November 2019

Your practice is likely serves many ‘digital natives’—millenials, who rely heavily on electronic apps and online sources for their healthcare. The trend has only grown since a 2015 tech survey reporting that female millennials specifically spend 200% more time on health and fitness apps than do all other users. The rapid developments in digital health sites and apps have transformed the provider-patient relationship such that today you are not only responsible for providing information but also for guiding patients’ search for and use of digital information. How can you advise your patients about the utility and the downfalls? Brian Nguyen and Leo Han recently curated a guide to digital resources relevant to family planning in the form of websites, mobile applications, and social media in Contraceptive Technology.[1]

The market for digital health apps is enormous and continually expanding. A 2015 survey conducted by the Institute for Healthcare Informatics found over 165,000 healthcare-related apps across both Apple and Android platforms. Of nearly 100,000 health apps available through Apple, 7% were relevant to women’s health and pregnancy.[2] However, there is currently a lack of expertise and resources with which to make evidence-based, unbiased, commercial-free referrals to apps that may be clinically useful to patients and healthcare providers. While the Apple platform requires a certification process for content and functionality, the Android platform does no quality screening.

Consequently, some apps exist in the online stores that claim to be able to determine when a woman ovulated, independent of her cycle, and others claim to be able to determine the gender of a woman’s pregnancy as influenced by her date of conception.[3] Additionally, many of the apps on both platforms are developed by groups with profit interests. These groups may not be advised by a professional committee from the healthcare field, and their apps may not have been validated by such a committee. These apps often cost the user money to download; those that are free are commonly subject the user to advertisements.

How do you keep up with the vast array of e-resources that change with the speed of light? You cannot, so apps described here are not be individually analyzed but instead the landscape of apps are assessed according to categories relevant to contraceptive technology to help you discuss the resources with your patients and steer them in a more reliable direction. (Examples of apps listed do not serve as any endorsement of the app.)

Menstrual Cycle And Fertility Tracking   

Menstrual tracking apps tend to be marketed by their ability to inform the user about one of two conditions that are based upon the same physiological premise: (1) fertility tracking apps to notify users when intercourse is optimal for conception and (2) contraceptive apps to notify users of the days when intercourse is less likely to lead to pregnancy. According to one survey, more than half of women initiating contraception report tracking their menses.[4] Menstrual cycle tracking apps are the fourth most popular health app among adults and the second most popular health app among adolescent females.[5] While many are free, most charge a small fee ($0.99 to $9.99).

Some of these apps (e.g., Clue) market themselves as a form of “nonhormonal” contraception and have substantial commercial financial backing. Given the uptake of these apps, one group conducted a survey of available menstrual tracking apps in 2016, finding more than 225 apps. Fewer than 20 of these apps were accurate, and only 5% of them had ever involved a professional health care consultant or cited any medical literature. Most available apps simply did not function as advertised or contained misleading information or misinformation.

To provide an accurate assessment, menstrual tracking apps should require the user to collect data over multiple cycles and account for several other factors that may have an impact on a user’s cycling. As a result, the authors of the survey concluded that apps could not be a primary tool for assisting with conception or contraception without the oversight of you or another health care provider.[6],[7] To date only one app appears to have a validation study of any kind (Natural Cycles),[8] and another is currently under way.[9]

Despite their shortcomings, tracking apps are more than fancy, pixelated alternatives to traditional cycle beads. A few theoretical advantages include the following features:

Sophisticated tracking mechanisms   

While traditional fertility predicting methods rely on a cycle length within a fairly normal range, some apps use proprietary algorithms to provide unique fertility predictions based on user-provided data. Some use additional inputs such as data from a thermometer (e.g., Natural Cycles, Kindara) and user reports of cervical mucus (e.g., Ovia). Others integrate data from multiple user inputs (e.g., Glow) as well as provide fertility recommendations for women using birth control (e.g., Clue). Nevertheless, almost none of the technological claims has a validating study and all of these apps ultimately come from a place of commercial interest (Glow for example has an IVF function that facilitates consultation with a reproductive endocrinologist and claims that IVF cycles are cheaper through Glow).

Push alerts   

Unlike Cycle Beads, apps not only automatically advance daily, but they can send notifications to patients of “at risk days.” What apps cannot do is prevent women from having intercourse on “fertile” days, and in fact, in the single validation study that is available, 51% of women logged unprotected intercourse during a day she was at risk for pregnancy.⁹

Symptom tracking   

For practitioners working with patients who experience menstrual-cycle-related health conditions, apps provide an opportunity for patients to keep a digital diary. Many fertility tracking apps also allow patients to record their bleeding pattern over time (e.g., Kindara, Clue, SpotOn). This feature can help patients track symptoms to help distinguish between heavy menstrual bleeding and intercycle bleeding for diagnostic purposes, assess the quantity of bleeding the patient is experiencing, and assess the effectiveness of treatments. Some apps are also available to track additional symptoms such as painful periods, mood-related symptoms, headaches, and pelvic pain. From these apps, HCPs can evaluate the cyclicity of symptoms prior to contraception as well as the frequency of symptoms after contraceptive initiation, whether for treatment or for monitoring side effects. Variants of these apps are marketed toward specific conditions such as menopause (e.g., Menopause View) and endometriosis (e.g., Futter).

Birth Control/Pill Reminders   

After fertility tracking, birth control/pill reminders are the second most prevalent app type available.[10] There are some dedicated reminder apps (e.g., Bedsider Birth Control Reminders), which are essentially glorified calendar alarms. However, they do allow the user to input which short-acting method (e.g., pills, patches, shots, or rings) is used and then tailor the reminder to the recommended dosing schedule. For the most part, this is also a functionality built into many of the fertility trackers apps (e.g., Spot On, Planned Parenthood). No validation studies of reminder apps have been done to date. However, a well-conducted RCT of a daily text-message reminder did not improve pill adherence.[11] It remains unclear if adherence would be improved with a better designed app that provides back-up alarms and task management software to establish routines and confirm task completion.[12]

Pregnancy Test Apps   

Multiple apps on the market currently claim to function as pregnancy tests. While most have a disclaimer that there is no medical basis for the app or that it is to be used only as a joke or prank, not all of them are labeled clearly. To date, there is no known app for any platform that can determine if a woman is pregnant

So there you have it. And one more word on digital resources that your millienial patients depend on: most rely on online ratings and descriptions before choosing a ‘doctor.’[13] We assume that designation might include advanced health care practitioners. So pay attention and manage

[1] Nguyen B, Han L. Digital resources for health and medical information. Appendix. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018.

[2] Quintiles IMS. Patient Adoption of mHealth. Report by the IMS Institute for Healthcare Informatics, 2015. www.imshealth.com/files/web/IMSH%20Institute/Reports/Patient%20Adoption%20of%20mHealth/IIHI-Patient-Adoption-mhealth-Exhibits-Full.pdf. Accessed Sep 20, 2017.

[3] Boulos MNK, Brewer AC, Karimkhani C, Buller DB, Dellavalle RP. Mobile medical and health apps: state of the art, concerns, regulatory control and certification. OJPHI 2014;5:229.

[4] Nippita S, Oviedo JD, Velasco MG, Westhoff CL, Davis AR, Castaño PM. A randomized controlled trial of daily text messages versus monthly paper diaries to collect bleeding data after intrauterine device insertion. Contraception 2015;92:578–584.

[5] Wartella E, Rideout V, Montague H, Beaudoin-Ryan L, Lauricella A. Teens, health and technology: A national survey. Media and Communication 2016;4:13–23.

[6] Moglia ML, Nguyen HV, Chyjek K, Chen KT, Castaño PM. Evaluation of smartphone menstrual cycle tracking applications using an adapted APPLICATIONS scoring system. Obstet Gynecol 2016;127:1153–1160.

[7] Duane M, Contreras A, Jensen ET, White A. The performance of fertility awareness-based method apps marketed to avoid pregnancy. J Am Board Fam Med 2016;29:508–511.

[8] Berglund Scherwitzl E, Gemzell Danielsson K, Sellberg JA, and Scherwitzl R. Fertility awareness-based mobile application for contraception. Eur J Contracep Repr Health Care 2016;21:234–241.

[9] Simmons RG, Shattuck DC, Jennings VH. Assessing the efficacy of an app-based method of family planning: the Dot Study Protocol. JMIR research protocols 2017;6:e5.

[10] Mangone ER, Lebrun V, and Muessig KE. Mobile phone apps for the prevention of unintended pregnancy: a systematic review and content analysis. JMIR mHealth uHealth 2016;4:e6.

[11] Hou MY, Hurwitz S, Kavanagh E, Fortin J, and Goldberg AB. Using daily text-message reminders to improve adherence with oral contraceptives: a randomized controlled trial. Obstet Gynecol 2010;116:633–640.

[12] Stawarz K, Cox AL, Blandford A. Don’t forget your pill!: designing effective medication reminder apps that support users’ daily routines. In Proceedings of the 32nd annual ACM conference on Human factors in computing systems, 2014.

[13] Comstock J. Survey: 54 percent of millennials look online before choosing a doctor. MobiHealth News https://www.mobihealthnews.com/46432/survey-54-percent-of-millennials-look-online-before-choosing-a-doctor/  [Accessed 10/29/2019]