Lidegaard O, Nielson LH, Skovlund CW, Lokkegaard E. Venous thrombosis in users of non-oral hormonal contraception: follow-up study, Denmark 2001-10 BMJ 2012;344:e2990 doi: 10.1136/bmj.e2990 (Published 10 May 2012)

This is basically a companion paper to the one published last year in the BMJ, which concentrated on the Pill and was comprehensively criticised in the January issue of the Journal (Dinger & Shapiro 2012), to which readers are referred, as well as to the Rapid Responses posted on the BMJ website. This analysis, also from the Danish registry looks at the EVRA patch NuvaRing, Implanon and the levonorgestrel-releasing intra-uterine system (Mirena IUS). All the previous issues of confounding, lack of information regarding smoking, BMI, and family history, and not comparing like with like apply here.

It is important to compare new users with new users, as a well-established fact is that the risk of VTE is highest in the first 6 months of use of oestrogen-containing contraceptives. It is therefore important to look at the launch dates of contraceptive products. NuvaRing was launched in Denmark in late 2001 / early 2002, while the EVRA patch was launched there in September 2003. Meanwhile combined pills containing levonorgestrel have been in use since the 1970s, and those containing norgestimate since the mid 1980s. Thus, since the study period began in 2001, all users of NuvaRing and EVRA must have been new users, and so also more likely to be first time users / women with risk factors. Meanwhile, the users of the comparator COCs were more likely to be long term users and therefore at lower risk, since the high risk women in those groups will have been weeded out within the first 6 months of use – before the study began (ie attrition of susceptibles). The effect of duration of use is most clearly seen with NuvaRing in Table 4, where compared with non-users of hormonal contraceptives,  the relative risk becomes appreciably lower with increasing duration of use, declining from 8.36 for <1 year of use to 3.83 for use of 1 to 4 years. In addition, the numbers in each duration category are small, leading to random variability.  For the patch (6 exposed women) and the implant (5 women) not even the overall numbers are adequate.

With regard to the two progestogen only methods under study, not surprisingly neither was associated with a significantly increased risk of VTE – progestogen only methods have not been implicated in VTE risk, since this is related to oestrogen (Reid et al, 2010). Indeed, progestogen only methods are advised for women with risk factors for VTE (Blanco-Molina et al 2012). However, in the abstract, the authors misleadingly state that ‘the relative risk was increased in women who used subcutaneous implants’ and yet their relative risk of 1.4 had confidence intervals of 0.6 – 3.4, ie not even approaching statistical significance.  For the IUS, not only was the relative risk not increased, it was significantly decreased at 0.6 (95% CI 0.4 – 0.8). This has no biological plausibility and simply highlights the lack of credibility of the analysis.

Anne Szarewski, Editor-in-Chief, J Fam Plann Reprod Health Care

Diana Mansour, Consultant in Community Gynaecology and Reproductive Health Care, Head of Sexual Health Services, Newcastle Upon Tyne,

References

Dinger JC, Shapiro S. Combined oral contraceptives, venous thromboembolism, and the problem of interpreting large but incomplete datasets  J Fam Plann Reprod Health Care 2012;38:2–6. doi:10.1136/jfprhc-2011-100260

Reid RL, Westhoff C, Mansour D, de Vries C, Verhaeghe J, Boschitsch E,et al.   Oral Contraceptives and Venous Thromboembolism: Consensus Opinion from an International Workshop held in Berlin, Germany in December 2009  J Fam Plann Reprod Health Care 2010; 36(3): 117–122

Blanco-Molina MA, Lozano M, Cano A, Cristobal I, Pallardo LP, Lete I. Progestin-only contraception and venous thromboembolism Thrombosis Research 129 (2012) e257–e262

Melinda Gates’ New Crusade: Investing Billions in Women’s Health

Melinda Gates this week pledged billions of dollars to be spent on improving access to contraception. In her many travels she repeatedly met women who were unable to gain access to something which most of the rest of the world take for granted. In an interview with Newsweek she recounted stories from the women many of whom were unable, for example, to get repeat injections of Depo Provera. In July she is teaming up with the British government to cosponsor a summit of world leaders in London, to start raising the $4 billion the Foundation says it will cost to get 120 million more women access to contraceptives by 2020. And in a move that could be hugely significant for American women, the Foundation is pouring money into the long-neglected field of contraceptive research, seeking entirely new methods of birth control. Ultimately Gates hopes to galvanize a global movement. “When I started to realize that that needed to get done in family planning, I finally said, OK, I’m the person that’s going to do that,” she says. More from the Gates Foundation website.

Paper confirms EC IUD failure rate less than 1 per 1000

Authors of the first ever systematic review of all available data from the last 35 years argue that IUDs should be routinely offered and available to those requesting emergency contraception. They found that the failure rate was less than 1 per 1000 when they analysed data from 42 studies involving 7034 women using 8 different IUDs. They also found that 85% clinicians in one study never offered this as an option. In a press release this week one of the authors, Professor James Trussell, said:

“This is an extremely difficult problem to deal with, especially as in many countries women can just go to their local pharmacy to obtain the ‘morning after pill’, but virtually no women know to ask for an IUD and many family planning clinics and surgeries do not offer same-day insertion. Offering same-day insertion would remove a huge barrier to the greater use of IUDs.”

Online First – Postnatal contraceptive choices in HIV-positive women [Duncan et al.]

Gillian Robinson (Associate Editor) writes:

“This paper describes an exciting example of how an integrated contraception and sexual health service can work to provide holistic care for women. This clinic provides women living with HIV with prenatal, antenatal and postnatal care in a community setting. The paper is a retrospective case note review. Uptake of postnatal contraception was high yet more than 20% of women were not seen postnatally. The authors suggest that the reasons for this are explored to ensure all women with HIV receive contraception in the early postnatal period to prevent unwanted pregnancy.”

NAT calls for new health bodies to tackle late diagnosis of HIV

“Halve It”, a broad coalition of leading experts and advocates in HIV and AIDS, welcomes the renewed call by the National AIDs Trust (NAT) for the urgent prioritisation of HIV testing in its new ‘HIV testing action plan’ which provides vital strategic guidance to health bodies on tackling the serious issue of late HIV diagnosis in the UK.

FDA Approves first pill for Heavy Menstrual Bleeding (HMB)

Natazia is a combination oral contraceptive (COC) consisting of estradiol valerate and estradiol valerate/dienogest. The US Food and Drug Administration (FDA) first approved Natazia in May 2010 to prevent pregnancy. On March 14, 2012, the FDA also approved Natazia to treat heavy menstrual bleeding (HMB), making it the first and only OC indicated for this purpose. One interesting thing is that until now we have known Natazia, in the UK, as Qlaira and until now it has not been widely used. More details at Medscape.

UK women misdiagnosing genital infections

To mark National BV Day on 18th April a study found that one in four British women has misdiagnosed themselves on the internet. Researchers found Dr Google is now the first port of call for women with genuine health concerns who are almost twice as likely to check online before consulting a doctor or even talking to Mum. But searching their symptoms online and self-medicating has led a tenth of the country’s women to endure unpleasant side effects as a result of their misdiagnosis.

This quarter’s Journal includes the following:

Redefinition of women’s health care

Last year the Royal College of Obstetricians and Gynaecologists published ‘High Quality Women’s Health Care: a Proposal for Change’ that proposed a radical change to the structure of UK women’s health services. Andrew Horne and Johannes Bitzer discuss this exciting document from both a UK and a European perspective, commenting on its implications for sexual health provision. See page 68

Multidrug-resistant gonorrhoea

Gonorrhoea infection is increasing in the UK with a 3% increase in cases between 2009 and 2010. Last year there was a report of a ceftriaxone-resistant isolate; there is a growing concern that gonorrhoea may become incurable. The commentary by Taylor and Bignell is timely. It reviews the current position and provides clear guidelines on screening and treatment, which may prove challenging for some community services that rely exclusively on the use of nucleic acid amplification tests. See page 70

At last, a COC licensed for use in a flexible extended regimen

Data are presented from Phase III studies of a 20 µg ethinylestradiol/3 mg drospirenone combined pill, designed to be used in a flexible regimen. The studies evaluated the efficacy of the regimen, bleeding patterns, safety (ie, metabolic and endometrial parameters) and effect on dysmenorrhoea. Comparisons were with a fixed extended regimen and the conventional 24-day regimen. Results show good efficacy, tolerability and safety with the flexible regimen, and a significant reduction in both bleeding and dysmenorrhoea. See pages 73, 84, 94

Does hormone replacement therapy cause breast cancer? Part 4. The Million Women Study

Shapiro et al. continue their review of breast cancer and hormone replacement therapy papers, this time focusing on the Million Women Study. They conclude that despite its massive size, this study did not satisfy causal criteria. The online version of this paper has already been the focus of a great deal of media publicity and both a news piece and an editorial in the BMJ. Readers should also look at the Letters section for related correspondence that the Journal has received as a result. See page 102

A new aid to diagnosis

Ultrasound imaging has been of value to our specialty for over two decades and skills and equipment have steadily become more available within sexual and reproductive health clinics. In their article on hysterosonography using a local anaesthetic gel, Pillai and Shefras present their experience with a simple and effective new technique that takes imaging a step further, allowing clear diagnosis of intrauterine abnormalities, particularly causes of abnormal bleeding or failed intrauterine device/system (IUD/IUS) insertion, as well as aiding location and easier retrieval of IUDs with missing threads. Many readers will be familiar with the use of lidocaine gel to aid IUD insertion: not surprisingly, uterine instrumentation in conjunction with scanning was reported to be less painful with this technique. This is a promising approach to simplifying and improving the cost-effectiveness of care for women presenting with some complex contraception problems. See page 110

Abortion legislation in a changed world

In his latest Legal Opinion article, Sam Rowlands reviews legislation governing early medical abortion (EMA) and the licensing of EMA drugs in the UK and in other jurisdictions. He then looks at the ways in which such legislation has been used – or in some cases circumvented. EMA has helped to fulfil the crucial need for safe abortion worldwide, but in the author’s view the laws governing abortion in most countries are out of step with scientific advances. Readers may find the author’s conclusions and suggestions for future changes to our own abortion laws thought-provoking. See page 117

Role of doulas in abortion care

Doulas, or lay support persons, have had a longstanding role in supporting women in labour. Chor et al. argue that their role should be extended to caring for women having abortions, where they can help women relax and provide information. They suggest that engagement of the medical community will be instrumental in successfully expanding the role of abortion doula programmes within abortion provision. See page 123

Abortion in the classical world

Lesley Smith continues her series on the history of contraception and reproductive health with a look at attitudes to and practices of abortion in ancient times. It appears that even then, abortion was at the heart of much medical ethical debate. See page 125

Status of health professionals in the 21st century

Has the status of health professionals in society today fallen? If so, why? And is it a good or a bad thing? The Journal’s Consumer Correspondent, Susan Quilliam, explores the issue in her latest article. See page 127

Twenty-five years on: HIV remains a concern

In his latest ‘Then and Now’ article, Lindsay Edouard looks at topics covered by this Journal in 1987. New approaches to contraception were emerging. But was there a threat to community family planning services and would litigation faced by USA manufacturers restrict contraceptive choice? However, the major concern was the emergence of HIV/AIDS, with reinforcement of the advice that barriers should be used in addition to hormonal methods. In 2012, in the light of controversial research suggesting a possible association between hormonal contraception and increased HIV risk in some settings, Edouard draws our attention to the WHO very recent guidance regarding dual protection: 25 years on, advice has not changed. See page 131

Plus – Online Poll

Will the recent article on hormone replacement therapy and breast cancer alter your prescribing practice with regard to HRT?

Faculty News

The latest edition of FSRH News is available on the website.

The celebration, hosted by Nitin Ganatra (Eastenders), to mark the hard work and dedication of people involved in sexual health across the UK took place at Troxy, London. Celebrities, including Janet Ellis, Zoe Margolis, Sharon Marshall, Johnny Partridge and our own Susan Quilliam and Alison Hadley were in attendance to show support and present awards to:

Sexual health professional of the year: Kay Elmy, Peterborough Contraceptive and Sexual Health Service.
JLS young person of the year: Azizi Kosoko, Terrence Higgins Trust.
Rosemary Goodchild Award for excellence in sexual health journalism: Sophie Goodchild for her article ‘Free love: what happened to AIDS?’  Men’s Health magazine.
Adult sexual health service/project of the year: ‘Morning-after-pill in the post’ campaign, bpas.
Young people’s sexual health service/project of the year: Sheffield Open Doors, Sheffield Contraception and Sexual Health Service, School Nursing Service and the Young People’s Drug and Alcohol Service.
Pamela Sheridan Award for Innovation in SRE: Shropshire Respect Yourself Relationship and Sex Education Programme.
Lifetime Achievement in sexual health award presented to Professor Michael Adler CBE.

Email alerts

Don’t miss out on blogs. Stay in touch with News, Views, Updates, Guidelines and information by signing up to email alerts. Click on the link on the right.

Research highlights risks with current tests for Chlamydia trachomatis

“Researchers, from the University of Southampton and the Wellcome Trust Sanger Institute, have discovered that Chlamydia is much more diverse than was previously thought. Using whole genome sequencing, the researchers show that the exchange of DNA between different strains of Chlamydia to form new strains is much more common than expected.”  Current clinical tests only give a positive or negative result and can not identify different strains.  In clinical practice those found to be chlamydia positive after treatment were assumed to have been re-infected but this may not be the case.  Up until now antibiotic resistance has not been seen in humans only in the laboratory but current tests would be unable to demonstrate this if it did occur.

New BASSH Patient Information Leaflets

The BASSH Clinical Effectiveness Group (CEG) has produced new patient leaflets on Safer Sex, Epididymo-orchitis and Gonorrhoea. These are available from their website along with details about up-coming events as well as news and other guidelines.

GMC seeks views on proposed changes to the way doctors are assessed for GP or specialist registration through the ‘equivalence’ or CESR/CEGPR route to registration

Information and access to consultations are via the GMC e-consultation website.

Amendments to FSRH Guidance Documents: Drug Interactions and Emergency Contraception
Drug Interactions (2011): Page 9 of the original version of this CEU Guidance Document (issued in January 2011) incorrectly stated that the interaction between lamotrigine and combined hormonal contraception (CHC) only applies to lamotrigine monotherapy. CHC also reduces lamotrigine levels when lamotrigine is combined with antiepileptic drugs that
do not alter its metabolism.

Emergency Contraception (2011): The original version of this CEU Guidance Document (issued in August 2011) contained some inconsistencies that the CEU has corrected in this version. These amendments are as follows: additional recommendation regarding offering a Cu-IUD to eligible women presenting between 0 and 120 hours of UPSI or within 5 days of expected ovulation added (pages ii and 8); references 12 and 13 updated (page 11); and acknowledgement of chart designer added to Appendix 2 (page 15).

New Examiners for the Multiple Choice Question Paper (MCQ)
The Examination Committee invites applications to join the MCQ Examiner Group of the MFSRH Panel of Examiners. Applicants should be accredited Members of the Faculty and active clinically in the sphere of the Faculty or, to be Clinicians, of equivalent status, with an interest in Sexual and Reproductive Healthcare but whose speciality is GUM, Public Health Medicine, Gynaecology or Primary Care. Further information and application forms from the Faculty website, closing date 29th February.

Committee Vacancies

• Clinical Standards: for a doctor and a nurse
• Workforce Planning: for an Associate member and a Fellow/Member/Diplomate

Information and details of how to apply are available from the committee’s page of the Faculty website

and in other news

Oral Ulipristal Proves Highly Effective for Uterine Fibroids
According to 2 studies published this week in the New England Journal of Medicine the oral selective progesterone receptor modulator, ulipristal, proved highly effective as a treatment for symptomatic uterine fibroids rapidly reducing excessive bleeding and reducing the size of uterine fibroids, and was well tolerated. The drug was approved for emergency contraception in 2010. Known as ella (HRA Pharma) in the United States and ellaOne in Europe, ulipristal works by interrupting ovulation. For emergency contraception, a 30-mg dose is used. By contrast, the newly-published studies tested 5-mg and 10-mg daily doses for fibroid treatment. In one of the studies (placebo-controlled) the drug controlled excess menstrual bleeding in over 90% of cases with a high incidence of amenorrhoea. If and when a product becomes available in the UK (Esmya is already approved and licensed in other countries) the issue of contraception will need to be highlighted to those that might use it because of the interaction with hormonal contraception.

The January edition of the Journal of Family Planning and Reproductive Health Care includes a number of articles previously available at Online First (the Dinger/Shapiro VTE commentary, Advances in IUD training by Connolly & Rybowski and Brown’s study looking at young mens’ views on contraception) as well as:

• a thought-provoking commentary by Raine-Fenning et al on pregnancy of unknown location (PUL) which points out that a recent recommendation from CMACE to abandon the term is at odds with current scientific evidence and clinical experience;
• a commentary by Wilkins of the Men’s Health Forum on men and sexual health;
• a study by Draper et al on 525 GP fittings over a period of 30 years confirms that routine IUD checks confer no benefit.  The paper suggested that current guidelines recommend annual checks though this is based on a statement from Australia dated 2007 and USA advice from 2000 and ignores more up to date FSRH and WHO guidance;
• a questionnaire study of clinic attendees and staff about what we should call ‘attendees’. This appears to show that there is a preference to retain the term ‘patient’ but was based on the respondents picking from only 4 options (‘patient’, ‘client’, ‘user’ or ‘customer’ – ie didn’t include ‘women’ and ‘men’) or asking them what they would prefer to be called;
• Kipp et al highlight the unmet need for effective methods of FP in HIV+ individuals in rural Uganda;
• womens’ views of the use of their leftover LBC samples for research purposes (Cooper et al);
• an important restrospective audit comparing unscheduled reattendance among women having EMA (early medical abortion) at home vs hospital (Astle et al);
• a review of appropriate use of Co-cyprindiol in a general practice (Tandy);
• a review of Clomifene use for ovulation induction in general practice (Wilkes & Murdoch)

Plus at Online First on 31 January 2012: Encouraging IUD uptake after medical TOP [Cameron et al.] 

Sharon Cameron and her colleagues in Edinburgh created a fast-track referral service so that women who had undergone early medical abortion who wished to use intrauterine contraception afterwards could be seen promptly for IUD/IUS fitting. However, only about half the women who were given appointments actually attended. In their article they analyse the differences between the attenders and the non-attenders and suggest ways to enhance the uptake of these effective methods for the prevention of further unwanted pregnancies. While some women would benefit from IUD/IUS insertion at the place of abortion, provision of a fast-track service to the family planning clinic may yet remain the best strategy for maximising uptake of intrauterine contraception in this specific client group. from David Horwell, Advisory Editor, JFPRHC

Journal Fiction Book Reviews for April 2012:
The fiction book that has been reviewed for the next Journal is: “Sense of an Ending” by Julian Barnes.  Read this and see if your views coincide with our reviewer.  If anyone has read “The Marriage Plot” by Jeffrey Eugenides and would like to review it and see their review in print in the April issue please submit a maximum of 400 words to journal@fsrh.org by 12 February at the latest.  In addition, let us know if there are any other books you have read recently that you feel would be of interest to readers.

New GMC Guidance
Two new documents have been published by the GMC: Raising concerns about patient safety and Leadership and management for all doctors 2012 which they “hope will contribute to a culture change within the health service – where raising and acting on concerns becomes part of every day practise in the UK.”

New mobile website for Brook
Brook, the young people’s sexual health charity, have launched a version of their website optimised for viewing on a mobile phone, funded by the JLS Foundation. See a screenshot of the new site below:

There has been a flurry of articles published at Online First this month:

1) Syncope and profound bradycardia associated with intrauterine contraceptive procedures by Aisling Baird, Jane Dickson, Mary Jensen and Martin Talbot (Case Report)

David Horwell (Advisory Editor) writes:

Avoiding a shocking experience

‘Cervical shock’ – severe bradycardia and loss of consciousness due to vagal stimulation – is a rare but potentially serious complication of procedures involving cervical manipulation such as IUD/IUS insertion or removal. The Journal has recently featured lively correspondence regarding the most appropriate means of preventing or managing this condition. In their case report, Aisling Baird and her co-authors make a compelling case for adherence to the current FSRH and UK Resuscitation Council guidelines, and in particular for the availability of atropine for intravenous use and the training of medical and nursing personnel for its prompt administration.

2 ) Does hormone replacement therapy cause breast cancer? An application of causal principles to three studies. Part 4. The Million Women Study by Samuel Shapiro, Richard D T Farmer, John C Stevenson, Henry G Burger and Alfred O Mueck (Article)

JFPRHC Editor-in-Chief, Anne Szarewski, comments:

Does HRT cause breast cancer? Part 4. The Million Women Study

Shapiro et al. continue their review of breast cancer and HRT papers, this time focusing on the Million Women Study. They conclude that despite its massive size, this study did not satisfy causal criteria.

The paper by Shapiro et al. has received an enormous amount of publicity in the last few days. Links to a number of articles are given below:

http://www.dailymail.co.uk/health/article-2087649/HRT-breast-cancer-alert-led-thousands-women-abandoning-treatment-based-bad-research.html?ito=feeds-newsxml

http://www.telegraph.co.uk/health/healthnews/9017783/HRT-link-to-breast-cancer-flawed.html

http://www.nhs.uk/news/2012/01January/Pages/HRT-breast-cancer-link-was-wrong.aspx

http://www.mirror.co.uk/news/health-news/2012/01/16/no-headline-115875-23703286/

http://www.huffingtonpost.co.uk/2012/01/16/fresh-doubts-over-hrt-treeatment-breast-cancer_n_1208863.html

http://www.express.co.uk/posts/view/296113/HRT-may-be-safe-after-all-new-study-reveals

http://www.medpagetoday.com/Endocrinology/Menopause/30698

http://www.businessweek.com/news/2012-01-16/study-disputes-finding-that-hormone-therapy-causes-breast-cancer.html

http://www.abc.net.au/science/articles/2012/01/17/3409576.htm

http://www.webmd.boots.com/menopause/news/20120117/study-linking-hrt-with-breast-cancer-was-flawed

http://www.independent.co.uk/life-style/health-and-families/health-news/hrt-breast-cancer-link-in-doubt-6290686.html

http://topnews.net.nz/content/220907-mws-irrelevant-claims-review

http://www.google.com/hostednews/afp/article/ALeqM5gCUNeCUJ4YzaeuYvTNL-A2txyQLQ?docId=CNG.fe5320085257b6a785e92ed673d14bb8.451

http://www.walesonline.co.uk/news/wales-news/2012/01/17/women-face-confusion-over-hrt-safety-91466-30135578/

http://lifestyle.aol.co.uk/2012/01/17/new-study-says-hrt-could-be-safe/

http://info.cancerresearchuk.org/news/archive/cancernews/2012-01-17-Researchers-defend-HRT-breast-cancer-study

3) Using a simulated patient to assess referral for abortion services in the USA by Laura E Dodge, Sadia Haider and Michele R Hacker (Article)

Henrietta Hughes (Associate Editor) says:

Accessing referral for abortion in the USA

All women seeking abortion services need to access services in a timely fashion, which depends on quick and appropriate referrals to abortion providers. In the USA, reproductive health facilities that do not provide abortion may refer women to abortion services. Dodge et al. have investigated the readiness of services to offer this referral. Simulated patients called gynaecological services in the most and least restrictive US states for abortion. The simulated patient received a direct referral for abortion services less than half the time, even after prompting a staff member to provide one. The least restrictive states were most likely to offer a direct referral and the least likely to offer no referral.

4) Ethnic differences in disease presentation of uterine cancer in New Zealand women by Ridvan Tupai Firestone, Lis Ellison-Loschmann, Andrew N Shelling, Alec Ekeroma, Bettina A Ikenasio-Thorpe, Neil Pearce and Mona Jeffreys (Article)

Andrew Horne (Associate Editor) writes:

Maori and Pacific women more likely to present with advanced uterine carcinoma

There is little known about the contributions of ethnicity to the presentation of uterine carcinoma. The authors of this article have retrospectively analysed uterine carcinoma cases presenting in New Zealand over a 10-year period. They show that Maori and Pacific women, specifically those from lower socioeconomic areas, are more likely to present with advanced disease. They propose that these women, similar to African-American women, may be presenting with a more aggressive histological subtype and that this warrants further investigation.

5) Not such a different world: providing contraception services in Lesotho by Nic Robertson (Margaret Jackson Prize Essay 2011)

Walli Bounds (Associate Editor) comments:

Contraception challenges in Lesotho – not so different from the UK

In his 2011 Margaret Jackson Prize Essay, Nic Robertson gives readers a fascinating insight into the challenges facing contraception services, and problems encountered with use of current contraceptive methods, in Lesotho. Based on personal observations during his elective there, he describes with clarity and compassion the difficulties women face in trying to avoid unwanted pregnancy and sexually transmitted infections. Only limited service provision, inadequate staff training, difficulty in accessing clinics, and inadequate clinic facilities, with no running water, electricity or privacy, are some of the obstacles discussed. In conclusion, the author recommends specific areas for future developments, which could help not only women in Lesotho but also those in the UK.

6) Cervical screening among migrant women: a qualitative study of Polish, Slovak and Romanian women in London, UK by Marta Jackowska, Christian von Wagner, Jane Wardle, Dorota Juszczyk, Aleksandra Luszczynska and Jo Waller (Article)

Imogen Stephens (Associate Editor) reflects:

Cervical screening among migrant women in London

Over half a million people from Central and Eastern Europe live in the UK: half of these are women and most of them are young working adults, with few health care needs. They are not familiar with UK health services, and sometimes struggle with language barriers and long working hours. Jackowska and colleagues, through a series of focus groups, have looked at some of the reasons why young women from some of these countries don’t take up cervical screening (“they just don’t trust the British healthcare”). Many of them prefer to travel back to their home countries once a year to visit the doctor in a more familiar setting. The NHSCP is well-organised, free and can be conveniently accessed in a wide range of settings, including community sexual health services. But this study identifies that we are not necessarily very good at getting this message across to migrant groups: and that our services need to be sensitive to language barriers in particular (“some doctors are mean towards someone who is shy or can’t speak English well”).

Consultation to lift ban on HIV-positive doctors and dentists:
according to media reports last week the DH is set to launch a consultation on lifting the ban imposed 20 years ago. Many believe the ban to be discriminatory, no longer justified on public health grounds and ignored in most hospitals who reportedly have a ‘don’t ask, don’t tell’ approach. The DH’s own expert group concluded that the risk of infection was in the region of one case in every 2400 years.

Correlation of Age at Oral Contraceptive Pill Start with Age at Breast Cancer Diagnosis
Based on a review of 1010 cases at the Breast Unit in Ashford, Kent and published in The Breast Journal – early view this week, the authors concluded that the age when the OCP was started was positively associated with the age when breast cancer was first diagnosed. They state that this effect may show a causal link but may also reflect other associated lifestyle factors associated with early OCP use.

Faculty Members Questionnaire
The FSRH are conducting a short questionnaire to elicit members’ views of its activities and possible future plans.

Joint BASHH and Faculty Meeting 2012
The next joint meeting between BASHH and the Faculty is being held on Friday 20th January 2012 at the Royal Society of Medicine. The theme for the meeting is ‘Recurring issues in Sexual Health‘ .

Systematic Review of Induced Abortion and Women’s Mental Health Published
The world’s largest, most comprehensive and systematic review into the mental health outcomes of induced abortion was published yesterday by the Academy of Medical Royal Colleges. The review concludes that having an abortion does not increase the risk of mental health problems. The best current evidence suggests that it makes no difference to a woman’s mental health whether she chooses to have an abortion or to continue with the pregnancy.

Should all nuns take the pill?

This was some of the media’s interpretation of an article published at The Lancet – Early Online this week. Britt and Short describe the well known health risks for nuns associated with their life of chastity, first documented in 1713. They also note that despite the roman catholic stance on not using any form of contraception apart from abstinence, dating from the Humanae Vitae document of 1968, this may be possible as the same document also states:

the Church in no way regards as unlawful therapeutic means considered necessary to cure organic diseases, even though they also have a contraceptive effect.

Following publication of the extended analysis of the Danish Cohort Study on VTE risk (with combined oral contraceptives with different progestogens and oestrogen doses) in the BMJ and the rapid responses since, Shapiro S and Dinger J have now produced a Commentary for the January 2012 edition of the Journal of Family Planning and Reproductive Healthcare (JFPRHC). This is now published at BMJ Online First.

To accompany the commentary Anne Szarewski, Editor in Chief of the JFPRHC writes

VTE and the Pill … again

The re-analysis of the Danish Cohort Study has recently been published in the British Medical Journal (BMJ). Unfortunately, there are still many methodological issues with it, as discussed in this commentary by Dinger and Shapiro. They also point out that the important analysis that was actually requested by the regulatory authority (but not published in the BMJ paper) showed no difference in risk between combined oral contraceptives.

FSRH Workforce Planning Committee

The Faculty has vacancies for 2 members on its Workforce Planning Committe (1 associate member and 1 diplomate, member or fellow). Details available on the Faculty website.

2 New Publications for Nurses -

as reported by Wendy Moore, Vice Chair of the Faculty Associate Members’ Working Group

RCN Competences for nurses undertaking bimanual pelvic examinations

Nurses working in sexual and reproductive health are increasingly extending their role, benefitting both the nurses and their client groups. The ability to carry out pelvic and bimanual examinations is now a key requirement for nurses working in these specialisms in primary, secondary and community care. The purpose of the competency framework is to ensure that women requiring a pelvic exam are cared for safely and that training and assessment processes are in line with local guidance.

RCN Competences for nurses assessing and counselling women who request and/or receive long-acting reversible methods of contraception (LARC)

Aimed at sexual and reproductive health practitioners this new set of competences is aimed at nurses who are assessing and counselling women who have requested or received long-acting reversible methods of contraception (LARC). The purpose of this competency framework is to ensure such women are cared for safely and helps professionals to identify their training needs, ensuring they have the skills and knowledge to undertake the delivery of contraception services competently and safely.

And finally we hope that reports from America that Apple’s new voice recognition software, Siri, is anti-abortion are exaggerated – the ‘tech’ giant says it will improve the software’s unintentional omissions so that it doesn’t say it cannot find abortion clinics. Knowing the age we live in we suspect this ‘issue’ will run for a while in blogs and tweets around the world.

The Clinical Effectiveness Unit (CEU) of the Faculty of Sexual & Reproductive Healthcare (FSRH) has achieved NHS Accreditation for the process used to produce its guidelines. The NHS Evidence Accreditation Scheme recognises organisations that demonstrate high standards in producing health or social care guidance. It is stated that users of accredited guidance can therefore have high confidence in the quality of the information. In future all CEU guidance will display the Accreditation Mark.

This coincides with the release of the latest clinical guidance: Combined Hormonal Contraception – an updated and extended version of the previous guidance on combined oral contraception published in 2006. There are now clinical guidelines on the vast majority of currently available methods as well as Drug Interactions, Quick Starting (methods), Emergency Contraception and others for specific, special groups. This is in addition to the UK Medical Eligibility Criteria.

The CEU was launched in 2002 and after initially being based in Aberdeen transferred to Sandyford in Glasgow in 2008. The director of the current unit is Dr Louise Melvin and its main tasks are producing evidence based guidance, new product reviews and running the Members Enquiry Service.

Clinical guidelines that are evidence-based are an important element of current clinical practice and underpin clinical competence and governance. Along with training they have the potential to raise standards and improve quality of care, though as their name suggests they are intended to guide clinical care not replace clinical judgement as they are applied to general situations rather than to individuals.  In sexual and reproductive health care CEU guidance and FSRH training is increasingly seen as the gold standard by which clinical care is likely to be judged. An example of this was seen earlier this year in a statement from the MDU in response to an increase in the number of claims related to problems with subdermal implants by GPs. The statement stresses the need for, particularly, GP members to ensure they have appropriate training and should ideally hold a Letter of Competence from the Faculty.