WILL THE DOCTOR DO IT?

Ninety-seven percent of practicing obstetrician-gynecologists encounter patients who are seeking abortions, but only 14% perform the procedure, according to results of a survey conducted in late 2008 and early 2009.¹ Multivariate analysis of data gathered from a nationally representative sample of 1,144 physicians aged 65 or younger revealed that women are more likely than men to perform abortions (odds ratio, 2.5), Jewish doctors are more likely than those with no religious affiliation to do so (3.3) and physicians for whom religion is not very important are more likely than those with a high degree of religiosity to do so (2.0–2.7). The likelihood of performing abortions was reduced among Christians (0.1–0.5) and employees of Catholic facilities (0.3); it also was lower among doctors aged 36–45 than among 26–35-year-olds. The odds that doctors perform abortions were elevated in the most urban areas and reduced in the South and the Midwest. The survey did not ask respondents who do not perform abortions whether they provide referrals.

1. Stulberg DB et al., Abortion provision among practicing obstetrician- gynecologists, Obstetrics & Gynecology, 2011, 118(3):609 –614.

REAL SEX, REAL RISK

The sex in adult films is real, often prolonged and unprotected, and it puts performers at substantial risk for STDs. Using 2008 data from California facilities that test adult film performers for STDs, analysts estimated that the cumulative annual incidence of chlamydia in this population is 14–22%, and that of gonorrhea is 5–8%; by comparison, for Los Angeles County overall, the rates among 18–29-year-olds are 2% and less than 1%, respectively.¹ Between 2004 and 2007, more than 2,000 adult film performers acquired STDs—57% of them chlamydia, 35% gonorrhea and 8% both. Moreover, within one year of a diagnosis, 26% of these men and women were reinfected. Reinfection occurred within less than six months, on average, and was more likely among women than among men. The analysts comment that the adult film industry, which is self-regulated, "has not sufficiently protected performers." They call on the federal and state governments to "[place] more responsibility on production companies to ensure the safety of their vulnerable employees."

1. Goldstein BY et al., High chlamydia and gonorrhea incidence and reinfection among performers in the adult film industry, Sexually Transmitted Diseases, 2011, 38(7):644–648.

NEW, IMPROVED HIV ESTIMATES

The overall incidence of HIV in the United States appears to have been stable between 2006 and 2009, according to a report by researchers who examined surveillance data from 16 states and two cities.¹ Using an estimation approach that sought to overcome the shortcomings of earlier strategies, they calculated that in each year, roughly 20 of every 100,000 Americans aged 13 and older became infected with HIV. The incidence of infection changed significantly only among 13–29-year-olds, who registered a 21% increase. Within this age-group, incidence rose only among men who have sex with men, and that increase was explained by a rise among blacks. Likewise, an overall increase in HIV incidence among young men who have sex with men was due entirely to an increase among blacks. HIV, the researchers observe, continues to take a "disproportionate toll … on several populations in the United States, including racial/ethnic and sexual minorities."

1. Prejean J et al., Estimated HIV incidence in the United States, 2006–2009, PLoS ONE, 2011, 6(8):e17502, doi:10.1371/journal.pone.0017502.

ANOTHER BENEFIT OF IUD USE?

The IUD, an effective contraceptive that is known to reduce the risk of endometrial cancer, may also be protective against cervical cancer. A pooled analysis of 26 studies conducted on four continents between 1993 and 2007 found that the odds of cervical cancer were reduced by 45% among women who had ever used an IUD.¹ The results were similar for the two major types of cervical tumors, but the association did not hold for women who were infected with human papillomavirus (HPV), and it was not affected by women’s duration of IUD use. "In view of the wide use of IUDs worldwide," the researchers remark, "women, gynaecologists, and reproductive-health professionals can be reassured that IUDs do not seem to increase the risk of cervical HPV infection."

1. Castellsagué X et al., Intrauterine device use, cervical infection with human papillomavirus, and risk of cervical cancer: a pooled analysis of 26 epidemiological studies, Lancet Oncology, 2011, 12(11):1023–1031.

THE NOT-FIVE-DAY-AFTER PILL

Levonorgestrel is effective as an emergency contraceptive when taken up to four days after unprotected intercourse, but the risk of pregnancy rises significantly if use is delayed beyond that window, according to findings from an analysis using pooled data from four randomized trials.¹ The combined data set includes nearly 7,000 women who took 1.5 mg of levonorgestrel, in one dose or in two doses 12 hours apart, and specifies the 24-hour interval between unprotected sex and administration of the drug. Pregnancy rates among women who took levonorgestrel one, two, three or four days after unprotected sex were statistically indistinguishable—about 1%. However, the rate was 5% among those who took the drug on the fifth day; logistic regression confirmed that this group was more likely to become pregnant than were those who took levonorgestrel within 24 hours. The analysts note that the number of women who seek emergency contraception more than 72 hours after having unprotected intercourse "is usually small." At the same time, they caution that "it is uncertain" whether levonorgestrel taken on the fifth day "still offers some protection against unwanted pregnancy."

1. Piaggio G, Kapp N and von Hertzen H, Effect on pregnancy rates of the delay in the administration of levonor gestrel for emergency contraception: a combined analysis of four WHO trials, Contraception, 2011, 84(1):35–39.

PRISONERS KNOW THEIR STUFF

Although the World Health Organization has targeted prisoners as a vulnerable population in need of STD education and services, levels of STD knowledge in this population have been largely unexplored. A study out of Australia, however, provides some evidence that prisoners are not far behind the general population in this regard and, in some ways, may be somewhat ahead.¹ In a 2001–2002 telephone survey, a random sample of prisoners aged 18–59 and a comparable sample of adults in the general population were asked four questions assessing their STD knowledge; the proportions answering each question correctly were 50–60% among prisoners and 17–69% in the general population. The former were more likely than the latter to know that chlamydia affects both men and women (odds ratio from an analysis adjusting for gender, education and STD history, 6.4) and that it can lead to infertility (2.4). They were less likely to know that one virus can cause both cold sores and genital herpes (0.8); the two groups did not differ in their knowledge that people who acquire genital herpes will have the virus for life. While acknowledging that increased STD knowledge "might not necessarily translate" into safer sexual behavior, the investigators conclude that their findings underscore the need for STD education among prisoners and the general population.

1. Malacova E et al., Knowledge of sexually transmissible infections: a comparison of prisoners and the general population, International Journal of STDs and AIDS, 2011, 22(7):381–386.

MARRIAGE LOSES THE ADVANTAGE

Married women are less likely than unmarried women to have a preterm birth, but the gap is closing, according to an analysis of Michigan birth certificate data for 1989–2006.¹ Over the study period, the incidence of preterm birth (i.e., birth before 37 weeks’ gestation) rose by 31% among married women and fell by 9% among unmarried women. In 1989, unmarried women had a 49% greater risk of this outcome than their married peers; in 2006, only a 21% greater risk. Married women at the end of the period were about half again as likely as their counterparts in 1989 to have a preterm birth; for unmarried women, the risk was essentially unchanged. The analysts suggest that further research explore "the changing dynamic of marriage as a determinant of adverse birth outcomes."

1. El-Sayed AM and Galea S, Changes in the relationship between marriage and preterm birth, 1989–2006, Public Health Reports, 2011, 126(5):717–725.

MISSED OPPORTUNITIES IN THE ER

Sexual risk assessment of teenage women who visit an emergency room because of symptoms that may suggest STD infection could be crucial to their treatment but often does not occur, a study conducted in a large urban hospital reveals.¹ Of the 327 women aged 14–19 who went to the emergency room with complaints that could point to an STD during a six-month period in 2009–2010, one in five did not have a sexual history taken by a physician; three-quarters of this group had told the doctor that they were sexually active. Women older than 14 and blacks were more likely than younger teenagers and those of other races, respectively, to have had a history taken (odds ratios, 2.6 and 2.0). The odds of STD testing were significantly elevated if a physician took a teenager’s sexual history (3.9) or documented that she was sexually active (6.8). The results, according to the researchers, suggest that physicians’ making assumptions about teenagers’ sexual activity "can potentially lead to missed opportunities" for identifying STDs. The investigators add that "future efforts should focus on educating [emergency department] physicians on the importance of routinely obtaining a sexual history from adolescents" visiting the emergency room.

1. Goyal M et al., Sexual history documentation in adolescent emergency department patients, Pediatrics, 128(1):86-91.

MISCARRIAGE RISK LINKED TO COMMON ANTI-INFLAMMATORIES

Use of prescription nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs) during pregnancy was linked to an increased risk of miscarriage in a study based on data from a registry that since 1997 has followed all women in Quebec for the duration of their pregnancies.¹ In analyses that adjusted for variables that may affect both use of nonaspirin NSAIDs and the risk of spontaneous abortion, the odds of miscarriage were more than doubled among women who had filled prescriptions for these drugs while pregnant (odds ratio, 2.4). Users were at increased risk regardless of the specific NSAID—or combination of NSAIDs—they took or the dosage. The risk was also elevated among women who had taken a nonaspirin NSAID within two weeks before miscarrying, but this association was not significantly different from that for users overall. The researchers acknowledge that the data indicate only that women obtained nonaspirin NSAIDs, and not that they actually took them, and that information about women’s use of over-the-counter versions of these drugs is lacking. Despite these and other study limitations, they warn that "nonaspirin NSAIDs should be used with caution during pregnancy."

1. Nakhai-Pour HR et al., Use of nonaspirin nonsteroidal anti-inflammatory drugs during pregnancy and the risk of spontaneous abortion, Canadian Medical Association Journal, 2011, doi:10.1503/cmaj.110454, accessed Sept. 6, 2011.