Websites Selling Direct-to-Consumer Anti-Mullerian Hormone Tests

Online Misleading Information About Women's Reproductive Health: A Narrative Review

Misinformation about reproductive health threatens to harm health outcomes, compromise medical trust, and enable misinformed policy restrictions. In recent years, reproductive health misinformation has proliferated online due to ideological campaigns and limited content moderation for reproductive health topics. Developing evidence-based practices to counter reproductive health misinformation requires an understanding of the content that women are exposed to online, which is currently lacking. This review sought to identify common claims and narratives about reproductive health on social media and the internet that could easily mislead. We performed a narrative review of articles about online reproductive health misinformation, from which we extracted misleading claims and narratives. We conducted a qualitative content analysis to describe the ways in which the claims and narratives could be misleading. We found that potentially misleading claims and narratives about reproductive topics relating to contraception and abortion, fertility, chronic disease, breast cancer, maternal health, and vaccines abound across social media platforms and websites, with 112 identified in total. One-third of this content could mislead by claiming that evidence-based interventions were associated with unattributed risks. Twenty-three percent made medical recommendations that do not align with professional guidelines. Fourteen percent promoted alternative medicine. Smaller numbers of claims and narratives exaggerated risks of medical interventions, discouraged evidence-based interventions, directly undermined medical trust, and proposed inaccurate biological mechanisms. Healthcare professionals can proactively promote evidence-based medical decision-making by increasing their awareness of prominent misleading claims and narratives.

Social Media Posts About Medical Tests With Potential for Overdiagnosis

Importance

Social media is an influential source of medical information, but little is known about how posts discuss medical tests that carry potential for overdiagnosis or overuse.

Objective

To investigate how social media posts discuss 5 popular medical tests: full-body magnetic resonance imaging, the multicancer early detection test, and tests for antimullerian hormone, gut microbiome, and testosterone.

Design, Setting, and Participants

This cross-sectional study assessed posts on Instagram and TikTok between April 30, 2015, and January 23, 2024, that discussed full-body magnetic resonance imaging, the multicancer early detection test, and tests for antimullerian hormone, gut microbiome, and testosterone. Using keywords on newly created accounts, posts were searched and screened until 100 posts for each test on each platform were identified (n = 1000). Posts were excluded if they did not discuss 1 of the 5 tests or were not in English or if the account holders had fewer than 1000 followers.

Main Outcomes and Measures

The main outcome was information about benefits, harms, and overall tone discussed in the post. All outcomes were summarized descriptively. Logistic regression was used to assess whether the use of evidence or the account holder being a physician or having financial interests influenced how tests were discussed.

Results

A total of 982 posts from account holders with a combined 194 200 000 followers were analyzed. Across all tests, benefits were mentioned in 855 posts (87.1%) and harms in 144 (14.7%), with 60 (6.1%) mentioning overdiagnosis or overuse. Overall, 823 posts (83.8%) had a promotional (vs neutral or negative) tone. Evidence was explicitly used in 63 posts (6.4%), personal anecdotes were used in 333 (33.9%), 498 posts (50.7%) encouraged viewers to take action and get the test, and 668 account holders (68.0%) had financial interests. Posts from physicians were more likely to mention harms (odds ratio, 4.49; 95% CI, 2.85-7.06) and less likely to have an overall promotional tone (odds ratio, 0.53; 95% CI, 0.35-0.80).

Conclusions and Relevance

In this cross-sectional study of social media posts about 5 popular medical tests, most posts were misleading or failed to mention important harms, including overdiagnosis or overuse. These data demonstrate a need for stronger regulation of misleading medical information on social media.

Ovarian reserve does not influence natural conception: insights from infertile women

PURPOSE

There is several albeit not univocal evidence suggesting that ovarian reserve is not related to the chance of natural pregnancy, provided that the remnant follicular pool is sufficient to ensure regular menstrual cycles. Nevertheless, available studies have some methodological limitations, and the issue cannot be considered definitively ascertained.

METHODS

To further address this issue, we retrospectively selected infertile women whose infertility diagnostic work-up was unremarkable (unexplained infertility-cases) and matched them by age and study period to a group of infertile women who were diagnosed with severe male infertility (controls). If ovarian reserve impacts on natural fertility, one had to expect lower ovarian reserve among women with unexplained infertility. Tested biomarkers included AMH, AFC and day 2-3 serum FSH. The primary aim was the frequency of women with serum AMH < 0.7 ng/ml.

RESULTS

Two-hundred fifty-two women with unexplained infertility and 252 women with male infertility were included. All biomarkers of ovarian reserve did not differ between the study groups. AMH levels < 0.7 ng/mL were observed in 26 (10%) women with unexplained infertility and 35 (14%) women with male infertility (p = 0.28). The adjusted OR was 0.76 (95% CI: 0.44-1.33). Significant differences did not also emerge when repeating this dichotomous analysis using other biomarkers and other thresholds for the definition of low-ovarian reserve.

CONCLUSION

This study confirms that ovarian reserve is unremarkable to natural conception. Physicians and patients should be aware of this concept to avoid inappropriate counseling and undue clinical decisions.

Women's interest, knowledge, and attitudes relating to anti-Mullerian hormone testing: a randomized controlled trial

STUDY QUESTION

What is the impact of co-designed, evidence-based information regarding the anti-Mullerian hormone (AMH) test on women's interest in having the test?

SUMMARY ANSWER

Women who viewed the evidence-based information about the AMH test had lower interest in having an AMH test than women who viewed information produced by an online company selling the test direct-to-consumers.

WHAT IS KNOWN ALREADY

Online information about AMH testing often has unfounded claims about its ability to predict fertility and conception, and evidence suggests that women seek out and are recommended the AMH test as a measure of their fertility potential.

STUDY DESIGN, SIZE, DURATION

An online randomized trial was conducted from November to December 2022. Women were randomized (double-blind, equal allocation) to view one of two types of information: co-designed, evidence-based information about the AMH test (intervention), or existing information about the AMH test from a website which markets the test direct-to-consumers (control). A total of 967 women were included in the final analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were women recruited through an online panel, who were aged 25-40 years, living in Australia or The Netherlands, had never given birth, were not currently pregnant but would like to have a child now or in the future, and had never had an AMH test. The primary outcome was interest in having an AMH test (seven-point scale; 1 = definitely NOT interested to 7 = definitely interested). Secondary outcomes included attitudes, knowledge, and psychosocial and behavioural outcomes relating to AMH testing.

MAIN RESULTS AND THE ROLE OF CHANCE

Women who viewed the evidence-based information about the AMH test had lower interest in having an AMH test (MD = 1.05, 95% CI = 0.83-1.30), less positive attitudes towards (MD = 1.29, 95% CI = 4.57-5.70), and higher knowledge about the test than women who viewed the control information (MD = 0.75, 95% CI = 0.71-0.82).

LIMITATIONS, REASONS FOR CAUTION

The sample was more highly educated than the broader Australian and Dutch populations and some measures (e.g. influence on family planning) were hypothetical in nature.

WIDER IMPLICATIONS OF THE FINDINGS

Women have higher knowledge of and lower interest in having the AMH test when given evidence-based information about the test and its limitations. Despite previous studies suggesting women are enthusiastic about AMH testing to learn about their fertility potential, we demonstrate that this enthusiasm does not hold when they are informed about the test's limitations.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by an NHMRC Emerging Leader Research Fellowship (2009419) and the Australian Health Research Alliance's Women's Health Research, Translation and Impact Network EMCR award. B.W.M. reports consultancy for ObsEva and Merck and travel support from Merck. D.L. is the Medical Director of, and holds stock in, City Fertility NSW and reports consultancy for Organon and honoraria from Ferring, Besins, and Merck. K.H. reports consultancy and travel support from Merck and Organon. K.M. is a director of Health Literacy Solutions that owns a licence of the Sydney Health Literacy Lab Health Literacy Editor. No other relevant disclosures exist.

TRIAL REGISTRATION NUMBER

ACTRN12622001136796.

TRIAL REGISTRATION DATE

17 August 2022.

DATE OF FIRST PATIENT’S ENROLMENT

21 November 2022.

Direct-to-consumer testing as consumer initiated testing: compromises to the testing process and opportunities for quality improvement

Direct-to-consumer testing (DTCT) refers to commercial laboratory tests initiated by laypersons without the involvement of healthcare professionals. As this market grows in size and variety of products, a clear definition of DTCT to ground the conceptualization of their harms and benefits is needed. We describe how three different modalities of DTCT (home self-testing, self-sampled tests, and direct access tests) present caveats to the traditional testing process ('brain-to-brain loop'), and how this might differ between medical vs. non-medical laboratories. We make recommendations for ways to improve quality and reduce errors with respect to DTCT. The potential benefits and harms of DTCT will invariably depend on the context and situation of individual consumers and the types of tests involved. Importantly, implications for both consumers and the healthcare system should be considered, such as the effects on improving health outcomes and reducing unnecessary testing and use of clinical resources. 'Consumer initiation' must be a central defining characteristic of DTCT, to clearly demarcate the key drawbacks as well as opportunities of this type of testing from a laboratory specialists' perspective. The concept of 'consumer initiated testing' should also help define DTCT regulation, and provide a locus of efforts to support consumers as the main decision-makers in the purchasing and conducting of these tests in the absence of clinician gatekeeping.

Attitudes, knowledge and practice regarding the anti-müllerian hormone test among general practitioners and reproductive specialists: A cross-sectional study

OBJECTIVE

To describe clinicians' attitudes, knowledge and practice relating to the anti-müllerian hormone (AMH) test.

DESIGN

Cross-sectional nationwide survey.

SETTING

Australia.

POPULATION OR SAMPLE

A total of 362 general practitioners (GPs), gynaecologists and reproductive specialists.

METHODS

Clinicians were recruited through relevant professional organisations, with data collected from May 2021 to April 2022.

MAIN OUTCOME MEASURES

Clinicians' attitudes, knowledge and practice relating to the AMH test, measured using multiple choice, Likert scales and open-ended items.

RESULTS

Fifteen percent of GPs (n = 27) and 40% of gynaecologists and other specialists (n = 73) order at least one AMH test per month. Specialists reported raising the idea of testing most of the time, whereas GPs reported that patient request was more common. Half of clinicians lacked confidence interpreting (n = 182, 51%) and explaining (n = 173, 48%) an AMH result to their patients. Five percent (n = 19) believed the test was moderately/very useful in predicting natural conception/birth and 22% (n = 82) believed the same for predicting premature menopause, despite evidence that the test cannot reliably predict either. Forty percent (n = 144) had previously ordered the test to help with reproductive planning and 21% (n = 75) to provide reassurance about fertility.

CONCLUSIONS

Clinicians reported use of AMH testing in clinical circumstances not supported by the evidence. With the proliferation of direct-to-consumer testing, efforts to support clinicians in the judicious use of testing and effectively navigating patient requests are needed.

Social Media Promotion of Health Tests With Potential for Overdiagnosis or Overuse: Protocol for a Content Analysis

BACKGROUND

In recent years, social media have emerged as important spaces for commercial marketing of health tests, which can be used for the screening and diagnosis of otherwise generally healthy people. However, little is known about how health tests are promoted on social media, whether the information provided is accurate and balanced, and if there is transparency around conflicts of interest.

OBJECTIVE

This study aims to understand and quantify how social media is being used to discuss or promote health tests with the potential for overdiagnosis or overuse to generally healthy people.

METHODS

Content analysis of social media posts on the anti-Mullerian hormone test, whole-body magnetic resonance imaging scan, multicancer early detection, testosterone test, and gut microbe test from influential international social media accounts on Instagram and TikTok. The 5 tests have been identified as having the following criteria: (1) there are evidence-based concerns about overdiagnosis or overuse, (2) there is evidence or concerns that the results of tests do not lead to improved health outcomes for generally healthy people and may cause harm or waste, and (3) the tests are being promoted on social media to generally healthy people. English language text-only posts, images, infographics, articles, recorded videos including reels, and audio-only posts are included. Posts from accounts with <1000 followers as well as stories, live videos, and non-English posts are excluded. Using keywords related to the test, the top posts were searched and screened until there were 100 eligible posts from each platform for each test (total of 1000 posts). Data from the caption, video, and on-screen text are being summarized and extracted into a Microsoft Excel (Microsoft Corporation) spreadsheet and included in the analysis. The analysis will take a combined inductive approach when generating key themes and a deductive approach using a prespecified framework. Quantitative data will be analyzed in Stata SE (version 18.0; Stata Corp).

RESULTS

Data on Instagram and TikTok have been searched and screened. Analysis has now commenced. The findings will be disseminated via publications in peer-reviewed international medical journals and will also be presented at national and international conferences in late 2024 and 2025.

CONCLUSIONS

This study will contribute to the limited evidence base on the nature of the relationship between social media and the problems of overdiagnosis and overuse of health care services. This understanding is essential to develop strategies to mitigate potential harm and plan solutions, with the aim of helping to protect members of the public from being marketed low-value tests, becoming patients unnecessarily, and taking resources away from genuine needs within the health system.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56899.

Promotion of an Algorithm-Based Tool for Pregnancy Prevention by Instagram Influencers

Objective: Despite growing concerns that some digital algorithm-reliant fertility awareness-based methods of pregnancy prevention are marketed in an inaccurate, opaque, and potentially harmful manner online, there has been limited systematic examination of such marketing practices. This article therefore provides an empirical examination of how social media influencers have promoted the fertility tracking tool Daysy on Instagram. We investigate: (1) how the tool is framed in relation to pregnancy prevention using Health Belief Model (HBM) constructs, and (2) the promotional and disclosure practices adopted by influencers. Materials and Methods: We collected Instagram posts mentioning Daysy made between June 2018 and May 2022 using the tool CrowdTangle. Using a qualitative content analysis approach, we coded a random sample of 400 Daysy posts. This yielded 122 Instagram influencer posts promoting Daysy for pregnancy prevention that we coded for promotional content and HBM constructs. Results: Posts originated primarily from Europe (n = 62, 50.82%) and the United States (n = 37, 30.33%). Findings indicate that barriers to use (n = 18, 15.57%) and the severity of risks from unplanned pregnancy (n = 8, 6.56%) were rarely conveyed, whereas benefits of use (n = 122, 100%) and the severity of risks of hormonal contraception (n = 31, 25.41%) were covered more extensively. Only about one third of posts disclosed any formal relationship to the brand Daysy. Conclusions: With many posts emphasizing benefits and obscuring potential limitations, we argue that accurate and transparent information about the effectiveness and limitations of fertility tracking technologies is critical for supporting informed decision-making and, as such, should remain a public health priority.

Direct-to-consumer tests advertised online in Australia and their implications for medical overuse: systematic online review and a typology of clinical utility

OBJECTIVES

The objective of this study is to map the range and variety of direct-to-consumer (DTC) tests advertised online in Australia and analyse their potential clinical utility and implications for medical overuse.

DESIGN

Systematic online search of DTC test products in Google and Google Shopping. DTC test advertisements data were collected and analysed to develop a typology of potential clinical utility of the tests at population level, assessing their potential benefits and harms using available evidence, informed by concepts of medical overuse.

RESULTS

We identified 484 DTC tests (103 unique products), ranging from $A12.99 to $A1947 in cost (mean $A197.83; median $A148.50). Using our typology, we assigned the tests into one of four categories: tests with potential clinical utility (10.7%); tests with limited clinical utility (30.6%); non-evidence-based commercial 'health checks' (41.9%); and tests whose methods and/or target conditions are not recognised by the general medical community (16.7%). Of the products identified, 56% did not state that they offered pretest or post-test consultation, and 51% did not report analytical performance of the test or laboratory accreditation.

CONCLUSIONS

This first-in-Australia study shows most DTC tests sold online have low potential clinical utility, with healthy consumers constituting the main target market. Harms may be caused by overdiagnosis, high rates of false positives and treatment decisions led by non-evidence-based tests, as well as financial costs of unnecessary and inappropriate testing. Regulatory mechanisms should demand a higher standard of evidence of clinical utility and efficacy for DTC tests. Better transparency and reporting of health outcomes, and the development of decision-support resources for consumers are needed.