Dr. Rahman is a resident physician in the Department of Obstetrics & Gynecology at George Washington University School of Medicine and Health Sciences in Washington, D.C.

Dr. Klebanoff is a practicing ob/gyn and fellow in minimally invasive gynecologic surgery at George Washington University School of Medicine and Health Sciences in Washington, D.C.

Dr. Moawad is an associate professor of obstetrics and gynecology, director of gynecological robotic surgery and FMIGS associate director at George Washington University School of Medicine and Health Sciences in Washington, D.C.

The coronavirus pandemic presents many challenges to gynecologists, particularly in surgery. Although efforts have been made to either limit or appropriately triage non-emergent surgery during the COVID-19 pandemic, emergent procedures, such as ruptured ectopic pregnancy, must still be performed. 

Contemporary data on COVID-19 transmission risk during surgery are limited and many have questioned the safety of laparoscopic surgery for fear of aerosolized viral particles in surgical plume putting healthcare providers at risk. 

The worry is that use of pneumoperitoneum and electrosurgery, both of which are integral parts of laparoscopy, may enhance this risk. We aim to discuss this theoretical risk and what safety measures can be taken to provide a safer work environment for vital healthcare workers.

The virus that causes the infection commonly referred to as COVID-19 is a novel respiratory pathogen (SARS-CoV-2), which spreads via droplets. The approximate size of COVID-19 virions range from 50 to 200 nm; N-95 masks filters, with 95% efficiency, against 300 nm particles.

However, viral particles can also spread with aerosolization procedures such as intubation. SARS-CoV-2 has also been detected in blood and stool specimens, but the infectivity of these extrapulmonary specimens is unknown.

 Since the viral RNA has been found in stool, it is suggested that the virus could also then be found within the gastrointestinal mucosa.

Some have theorized that pneumoperitoneum in laparoscopy can create a stagnant heated volume of gas in the abdominal cavity, which could allow for concentrated aerosolization of the virus. Release of pneumoperitoneum from trocar valves during instrument exchange, venting, or removal could allow for virus transmission. 

Another concern stems from electrosurgical plume; when activated in laparoscopy, electrosurgical devices could release aerosolized debris into the abdomen. Both of these post a potential risk of viral transmission.

Most of our understanding of viral aerosolization comes from the study of other viral diseases, mainly hepatitis B (HBV) and human papillomavirus (HPV), although admittedly, this issue is not well-studied in laparoscopy. 

One study demonstrated that HBV was detected from the surgical plume of infected patients.

However, no subsequent studies were performed to determine if those HBV particles had viral infectivity or were capable of transmitting the disease. Several studies found that although aerosolized HPV DNA couldbe detected in surgical plume, there was no evidence that these particles could develop into an active infection or be transmitted to the surgical team.

Furthermore, one of these studies demonstrated that with use of smoke evacuation systems and proper personal protective equipment (PPE), there was no evidence of dispersion of viral DNA onto the skin of the surgeon.

 Although the route of transmission for HBV and HPV is different than for SARS-CoV-2, there are no data to support viral transmission by laparoscopy. 

To mitigate the theorized risk of viral transmission during laparoscopy, many believe that using a closed-circuit surgical system for smoke evacuation prevents room contamination with aerosolized particles and minimizes the potential risk for transmission. 

Several different insufflation systems exist, some of which also include smoke evacuation components. Independent laparoscopic smoke evacuator systems also exist.

One system that has been suggested for use during the COVID-19 pandemic is the AirSeal (Conmed, Utica, NY). This device has valve-less access ports, which minimizes any loss of pneumoperitoneum during instrument exchanges. 

The trilumen flow tube filters particles while simultaneously allowing carbon dioxide inflow and outflow. AirSeal also has a special mode that allows for smoke evacuation and more liberal circulation of pneumoperitoneum, decreasing possible concentration of aerosolized virus. The PneumoClear (Stryker, Kalamazoo, MI) is another integrated insufflator but uses traditional trocars with valves. 

The PneumoClear also has an added feature of de-sufflating the abdomen at the end of the case, which removes the need for release of any pneumoperitoneum. For both of these systems, ultra-low particle (ULPA) filters can be used, if available, to help filter viral particles that have been aerosolized during surgery. 

In conjunction with tightly fitting laparoscopic ports, a smoke evacuation and filtration system can be used to minimize release of potential virus in the operating room.

When smoke evacuation systems are not available, direct wall suction can be used to evacuate plume through a laparoscopic trocar. Wall suction devices can also be attached to the same ULPA filters used for endotracheal tubes, although this method does not guarantee the high filtration efficiency of manufactured smoke evacuation devices.

In addition, minimizing use of energy devices during procedures whenever possible may decrease aerosolization of particles. Final risk reduction methods may include reducing the abdominal pressure of pneumoperitoneum required for the operation. 

Regardless, it is extremely important that all individuals in the operating room wear proper personal protective equipment (PPE), including N95 respirators.

The aforementioned risks and possible solutions have been recognized by surgical societies worldwide. A joint statement issued by the American Association of Gynecologic Laparoscopists (AAGL) with multiple other gynecology profressional societies acknowledged that steps must be taken for the safety our patients and our healthcare providers. 

Minimally invasive techniques are the preferred method if urgent surgery is required. Data about the risk of transmission of COVID-19 via surgical plume is limited. Proper PPE is always recommended.

There is only a theoretical risk of transmission of viral particles from the abdomen of a COVID-19-infected individual. However, until definitive data are available, it seems prudent to use simple strategies to help mitigate these risks. 

These strategies include closed-circulation smoke evacuation, PPE, minimizing use of energy devices, low pneumoperitoneum pressures, and de-sufflating the abdomen using a smoke evacuation device or suction substitute with ULPA filters, if available. 

With the paucity of data, more research needs to be conducted around COVID-19 and laparoscopy. 

Drs. Rahman, Klebanoff and Moawad report no conflicts.

Chen N, Zhou M. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507–513.

3M. 3M Infection Prevention N95 Particulate Respirators, 1860/1860S and 1870. Frequently asked questions. Available at: http://multimedia.3m.com/mws/media/323208O/n95-particulate-respirators-1860-1860s-1870-faqs.pdf. Published 2008.

Information for Healthcare Professionals about Coronavirus (COVID-19) | CDC [Internet]. [cited 2020 May 18]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/

Gu J, Han B, Wang J. COVID-19. Gastrointestinal Manifestations and Potential Fecal-Oral Transmission. 2020 [cited 2020 May 18]; Available from: https://doi.org/10.1053/j.gastro.2020.02.054

5. Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H. Brief communications: Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology. 2020;158:1831-1833.e3. Available from: https://doi.org/10.1053/j.gastro.2020.02.055

Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. Surgical smoke and infection control. 

Kwak HD, Kim SH, Seo YS, Song KJ. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. 

Weyandt GH, Tollmann F, Kristen P, Weissbrich B. Low risk of contamination with human papilloma virus during treatment of condylomata acuminata with multilayer argon plasma coagulation and CO 2 laser ablation. 

Ferenczy A, Bergeron C, Richart RM. Human papillomavirus DNA in CO2 laser-generated plume of smoke and its consequences to the surgeon. 

Manson LT, Damrose EJ. Does exposure to laser plume place the surgeon at high risk for acquiring clinical human papillomavirus infection? 

Kunachak S, Sithisarn P, Kulapaditharom B. Are laryngeal papilloma virus-infected cells viable in the plume derived from a continuous mode carbon dioxide laser, and are they infectious? A preliminary report on one laser mode. 

Vigneswaran Y, Prachand VN, Posner MC, Matthews JB, Hussain M. What Is the appropriate use of laparoscopy over open procedures in the current COVID-19 climate? 

. 2020;Apr13:1-6 doi: 10.1007/s11605-020-04592-9.

Https://Www.Augs.Org/Joint-Statement-On-Minimally-Invasive-Gynecologic-Surgery-During-The-Covid-19-Pandemic-/

. [online] Available at: <https://www.augs.org/joint-statement-on-minimally-invasive-gynecologic-surgery-during-the-covid-19-pandemic-/> [Accessed 27 March 2020].

Articles

Though theoretical, the threat of aerosolized viral particles places health care providers at risk. Certain safety measures can be taken.

Smoke evacuation in the age of COVID-19

The updated list expands possible underlying medical conditions and removes the age threshold. At first, the CDC deemed older adults and those with underlying medical conditions to be most at-risk. The new list has removed the specific age threshold.

The updates also included an expansion of underlying medical conditions, including type 2 diabetes; an immuno-compromised state in individuals going through cancer treatment; poorly controlled HIV/AIDS; sickle cell disease; and severe obesity or BMI of 30 or higher.

Morbidity and Mortality Weekly Report (MMWR)

 also analyzed the at-risk potential of pregnant and non-pregnant women, finding that pregnant women were not at greater risk of death from COVID-19 than non-pregnant women. 

However, the study did determine that pregnant women were more likely to be hospitalized and admitted into the intensive care unit (ICU) than non-pregnant women.

For more information on the CDC’s updated list of risk factors, read the 

The Centers for Disease Control (CDC) updated its list of demographics at higher risk for COVID-19, due to new evidence. 

Additional risk factors for COVID-19

Dr. Spong is Chief of the Pregnancy and Perinatology Branch at the National Institute of Child Health and Human Development (NICHD), and Program Scientist for the Maternal-Fetal Medicine Unit Network. A Maternal-Fetal Medicine Specialist with INOVA Alexan

In the throes of COVID-19, with cases continuing to increase daily at my hospital, we are now further stressed with the brutal death of George Floyd, an African American whose death at the hands of law enforcement, while pleading that he could not breathe, is immortalized in a visceral video. 

His death and those of others has spurred nationwide protests against systemic racism that are colliding with attempts to mitigate the COVID-19 pandemic. With these crises on multiple fronts, we face increased tensions, anxiety, and stress.

COVID-19 has resulted in myriad changes and heightened anxieties, especially for patients of mine who are among the hardest hit. With schools no longer open, their children are home – as often are their spouses, as their jobs are lost and wages scarce. 

To add to this burden, we as a society are recognizing that we do not treat people equally, and just as the slogan “Black Lives Matter” says, we need to recognize that systemic racism and implicit bias are an issue and need to be addressed directly. 

Furthermore, COVID-19 disproportionately impacts people of color, another blow we must mitigate.

Nearly every professional society I belong to has launched campaigns and sent emails highlighting a zero tolerance policy of racism, for example:

“The American College of Obstetricians and Gynecologists (ACOG) is committed to eliminating disparities in women’s health and to confronting implicit and explicit bias and racism. This means recognizing and examining our own prejudice and bias and addressing the way in which health care systems perpetuate inequality.”

“The Society for Maternal-Fetal Medicine (SMFM) recognizes the impact of racism and is committed to working towards the elimination of the racism and health inequities that impact our members and the patients they serve.”

“The American Board of Obstetrics and Gynecology (ABOG) stands in solidarity with our health care community in opposition to the institutional racism, discrimination, and violence that has plagued the country for so long.”

As healers, Alpha Omega Alpha (AΩA) condemns racism and bias in all forms, including police brutality. Racism, discrimination, and social injustice are barriers in the care of patients and public health. 

AΩA stands with and cares for people of all races, ethnicities, and gender identities. In these times of crisis for our country and world, we must guide medicine to be unbiased, open, accepting, inclusive, and culturally aware in order to be worthy to serve the suffering.”

In addition to stating their support and the importance of these issues, these professional societies are committing to action. 

SMFM is educating their members and collaborating with other groups to promote policies to improve access to care and advocating for research. 

AΩA, a medical honor society, has a new award for excellence in inclusion, diversity, and equity in medical education and patient care.

Both COVID-19 and racism have far-reaching impacts politically and medically. It is imperative that we as providers highlight these impacts, recognizing the serious consequences that may follow. 

A household survey by the Centers for Disease Control and Prevention that was intended to monitor anxiety and depression in the setting of COVID-19 – an important metric given the social distancing and isolation – takes on new meaning now.

 Anxiety and depression have tripled in the last year, with US rates for anxiety around 8% in 2019 and over 30% in 2020 (Figure 1). 

Importantly, the rates of anxiety vary notably across racial groups, and those of mixed race have the highest rates with the ongoing demonstrations and protests. During the pandemic, women are reporting more anxiety than are men. 

In addition, people of reproductive age have the highest rates of anxiety (Figure 2). As the initial collision of crises passes, it will be vitally important to understand the impact going forward.

Critically, as the movement to raise awareness of social injustice and racism escalates, the rates of cases of COVID-19 continue to increase – the directionality of the interrelationship is unclear.

Unfortunately, they are not mutually exclusive, and the critical need to raise awareness clashes with the social isolation needed to quell the spread of COVID-19. Neither is more important, neither is less.

As I round on my antepartum patients, I have a new routine speech. It is hard to live in the world today, much less to be pregnant. Being hospitalized without visitors, juggling the media and messages of racism with the need for social distancing, does not easily allow for a healthy mental or physical state. 

I listen, try to understand, and offer the services of psychiatry and psychology to provide some attempt at mental balance, although far from normalcy. 

We discuss that this is situational, not specific to my patients, and they may benefit from external support. In truth, 

American College of Obstetricians and Gynecologists. Our commitment to changing the culture of medicine and eliminating racial disparities in women's health outcomes. Available at 

https://www.acog.org/about/our-commitment-to-changing-the-culture-of-medicine-and-eliminating-racial-disparities-in-womens-health-outcomes Accessed June 15

Society for Maternal-Fetal Medicine. SMFM issues a statement to its membership on racism as a publichealth crisis. Available at 

https://s3.amazonaws.com/cdn.smfm.org/media/2391/Racism_Statement.pdf

American Board of Obstetrics and Gynecology. ABOG statement on racism. Available at 

https://www.abog.org/about-abog/news-announcements/2020/06/03/abog-statement-on-racism

Alpha Omega Alpha Honor Medical Society. Statement on inclusion, diversity, equity, and service in the profession of medicine. Available at 

https://www.alphaomegaalpha.org/#gsc.tab=0

Centers for Disease Control and Prevention. National Center for Health Statistics. Household Pulse Survey. Available at 

https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

As a pandemic and protests converge, there is a need to recognize long-term effects.

A Collision of Crises

According to the Centers for Disease Control and Prevention (CDC), racial and ethnic minority communities have been disproportionately affected by the virus. In health care, it is impossible to treat patients without acknowledging these disparities.

, Editor-in-Chief Catherine Y. Spong, MD, addresses implicit bias and makes the connection with COVID-19 in “

As we prepare for a potential second wave of illness in the fall, our new website will continue to reflect the ever-evolving landscape. It launched on June 12, and streamlines our industry-leading content for a more concise, reader-friendly user experience. 

We are eager to hear your feedback. As we continue to evolve with each generation, we hope to continue to provide practicing ob/gyns with the exceptional clinical, peerreviewed content they look for. 

We would also like to announce the launch of our new podcast, Pap Talk, a weekly medical podcast that features in-depth interviews, treatment advice, commentary from industry experts and more. 

 page to learn more, and don’t forget to subscribe on Apple Podcasts, Spotify, or wherever you listen. And, as always, let us know your thoughts by contacting Senior Editor Angie DeRosa at aderosa@mjhlifesciences.com.

The COVID-19 pandemic has been at the top of everyone's mind for the past several months. More recently, social justice has taken the spotlight.

Chairman's Letter: Website overhaul, podcast & more

There are numerous coding options when reporting visits other than traditional face-to-face visits.

details a variety of coding options telehealth practitioners should note, such as office codes, virtual check-ins, e-visits and more. For a complete list, visit the 

As telehealth becomes more and more prevalent in practices everywhere, there are many things practitioners need to know. 

Telehealth codes: What you should know

Researchers analyzed data from the United Kingdom’s Care of Next Infant (CONI) program, designed to provide additional care to families who had experienced SUDI following successful births.

Researchers found that the SUDI rate among siblings is 10 times higher than the current rate of SUDI in the UK, and that many parents continued habits such as smoking and hazardous co-sleeping conditions following the first incident of SUDI.

For additional details and findings, read the 

A new report in Archives of Disease in Children examined the rates of sudden unexpected death in infancy (SUDI) among families that occurred after a previous incident of SUDI. 

Recurrent SUDI and causes of death

Many of the important changes affect physicians with student loans, according to 

recent interview with Andrew Musbach, C.F.P., co-founder and financial advisor with MD Wealth Management, LLC, in Chelsea, Mich.

The conversation highlighted many changes that physicians with student loans should be aware of, including the suspension of all federal direct loan payments until September 30, 2020. The CARES Act also set a 0% interest rate, so nothing is accruing on them.

For details on this suspension, more information about the Public Service Loan Forgiveness, and what to do if private loans are affecting your cash flow, read the 

In late March, the Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law. 

What the CARES Act means for medical student loans

The current climate around race and implicit bias has forced us to take a step back and observe its presence in our day-to-day lives. Now is a time that demands these conversations, even if they make you or your peers uncomfortable. Often times, that may mean they’re even more necessary.

 explores the ways in which physicians can address implicit bias in their lives and in their practices. 

From acknowledging blind spots to doing independent research and implementing it in patient care, here are some things physicians everywhere are doing to negate bias in the workplace.

The work is far from done and we must keep pushing forward. Read the 

The current climate around race and implicit bias has forced us to take a step back and confront its presence in our day-to-day lives. 

Implicit bias: What can you do? 

It is a crucial vaccine for all patients, especially since 14 million new cases appear in the United States each year.

However, not all patients complete the vaccine series. A new article from 

analyzed a study on the effectiveness of Development of Systems and Education for Human Papillomavirus Vaccination (DOES HPV), a multilevel intervention.

For program details and more on the findings, read the 

The human papillomavirus (HPV) vaccine is a key vaccine for children and adolescents to get in their early lives. 

Can intensive intervention improve HPV vaccination rates?

As we continue to find ourselves in the middle of a global pandemic, anxiety may be at an all-time high. How do you balance calming an anxious patient and providing treatment in a safe and healthy way?

sat down with integrative psychiatrist James Lake, MD, for insights and adnive for patients to reduce stress and take care of their mental health on a daily basis. 

According to Dr. Lake, focusing on improving lifestyle factors, which may then translate to improved general mental health, is crucial.

Dr. Lake’s 4 pillars are: getting enough sleep, regular physical activity, healthy nutrition, and a practice addressed at stress management.

Hear more from Dr. Lake on these patient recommendations here in the 

As we continue to find ourselves in the middle of a global pandemic, anxiety may be at an all-time high. 

Calming anxious patients: 4 mental health pillars

Judith M. Orvos, ELS, is a a BELS-certified medical writer and editor and an editorial consultant for Contemporary OB/GYN.

ACOG notes that for an adolescent reproductive health visit, an internal pelvic exam may be appropriate if issues such as abnormal bleeding or discharge, or abdominal or pelvic pain is a concern, but that an adolescent may visit a gynecologist several times before a biannual exam is needed. 

If a speculum or bimanual exam is indicated, a thorough explanation should always precede the procedure. Patients can find information about a gynecologic visit in the ACOG FAQ document, “Your First Gynecological Visit (Espe-cially for Teens)”. Pap tests are not recommended until age 21.

Published in JAMA Internal Medicine, the new fi ndings are from a cross-sec-tional analysis of the National Survey of Family Growth (NSFG) from Septem-ber 2011 through September 2017 focused on a population-based sample of young women aged 15 to 20 years. The main outcomes were receipt of a BPE or a Pap test in the last 12 months and the proportion of potentially unnecessary examinations and tests.

Of the young women surveyed, 4.8% were pregnant, 22.3% had undergone testing for a sexually transmitted infection (STI) and 4.5% received treat-ment or medication for an STI in the past 12 months. 

Only 2.0% reported using an intrauterine device (IUD) and 33.5% used at least one other type of contraception in the past 12 months. Having a BPE was associated with having a Pap test (adjusted prevalence ratio [aPR] 7.12; 95% CI, 5.56 to 9.12), testing for STIs (aPR 1.60; 95% CI, 1.34 to 1.90) and using hormonal contraception other than an IUD (aPR 1.31; 95% CI, 1.11 to 1.54). 

It was also associated with being older (aPR 1.25; 95% CI, 1.08 to 1.45). Young women who had a Pap test were seven times more likely to also report receiving a BPE (aPR 7.12; 95% CI, 5.56 to 9.12). 

Using hormonal contraception other than an IUD was associated with a 31% higher risk of receiving a BPE than in women who did not use those forms of contraception. This is in spite of ACOG’s clear statement that “A pelvic examination is not necessary before initiating or prescribing contraception, other than an intrauterine device, or to screen for STIs.” 

Looking at the impact of insurance, the authors found that young women with public or no insurance were less likely to receive a BPE than those with private insurance. Race/ethnicity and STI treatment were not found to be associated with having a BPE when adjusting for other covariates. 

Among US young women aged 15 to 20 years surveyed in the years 2011 to 2017, approximately 2.6 million reported having received a BPE in the last 12 months. Th e authors estimated that more than half (54.5%) or 1.4 million of those exams may have been unnecessary. 

An estimated 1.6 million of the women, the researchers say, may have had an unnecessary Pap test during the same period. Based on the results of their analysis and assuming that a Medicare payment for a screening BPE of $37.97 and for a screening Pap test of is $44.78, as was the case in 2014, the authors estimate that the potentially unnecessary BPEs and Pap tests would have cost more than $123 million in 1 year. 

Commenting on the findings, the researchers concluded that they “suggest the need for education for health care professionals, parents, and young women themselves to improve awareness of professional guidelines and the limitations and harms of routine pelvic examination and Pap test and to ensure that these tests and examinations are performed only when medically necessary among young women.” 

Qin J, Saraiya M, Martinez G, Sawaya GF. Prevalence of potentially unneces-sary bimanual pelvic examinations and papanicolaou tests among adolescent girls and young women aged 15-20 years in the United States. JAMA Intern Med. June 2020. doi:10.1001/jamainternmed.2019.5727

Results of a nationally representative study indicate that many young women receive bimanual pelvic exams (BPEs) and Pap tests that may be unnecessary, and not in compliance with the latest guidance from the American College of Obstetricians and Gynecologists (ACOG). 


Too many teen pelvic exams and Pap tests?

Ben Schwartz is Associate Editor, Contemporary OB/GYN.

Like some aspects of reproductive function, menopausal symptoms appear to exhibit seasonal variation, according to new research from 

The Journal of the North American Menopause Society

. The study assessed the impact of season and proximity to the fi nal men-strual period (FMP) on frequency of symptom reporting. 

The authors included 955 participants from the Study of Women’s Health Across the Nation, a cohort study that followed a multiethnic sample during the transition from premenopause to postmenopause over a 10-year period. 

Participants fi lled out men-strual calendars daily to capture days when spotting or bleeding occurred. Women answered questions about hormone therapy (HT) use and gyne-cological procedures that could aff ect their bleeding reports monthly and also completed a short survey about whether they had experienced symp-toms (hot fl ashes, night sweats, and trouble sleeping) in the past month.

FMP was defi ned as the fi rst day of the bleeding episode that was fol-lowed by at least 12 months of amenorrhea. Hot flashes, night sweats, and trouble sleeping were coded as a binary variable (yes/no) for each month of observation. HT use varied by time and was coded based on current use (yes/no) for each month of observation.

The authors found that 5 to 10 years before the FMP, approximately 20% of women reported hot flashes and night sweats. During that period, approximately 40% reported trouble sleeping. These numbers rose approximately 4 years before the FMP with a sharp jump in prevalence of hot flashes (~60%) and night sweats (~40) coincident with the FMP. 

the authors noted that a peak in hot flash reports was observed in July, while January had a trough in hot flash reports

. Women had 66% greater odds of a hot flash at their seasonal peak compared to their seasonal minimum in both the unadjusted model and the model adjusted for smoking, race, age at FMP, and body mass index. The corresponding odds for night sweats and sleep problems were 50% and 24%, respectively. 

The authors also noted that odds of reporting all three symptoms increased as women approached the FMP. The authors believe their findings indicate that menopausal symptoms exhibit seasonal variation based on summer and winter. They believe their findings indicate the need for physicians to recognize the summer months as a critical period for managing their patients’ symptoms.

Harlow SD, Elliott MR, Bondarenko I, Thurston RC, Jackson EA. Monthly variation of hot ﬂ ashes, night sweats, and trouble sleeping. Menopause. 2020;27(1):5-13. doi:10.1097/gme.0000000000001420

A peak in hot fl ash reports was observed in July, while January had a trough in hot fl ash reports.

Menopause symptoms through the seasons

, the study focused on trends in Los Angeles and Indianapolis and looked at not only domestic violence but crimes such as burglary, assault, and vehicle theft.

For the research, the authors analyzed daily counts of calls for service in the two cities beginning on January 2, 2020 and ending on April 21 for Los Angeles and April 18 for Indianapolis. Those time periods were defined as after shelter-in-place orders were given. Excluded from the analysis were time periods between school closings and shelter-in-place orders.

The objective was to compare full social distancing effects (post stay-at-home orders) to a baseline with no social distancing orders yet implemented. Expected police call rate change was computed by multiplying the estimated coefficient of residential mobility by the average residential mobility index post-shelter-in-place minus the average pre-school closing.

Significant increases in domestic violence calls were found in both Los Angeles and Indianapolis (expected call rate increases of 13.5495 and 15.2112; 

In contrast, call rate changes for burglary in Los Angeles and Indianapolis declined by 19.2740 and 2.3061, respectively. For robbery and battery, rates declined in both in Los Angeles and stayed the same in Indianapolis.

“The marginal decline in residential burglaries, marginal increase in auto thefts, and increase in domestic violence calls points to shifts in crime patterns to which police departments will necessarily have to respond,” said the authors. 

They noted, however, that “despite domestic violence having been one of the crimes least reported to the police, with approximately half of domestic victimization being unreported, our results indicate that calls concerning domestic violence significantly increased in both Indianapolis and Los Angeles.”

Mohler G, Bertozzi AL, Carter J, Short MB, Sledge D, Tita GE, et al. Impact of social distancing during COVID-19 pandemic on crime in Los Angeles and Indianapolis. 

. 2020;68:101692. https://doi.org/10.1016/j.jcrimjus.2020.101692

A new analysis by researchers who analyze crime statistics shows that in two major metropolitan areas, domestic violence reports increased during the COVID-19 pandemic.

Domestic violence reports increase in two major cities during COVID-19

Though her face was covered with a mask, her frustration was clear. As a 38-year-old woman who had recently moved to the United States with her husband for an exciting job opportunity, she has been taking combined oral contraceptives (COCs) reliably for the past 20 years with no pregnancies. 

In Brazil, she would simply walk into her neighborhood store and buy a pack of COCs along with her shampoo. She had known for her whole life that she didn’t want children and remained highly motivated to avoid pregnancy, especially now that she is in America and had a chance to further her career beyond what she could achieve in Brazil.

I met her amid a global pandemic, as she had been granted an urgent appointment to our otherwise closed outpatient clinic due to an early undesired pregnancy. The last physician she saw would only provide her with 1 month of COCs to carry her over until she could be seen for an annual exam. 

This single pill pack ended as the COVID-19 pandemic reached our state and the stay-at-home order was initiated. She was unable to get a refill from the initial prescribing physician and, though she tried to be careful, ultimately conceived.

The current COVID-19 pandemic has amplified the existing unnecessary barriers to contraception, much to the detriment of women. My patient wasn’t alone in her interest in over-the counter (OTC) contraception. 

A survey nearly 10 years ago in the United States demonstrated that two-thirds of women were in favor of the concept and one-third would utilize it themselves.

A recent survey of over 2,000 women and 500 adolescents in the United States revealed that nearly 40% and 30% of each group would be interested in OTC progestin-only pill (POP) access.

Now is the time to give women like my patient access to hormonal contraception over the counter.

In the United States, there are an estimated 43 million women at risk of unintended pregnancy.3 Prescription-based contraceptive methods are actively used by nearly one-third of contracepting women, and four of five sexually experienced women have used an oral contraceptive (OC) pill at some point in their lifetime.

Although physicians are typically most familiar prescribing OCs, the transdermal patch, and the monthly vaginal ring, there is also a self-administered subcutaneous form (104 mg) of depot-medroxyprogesterone acetate (DMPA) that can be directly prescribed to women.5 

With the subcutaneous formulation, women can self-inject their DMPA via a small 3/8-inch needle without requiring an in-person visit for the standard 150mg intramuscular injection (Figure 1).

Barriers to accessing hormonal contraception

Unfortunately, women experienced a multitude of barriers to prescription-based contraception long before the COVID-19 pandemic. One large survey of US women currently on prescription methods including OCs, the transdermal patch, and monthly vaginal ring, revealed that one-third of them had experienced access barriers while initiating or continuing their chosen method.

Of the women who reported barriers, the vast majority (62%) were related to the physical need to see a provider in an office to obtain a prescription. Other factors such as cost (25%), pharmacy access (7%), and non-specified barriers (6%) were significantly less common.

Our specialty has successfully overcome the limitations of prescription status on access to reproductive health services, specifically in the context of oral levonorgestrel emergency contraception. Although initially prescription-only when approved by the US Food and Drug Administration in 1998, oral levonorgestrel emergency contraception (EC) was given OTC status in 2006 for women age 18 and above.

In 2013, the age restriction was removed so anyone with reproductive potential could access this form of EC.

 After transitioning to OTC status, adult use of oral levonorgestrel EC increased from 4% of women in 2002 (prior to OTC conversion) to 11% of women by 2010, amounting to a total of 5.8 million women who had ever used this product.

Since the day-to-day intricacies of women's lives vary tremendously, we need a multitude of ways that they can access their preferred contraceptive method. Some women may still prefer in-office visits, but our experience with the OTC transition of oral levonorgestrel EC showed that women need the option to buy contraceptive methods directly off the shelf.

As an intermediate step toward OTC status, some states have given pharmacists the ability to provide hormonal contraception directly to people without a prescription from a provider. Through this behind-the-counter model, the pharmacist performs a risk assessment and sometimes a blood pressure measurement prior to dispensing combined hormonal contraception (CHC) (COC), transdermal patch, monthly vaginal ring). 

The most recent tally shows that 13 states along with Washington, D.C., allow pharmacists to directly dispense some types of hormonal contraception.

 Nuances of behind-the-counter provision vary. Only nine of these states (along with Washington, D.C.,) allow the pharmacist to give the method directly to the patient without any prescriber involvement.

Four states actually require a collaborative practice agreement between pharmacists and providers, creating another possible barrier.

Though a step in the right direction, behind-the-counter hormonal contraception still has its limitations. Pharmacist reimbursement for their patient assessment and counseling has also been a logistical obstacle and potential disincentive.

These visit costs can get passed down to patients. In addition, we know that women experience pharmacist objection to dispensation of reproductive health products such as EC and this is will likely occur with other contraceptive products.

A variety of health care organizations and private companies have tried to address theseaccess barriers and created systems of online contraceptive consultation with mail-order products. Women undergo standard health screening, with variation in other requirements like recent blood pressure measurement. 

“This wouldn’t have happened if I was still in Brazil!” exclaimed my patient.