rates, a common issue with surveys in this literature.3,4 It is also possible that a study design with multiple, potentially redundant streams of data collection (eg, similar to that which has been employed to measure HIV treatment adherence5) might have greater sensitivity for detecting global health opportunities at community hospital–based residency programs. Such a study might include a web-based search protocol, a survey of program directors, and a survey of graduating residents, with prespecified algorithms to consistently reconcile the conflicting data we might get from different sources in a single program. To our knowledge, such a study design, although appealing, has not yet been attempted. It is unclear whether a web presence or a different study design, counter to fact, would have substantively altered the data available to us for analysis. Future updates of our study, potentially with some of the adaptations described above, may permit the inclusion of programs such as the one described by Haber et al that were established subsequent to the conduct of our study.6 Financial Disclosure: The authors did not report any potential conflicts of interest.

Kristin J. Hung, MD Beth Israel Deaconess Medical Center, Boston, Massachusetts Alexander C. Tsai, MD, PhD Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts Timothy R. B. Johnson, MD University of Michigan, Ann Arbor, Michigan Rochelle P. Walensky, MD, MPH David R. Bangsberg, MD, MPH Vanessa B. Kerry, MD, MSc Massachusetts General Hospital and, Harvard Medical School, Boston, Massachusetts

REFERENCES 1. Hung KJ, Tsai AC, Johnson T, Walensky RP, Bangsberg DR, Kerry VB. Scope of global health Training in U.S. obstetrics and gynecology residency programs. Obstet Gynecol 2013; 122:1101–9. 2. Kanter SL. More about the evidence in evidence-based integrative medicine programs. Acad Med 2010;85:187.

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3. Jayaraman SP, Ayzengart AL, Goetz LH, Ozgediz D, Farmer DL. Global health in general surgery residency: a national survey. J Am Coll Surg 2009;208: 426–33. 4. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: a call for cooperation and consortium. World J Surg 2011;35: 2617–24. 5. Liu H, Golin CE, Miller LG, Hays RD, Beck CK, Sanandaji S, et al. A comparison study of multiple measures of adherence to HIV protease inhibitors. Ann Intern Med 2001;134:968–77. 6. Miller R. Local health care goes global. The News-Times 2012 Jul 17. Available at: http://www.newstimes.com/news/article/ Local-healthcare-goes-global-3711196.php. Retrieved November 13, 2013.

remain unanswered: were bleeding patterns influenced by age, body mass index, or the contraceptive used before placement; and how consistent were bleeding patterns throughout the first year of use? The authors propose that the smaller levonorgestrel intrauterine systems placed using a narrower insertion tube (3.8-mm diameter) may be more suitable for women who have not delivered vaginally. However, Mirena can be placed in most nulligravidous women without complication. Nevertheless, I hope that the availability of the 13.5-mg system will encourage health care professionals to offer a levonorgestrel intrauterine system to a wider range of women. Financial Disclosure: Dr. Bahamondes has received editorial support from Chameleon Communications, which was funded by Bayer HealthCare.

Two Low-Dose Levonorgestrel Intrauterine Contraceptive Systems: A Randomized Controlled Trial To the Editor: I have performed intrauterine device and levonorgestrel intrauterine system insertions for more than 40 years at a clinic where more than 100 devices are placed per month. In my opinion, the Phase III study of two smaller (28330 mm), lower-dose (13.5 mg and 19.5 mg total content) levonorgestrel intrauterine systems by Nelson et al1 produced relevant results. Both levonorgestrel intrauterine systems were highly effective and well-tolerated, with favorable safety profiles. These data and the interest surrounding the recent approval of the 13.5-mg system (Skyla in the United States) could be used as an opportunity to dispel the misconceptions that limit the use of intrauterine contraception. The study enrolled nulliparous and parous women aged 18235 years. However, outcomes were reported for the overall cohort. The ease and pain of placement should be evaluated according to parity. In addition, subgroup analyses are required to determine whether age or parity influenced efficacy, risk of expulsion and uterine perforation, discontinuation rates, or reasons for discontinuation. The mean number of bleeding and spotting days declined over time during use of both levonorgestrel intrauterine systems. However, some questions

Luis Bahamondes, MD Department of Obstetrics & Gynecology, School of Medicine, University of Campinas (UNICAMP), Campinas, Brazil

REFERENCE 1. Nelson A, Apter D, Hauck B, Schmelter T, Rybowski S, Rosen K, et al. Two low-dose levonorgestrel intrauterine contraceptive systems: a randomized controlled trial. Obstet Gynecol 2013;122:1205–15.

In Reply: I applaud Dr. Bahamondes for the efforts he and his clinic have made to reduce unwanted pregnancies in Brazil and for the amazing contributions he has made to furthering our understanding of contraception through his research. In this first overview article,1 we tried to include all the important outcomes for the entire study population. I agree entirely that the issues he has raised—the need to do subgroup analyses for nulliparous and parous women for ease of placement, efficacy, expulsion, continuation, and other outcomes. Owing to space constraints, we were not able to include all those outcomes in this overview article. We have tried to answer those questions in a second article and have already drafted a third to analyze the bleeding patterns in more detail. There are some unexpected findings—such as the fact that the expulsion rates for nulliparous

Letters to the Editor

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