This month’s clinical pearl

February 2018 Pearl:

There are three national guidelines; each one says something different. All three agree that there is no evidence that the [screening pelvic exam] is beneficial. There is evidence of harms, including false alarms.” — Contraceptive Technology, upcoming 21st edition, in preparation

January 2018 Pearl:

“The Centers for Disease Control and Prevention’s Medical Eligibility Criteria and Selective Practice Recommendations website and mobile app … will have answers to most contraceptive questions healthcare providers might have when initiating contraceptives with their patients. These resources are also maintained regularly.” — Contraceptive Technology, upcoming 21st edition, in preparation

December 2017 Pearl:

“No contraceptive method is contraindicated on the basis of age alone.” — Contraceptive Technology, upcoming 21st edition, in preparation

November  2017 Pearl:

“Cumulatively, evidence supports the conclusion that once the implant is in place, it provides convenient, “forgettable,” ongoing pregnancy protection that is not affected by BMI.” — Contraceptive Technology, upcoming 21st edition, in preparation

October 2017 Pearl:

” All patients should be offered counseling and voluntary HIV testing, and those at risk should be linked to services that provide HIV PrEP. A useful resource is the PrEP in Family Planning Tool Kit, available at” — Contraceptive Technology, upcoming 21st edition, in preparation

September 2017 Pearl:

“Although abstinence has become associated with saying “no,” viewed from another perspective, abstinence can mean saying “yes” to a number of other sexual activities and personal priorities.”— Contraceptive Technology, upcoming 21st edition, in preparation

August 2017 Pearl:

“As more than 75% of patients will begin their search for health information by using popular search engines such as Google, Bing, or Yahoo, they may face difficulty in parsing out the most appropriate sources for their queries.”— Contraceptive Technology, upcoming 21st edition, in preparation

July 2017 Pearl:

“In a review of [the] literature, IUDs were placed up to 7 days after unprotected intercourse (UPI) in three studies, up to 10 days after UPI in one study, and up to 10+ days after UPI in one study; there were 0 pregnancies.”— Contraceptive Technology, upcoming 21st edition, in preparation

June 2017 Pearl:

User instructions for progestin-only pills: “If you vomit within 4 hours after taking a pill, or if you have diarrhea…Keep taking the pills on schedule, but use a back-up method until 48 hours after vomiting or diarrhea are over.”— Contraceptive Technology, p. 244

May 2017 Pearl:

“…approximately 15% of clinical recognized pregnancies end spontaneously in early pregnancy…a prospective observational trial of 30 women having spontaneous abortion found success rates for expectant management are 82.1% at 2 weeks and 100% by 30 days…as long as the woman is stable.”— Contraceptive Technology, p. 677

April 2017 Pearl:

“When we counsel patients about birth control, help patients make decisions about an unintended pregnancy, help women plan for pregnancy and safely traverse its nine months…whether or not we are aware of it, we are engaged in a critically important and deeply moral undertaking.”—Contraceptive Technology, p. xxiii

March 2017 Pearl:

“Women with osteopenia have twice the risk for hip fracture…and women with osteoporosis have a nearly 9-fold increased risk.”—Contraceptive Technology, p. 750

February 2017 Pearl:

“Tubal infertility per PID episode: 8% after first episode; 20% after second episode; 40% after third episode.”—Contraceptive Technology, p. 573

January 2017 Pearl:

“The difference between pregnancy rates during typical use and pregnancy rates during perfect use reveals the consequences of imperfect use; this difference depends both on how unforgiving of imperfect use a method is and on how hard it is to use that method perfectly.”—Contraceptive Technology, p. 49

December 2016 Pearl:

“Although abstinence has become associated with saying “no,” viewed from another perspective, abstinence can mean saying “yes” to a number of other sexual activities…an abstinent person does not lose his or her sexuality…” —Contraceptive Technology, p. 106-7

November 2016 Pearl:

“The best approach to reducing the impact of [bleeding changes associated with using contraceptive implants] is to forewarn women about it emphasizing that it is generally not dangerous.” —Contraceptive Technology, p. 198

October 2016 Pearl:

“Low levels of hCG (5 to 30 mIU) may be associated with tumors of the pancreas, ovaries, breast, and many other sites. some normal postmenopausal women also have low levels of circulating hCG-like substance of pituitary origin.”Contraceptive Technology, p.  667

September 2016 Pearl:

“… double-blind placebo-controlled trials have shown no difference in the incidence of any of the major side effects in COC users compared to pill users; similar percentages…developed headaches, nausea, vomiting, mastalgia excessive weight gain, etc. However, some women may be more sensitive to exogenous hormones, so counsel all potential hormonal contraceptive users that side effects may be possible but not necessarily to be expected.”Contraceptive Technology, p.  311

August 2016 Pearl:

“Milk expression, such as by hand or pump, is not a substitute for breastfeeding in terms of its fertility-inhibiting effect.”Contraceptive Technology, p.  487

July 2016 Pearl:

“When a woman has had unprotected sex, we can offer her an intrauterine contraceptive rather than emergency contraceptive pills. Placement of the IUD within several days of unprotected sex reduces a woman’s risk of pregnancy to about 1 in 1,000 and providers her with 10 to 20 years of highly effective, fully reversible contraception…”Contraceptive Technology, p.  xxvi

June 2016 Pearl:

“… severe diarrhea can decrease your body’s ability to absorb the pill’s hormone. If you have vomiting or diarrhea, treat it as if you had missed pills.”—Contraceptive Technology, p.  322

May 2016 Pearl:

“Breastfeeding has a major protective effect against premenopausal cancers of the ovary, endometrium, and breast and protects against type 2 diabetes.”—Contraceptive Technology, p.  501

April 2016 Pearl:

“For some areas of clinical medicine, the why seems hardly to need articulating…The value of work as a heart disease clinician [for example] is not likely to be attacked as immoral…Unfortunately, tis is not true for clinicians working in the field of family planning services and reproductive health.” —Felicia Stewart, MD, in Contraceptive Technology, p.  xxiii

March 2016 Pearl:

“More frequently, women with [heavy menstrual bleeding] have functional problems with excessive endometrial fibrinolysis, a prostaglandin imbalance, vessel instability, or inhibition of matrix metalloproteinase activity. only about half of women with heavy menstrual bleeding have an anatomical pathology…”—Contraceptive Technology, p.  548

February 2016 Pearl:

“The conditions that cause secondary amenorrhea…also commonly cause infrequent menses. Once pregnancy is ruled out, most cases are round to be associated with estrogen production but with a lack of progesterone.”—Contraceptive Technology, p.  541

December 2015 Pearl:

“IUC use appears safe and effective for women who are immunosuppressed due to organ transplantation, autoimmune disease, or infection with HIV. IUC use has not been shown to increase viral shedding, and clinical HIV disease progression was slower among women using the TCU380A than among women using hormonal contraception.”—Contraceptive Technology, p. 159

November 2015 Pearl:

“Ovulation can occur even though the breastfeeding mother has not yet resumed menstruation…33-45% during the first 3 months postpartum; 64-71% during months 4 through 12; 87-100% after 12 months.”—Contraceptive Technology, p. 486

October 2015 Pearl:

“…the risk of infection and infertility among IUC users is very low. …the placement process, and not the device or its thread, poses a small transient risk of infection… However, antibiotic prophylaxis should not be routinely used before placement.”—Contraceptive Technology, p. 156

September 2015 Pearl:

“…insulin resistance in women with polycystic ovarian syndrome does not predictably worsen with COC use.”—Contraceptive Technology, p. 287

August 2015 Pearl:

Risk of death (per year)Using combined oral contraceptives (and presumably the path and ring) for nonsmokers aged 15-34: 1 in 1,667,000 / From an automobile accidents: 1 in 5,000 / From a fire: 1 in 20,000 / In an airplane crash: 1 in 250,00.”  —Contraceptive Technology, back inside cover

July 2015 Pearl:

“Most studies show that during vaginal sex, condoms break approximately 2 percent of the time during intercourse or withdrawal and a similar proportion slip off completely…advise users to have several condoms available in case a condom is torn or put on incorrectly…”               —Contraceptive Technology, p. 380

June 2015 Pearl:

“The risk of VTE [venous thromboembolism] with COCs [and other hormonal contraceptives] is greatest in the first 3 to 12 months of use and declines thereafter.”               —Contraceptive Technology, p. 277 

May 2015 Pearl:

“COC use increases bone mineral density (BMD) in … anorexic teenagers. COC use by women with osteopenia due to anorexia nervosa is not sufficient to completely protect bone, but when added to anabolic agents such as insulin growth factor, COC use significantly improves that agent’s effectiveness. –Contraceptive Technology, p 270

April 2015 Pearl:

“Preventing pregnancy is generally safer than pregnancy. Compare the risk of death associated with using combined hormonal contraceptives with the risk of death associated with pregnancy:

  • Pregnancy: 1 in 6,700
  • Nonsmokers: the risk for women aged 15-34 is 1 in 1,667,000 and for women aged 35-44 it is 1 in 33,000.
  • Smokers: the risk for women aged 15-34 is 1 in 57,800 and for women aged 35-44 it is 1 in 5,200.” –Contraceptive Technology, inside back cover

March 2015 Pearl:

“Women using ACE inhibitors, angiotensin-II antagonists, potassium-sparing diuretics, heparin, aldosterone antagonists, and NSAIDS on a chronic daily basis to treat chronic conditions or diseases should have their serum potassium checked during the first cycle of drospirenone use (usually about 14 days after pill initiation). If those levels are normal, no future testing is necessary.” –Contraceptive Technology, p. 308

February 2015 Pearl:

“In a study of high-school students who consider themselves virgins, 30% had engaged in heterosexual masturbation of or by a partner, 9% had engaged in fellatio (oral-penile contact) with ejaculation, and 10% had engaged in cunnilingus (oral-female genital contact).”–Contraceptive Technology, p. 102

January 2015 Pearl:

“Women with continued spotting or bleeding following their scheduled bleeding may need more estrogen to proliferate the endometrium. Increase the estrogen to proliferate the endometrium. increase the estrogen in the first pills in the pack or decrease the progestin content of those first pills.”–Contraceptive Technology, p. 313

December 2014 Pearl:

 “…probabilities of pregnancy cumulate over time. For example, suppose that each year the typical proportion of women becoming pregnant while taking the pill is 8%…Within 5 years [of pill use], 34%…will become pregnant.” —Contraceptive Technology, p. 55

November 2014 Pearl:

“In terms of contraceptive service delivery, routine adherence to the 6-week convention does not seem appropriate…Although nearly all contraceptive methods can be used postpartum, the methods vary in terms of when in postpartum period they should be initiated. 6 weeks is too late to begin contraceptive for nonbreastfeeding mothers who wish to start using [hormonal methods]; 3 weeks is too soon for inserting an IUC…” —Contraceptive Technology, p. 490

October 2014 Pearl:

“Unintended pregnancy/coital act: 17%-30% midcycle, <1% during menses.” —Contraceptive Technology, p. 573

September 2014 Pearl:

“Among nonmarried women, 32% reported they had not had sex in the past year, 25% reported only a few times in the past year, 26% reported a few times in the past month, and 26% reported two or more times per week.”  —Contraceptive Technology, p. 5

August 2014 Pearl:

“Most women wish to discuss sexual concerns but report that most providers neither inquire about nor follow up on sexual issues…” —Contraceptive Technology, p. 2

July 2014 Pearl:

“While there is considerable variation in cycle length, less than 1% of women have a regular cycle length of less than 21 days or more than 35 days.” — Contraceptive Technology, p. 30

June 2014 Pearl:

“Leiomyoma (uterine fibroids) contain both estrogen and progesterone receptors…However, clinical studies with low-dose COCs have found no impact on the risk of developing new fibroids or on increasing the size of pre-existing fibroids, except in women who used COCs early in life.” — Contraceptive Technology, p. 287

May 2014 Pearl:

“While chronic daily use of some drugs may increase serum potassium in some women using drospirenone-containing contraceptive pills, note that intermittent use of NSAIDS does not pose any problems. If a woman is using other potassium-sparing drugs, test her potassium about 14 days after starting her first pack; if that value is normal, no further testing is needed for potassium.”                                                                                                 — Contraceptive Technology, p. 287-88

 April 2014 Pearl:

“The typical woman who uses reversible methods of contraception continuously from age 15 to age 45 would experience 1.8 contraceptive failures.”                                                                         — Contraceptive Technology, p. 55

 March 2014 Pearl:

“The protective effect of transabdominal tubal sterilization on ovarian cancer persists over many years…The risk remained low up to 25 years after surgery and was irrespective of sterilization technique.”
 Contraceptive Technology, p. 441

February 2014 Pearl:

“What about new contraceptives for men? Except for gossypol, no method has been developed sufficiently for clinical studies.”
 Contraceptive Technology, p. 525

January 2014 Pearl:

“…we need to convey not only the science of reproductive health, but also why it is of vital importance in people’s lives…If we fail to do so, we are abdicating the moral high ground to those who oppose efforts to provide reproductive health care.”

 Felicia Stewart, MD (1943-2006)

December 2013 Pearl:

“IUCs [intrauterine contraceptives] protect women from ectopic pregnancy…However when a woman does conceive with an IUC in place she is at increased risk of having an ectopic pregnancy…6% to 50% of pregnancies are ectopic.”
 Contraceptive Technology, p. 157

November 2013 Pearl:

“…antibiotic prophylaxis should not be routinely used before placement [of an intrauterine device].”
 Contraceptive Technology, p. 156

October 2013 Pearl:
“Spermatozoa appear in the pre-ejaculatory fluid of some men and could cause pregnancy even if the man withdraws prior to ejaculation.”
Contraceptive Technology, p. 409

September 2013 Pearl:
“…a women’s blood loss is excessive when she says it is excessive…the key factor in making a diagnosis of [heavy menstrual bleeding] is not the amount of blood a woman loses, which is difficult to ascertain, but how a woman’s HMB disrupts her life.
Contraceptive Technology, p. 547