examination is not likely to detect any conditions for which hormonal contraceptives would be unsafe.