Current Women's Health Reviews - Volume 10, Issue 2, 2014

Abortion is one of the most common procedures in the US, with over 1.06 million performed, in 2011. The number of abortion providers has decreased by 40% since 1981, resulting in 89% of counties without a provider. Efforts to counteract this decline include legislation to expand the types of abortion providers and training programs to support residents in a dedicated family planning rotation. However, states are increasingly passing laws impacting abortion access, from gestational age limits, TRAP laws, and funding restrictions. This article reviews the incidence of abortion in the United States and explores the myriad of factors affecting the availability of abortion services.

Abortion has been legal since the 1973 United States Supreme Court decision in Roe versus Wade. Since 1973, there have been nearly 53 million abortions performed, with 1.06 million abortions in 2011 [1]. In 2011, the abortion rate was the lowest since 1973, with 16.9 abortions per 1000 women age 15- 44 years [2]. Although the abortion rate had declined, the unintended pregnancy rate remained constant at 50% and almost half of these pregnancies resulted in abortion [3]. There has been a consistent demand for abortion services; however, the number of U.S. abortion providers declined 4% between 2008 (1,793) and 2011 (1,720) [1]. Studies have shown that physician intent to provide abortions prior to residency training and sufficient abortion training in residency are positively associated with future abortion provisions after residency [4-6]. Abortion education in medical school and abortion training in residency are thus essential to continued access to safe abortion services for women. This article will provide a brief history and update of the current state of U.S. abortion education, focusing specifically on education and training of physicians.

Use of any form of contraception results in cost-savings compared to non-use of contraception, regardless of payer type. Long-acting reversible contraceptive (LARC) methods are significantly more cost-effective than short-term hormonal and barrier methods, even when LARC methods are not used for their full duration of efficacy. Despite increased contraceptive coverage and reduced patient cost-sharing under the Affordable Care Act, significant barriers remain in addressing the unmet need for effective contraception and fully realizing the decreased health care costs associated with use of contraception in the United States.

Since the introduction of hormonal contraception in the 1960s, their popularity has grown exponentially and benefits a large population of reproductive aged women. Currently available options are lacking for women with comorbidities such as hypertension, migraines, lupus, liver pathology, thrombophilias, obesity, etc. Recent studies reveal promising evidence of several non-hormonal contraceptive methods that will be of tremendous benefit to women with these comorbidities. Non-hormonal contraceptive methods under investigation include Phosphodiesterase (PDE) 3/5/9 inhibitors, matrix metalloprotease (MMP) inhibitors, cyclooxygenase-2 inhibitors, prostaglandin E2 receptor antagonists, C31G spermicide, SGK/AKT, polidocanol foam, quinacrine pellets, proprotein convertase 6 inhibitors, interleukin 11 (IL-11), leukemia inhibitory factor (LIF), and Juno-Izumo binding vesicles. These methods would provide new options for female contraception particularly for those women who can’t use hormonal contraception.

Addressing contraception and prevention of sexually transmitted infections world-wide, including HIV-1, is imperative. The HIV/AIDS pandemic, and its impact on women, has prompted the investigation of multipurpose technologies, specifically, prevention strategies to protect against unwanted pregnancy and prevent the sexual transmission of HIV. Current research in multipurpose technologies is targeted to develop a discrete and long acting device, highly effective in preventing both HIV and unintended pregnancy. Significant advances in research development in contraception devices, that also prevent STDs, have occurred in the last decade. There are currently no approved MPTs on the market; however a number of fixed dose drug combination medications targeted to treat a single indication exist. These combined medications have been shown to improve ease of use, patient compliance, and outcomes. Multipurpose technologies have the potential to provide dual therapies, each with its own selected properties and mechanism of action. The need for MPTs conceptually has been known since the early 1990s, but little to no progress has been made until recently. This section will focus on need for MPTs in the face of the HIV pandemic, and the need for highly effective contraception in HIV positive women.

The majority of safety profile data on current contraceptive options were studied on young, healthy women without significant medical co-morbidities. However many women of reproductive age have important medical conditions, in which certain contraceptive options may have increased risk and side effects. Therefore extrapolating the risk profile of contraceptive options from healthy women to women with coexisting medical conditioning is potentially dangerous. More importantly, pregnancy, especially unintended pregnancy, among women with certain medical conditions increased both maternal and fetal health risk, thereby increasing the importance of reliable, safe contraception. The Medical Eligibility Criteria for Contraceptive Use (MEC) by the World Health Organization (WHO) and Centers for Disease Control was created to help bridge the gap in contraceptive care in women with certain medical conditions. It provides guidance for healthcare providers to help choose the safest, most reliable form of contraception for their patients. The MEC document categorizes medical eligibility for contraceptive use into categories based upon risk. The purpose of this article is to review the evidence behind these recommendations and review new information published since release of the MEC.

For a number of years the only options for male contraception were condoms or vasectomy. In the past two decades a number of hormonal and non-hormonal options have been evaluated in basic science, animal and clinical studies. This section will review the mechanism of action, limitations, and efficacy of male contraceptives that are in current clinical use as well as products that are in development.

Polycystic ovary syndrome (PCOS) is a multifactorial disorder that becomes apparent during adolescence with a variety of hormonal and metabolic symptoms. Patients with PCOS can present with ovulatory dysfunction, polycystic ovaries, androgen excess, metabolic abnormalities or a combination of some or all of these problems. The cause of PCOS is unknown but studies suggest a strong genetic component that is affected by the gestational environment and lifestyle factors. Recent advances in our understanding of genetics, diet-induced inflammation, gut microbiome, epigenetics and molecular toxicology suggest that there may be multiple mechanisms that could contribute to the variety of clinical presentations observed in PCOS. Prepubertal metabolic dysfunction may be one of the first phenotypic traits observed in adolescent girls likely to develop PCOS. In the future it may be possible to identify girls at risk of developing PCOS and implement preventative measures prior to the onset of clinical signs and symptoms. PCOS can be effectively treated with a combination of lifestyle approaches including diet and exercise. There is emerging evidence that a high quality low glycaemic load (GL) diet may have an important role in improving anthropomorphic and metabolic outcomes in women with PCOS.

The purpose of a cervical screening program is to reduce morbidity and mortality from invasive cervical cancer. High-risk HPV DNA testing is more sensitive but less specific than conventional cytology. The increase in sensitivity results in doubling of positive subjects compared with Pap smear. However, lowgrade epithelial anomalies are over-represented when using HPV testing. Investigation and eventual treatment of many self-limiting conditions that would regress spontaneously result in needless psychological morbidity and increased costs. The same holds true for false positive results caused by a reduction in specificity. Moreover, the difference in sensitivity in favour of HPV testing has been demonstrated mainly at single testing. However, performance of repeated Pap smears at pre-determined time intervals greatly improves the accuracy of cytology. Limited adherence to prevention programs of women in lower socio-economic strata is among the risks related to the increase in cost of screening. The widespread utilization of different molecular tests not applied consistently according to the rules of good scientific practice has an economic, social, and psychological impact that seems to have greatly outweighed benefits. Indeed, a true reduction in mortality from invasive cervical cancer after the introduction of HPV testing has not yet been demonstrated. In addition, there is no general agreement on appropriate triage test for a positive HPV result, and guidelines are often not followed in general practice. Inappropriate testing increases costs without benefit, and potentially results in overtreatment. In European countries as well as in those countries where infrastructures are available, cytology is likely to remain the most cost-effective strategy in cervical cancer prevention, together with the implementation of HPV vaccination programs.