This ongoing controversy recently resulted in the decision of the French authorities to withdraw the COC containing ethinylestradiol (EE) and cyproterone acetate (CPA) ie Diane 35 from the market. Just published online in the JFPRHC is a joint statement from 26 international experts in contraception, whose conclusion is: ‘Both epidemiological data and clinical trials must be taken into account when best practice is defined. Regulatory restrictions of previously registered methods should only be made after careful assessment of all the available evidence.’

Readers’ attention is also drawn to two similar Position Statements recently issued by the Society of Obstetricians and Gynaecologists of Canada, the first on hormonal contraception and risk of VTE, the second specifically relating to Diane 35.

http://www.sogc.com/media/documents/medHormonalContraceptionVTE130219.pdf.

http://www.sogc.com/media/documents/medDiane35VTE130219.pdf.

‘A Framework for Sexual Health Improvement in England’ sets out the government’s ambitions for improving sexual health.

Designed to be used by local organisations when they are looking at how best to provide sexual health services in their area. This includes the need for:

• a fall in the number of unwanted pregnancies
•  greater efforts to prevent STIs and HIV
•  an increase in the number of people in high-risk groups being tested for HIV
• building an honest and open culture where everyone is able to make informed and responsible choices about relationships and sex
• making sure that all people have rapid and easy access to appropriate sexual health services
• offering counselling to all women who request an abortion so they can discuss the options and choices available with a trained counsellor

Responses to ‘Framework for Sexual Health Improvement’.

 The Sex Education Forum, based at leading children’s charity The National Children’s Bureau, welcomed the publication of the government’s strategy for improving sexual health and its focus on preventative measures, such as good quality sex and relationships education (SRE). However, more needs to be done to ensure all schools step up to the mark, in providing the information, support and advice that children want and need.

FPA welcomes the Government’s long-overdue publication of its Framework for Sexual Health Improvement in England document, which finally provides guidance to local government to help ensure that the nation’s sexual health improves.

Although we support the Government’s formal endorsement of the need to improve areas of sexual health like sexually transmitted infection (STI) and teenage pregnancy rates, we are acutely aware that there is absolutely no guarantee that local councils will actually act on this guidance.

We know from our Unprotected Nation report, released in January, that if the situation worsens, and local government chooses not to invest in sexual health services, the additional cost to the economy is likely to be over £135 billion over the next few years.

Brook

Responding to the publication of A Framework for Sexual Health Improvement in England Simon Blake OBE, Brook’s Chief Executive, said:

“We are pleased that the Framework for Sexual health has been published just in time for the move to local authorities and that there are clear aspirations for the improvement of young people’s sexual health, in particular that all young people have access to confidential services and support.

“We are also pleased to see the ambition that all children and young people should receive good quality Sex and Relationships Education (SRE) at school which we know is vital in preventing abuse and exploitation and promoting positive relationships. However, this ambition will never be realised whilst the Department for Education fails to ensure that every school is required to deliver a comprehensive programme of SRE.

“As we move towards 1st April we look forward to working local authorities to realise these ambitions and improve young people’s lives.”

FAMILY PLANNING 2020 names Director of the global partnership

The Family Planning 2020 (FP2020) Reference Group announced that long time global advocate for family planning and reproductive health Valerie DeFillipo has been named Director of the global partnership. FP2020 builds on the partnerships launched at the London Summit on Family Planning. It will sustain the momentum from London and ensure all partners are working together to achieve and support the goals and commitments announced at the Summit.

Hightlights from this month’s Journal include:

Romanian women’s struggle to manage their fertility – Editor’s Choice 

Mihai Horga et al. tell the remarkable story of Romanian women’s struggle to manage their fertility. The sudden reversal of liberal abortion laws in 1966 led to a doubling of the total fertility rate within a year, and then to a dramatic increase in maternal mortality from unsafe abortion. In 1989, the Ceausescu regime fell and the anti-abortion law was abolished; within a year, the maternal mortality halved. Since then, contraceptive use has increased and there has been a reduction in the abortion rate. As the authors say “Countries which increasingly seek to restrict access to abortion and contraception should look and learn”. See page 2

Whither abortion policy in Britain? 

This commentary discusses the current situation regarding Government policy on abortion in Britain. It begins by setting out the ways in which the policy of the Coalition Government appears to differ from that of the new Labour administration. The article notes that 2012 brought furious debate about abortion services, focusing on counselling, ‘sex-selection’ abortion, and signing of HSA1 forms, and discusses what has emerged to date from these furores. Finally, thoughts are offered on how to respond to the problems raised by the current approach of policymakers. See page 5

SLE in relation to SRH

Systemic lupus erythematosus (SLE) is an autoimmune disease of uncertain aetiology that can affect multiple organ systems. Unfortunately, despite the complications that an unintended pregnancy can cause for a woman with SLE, many women with SLE are not counselled regarding contraceptive use or are counselled against contraceptive use based on concerns that contraceptives will adversely affect their disease. The primary risks from use of hormonal contraceptives in women with SLE involve thrombogenic risks. The best available evidence does not, however, indicate a risk of worsening disease activity in women with mild to moderate SLE who use hormonal contraceptives, either combined or progestogen-only, and indeed the benefits of contraception outweigh the risks for most women with SLE. See page 9

Low-calorie sweeteners/drinks and preterm delivery

In his commentary, Carlo La Vecchia examines the possible relationship between low-calorie sweeteners/drinks and preterm delivery. He presents a meta-analysis of published data, which shows no difference in the risk estimates for sugar-sweetened and low-calorie drinks. This should be reassuring for women who consume low-calorie drinks during pregnancy. See page 12

Preparing tomorrow’s medical educators today

The FSRH Letter of Competence in Medical Education has been replaced by a formal university-accredited Postgraduate Award in Medical Education, the PGA Med Ed. The details are set out in this commentary by Heathcote and Nyholm and will be of interest to those wishing to become Faculty Trainers. See page14

Postnatal contraceptive choices in HIV-positive women

This article 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. 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. See page 17

Chlamydia screening in young people

The major burden of Chlamydia trachomatis infection is borne in individuals under 25 years of age. Complications of untreated infection are manifold and encompass pelvic inflammatory disease, sub-fertility, epididymo-orchitis, urethritis, arthritis, conjunctivitis and proctitis. Despite high hopes, uptake of the English National Chlamydia Screening Programme has been lower than expected. As a result, the expected decline in chlamydia prevalence has not been observed. Horner et al. have investigated the use of a peer-led approach to increase screening and examine the feasibility and acceptability of this strategy in young people. See page 21

Inequity in family planning provision in urban nigeria

In Nigeria, contraceptive use is low. Provision needs to improve, and understanding the roles and perspective of the mixed economy of contraceptive providers is a key step in designing better services. This qualitative study explores the experiences and challenges faced by a range of providers in two urban Nigerian areas. Using structured in-depth interviews and checklists, researchers identified the need for further training and support for all providers to empower them to provide a wider range of contraception. Vulnerable groups, likely to have high needs for contraceptive advice and provision, were routinely excluded from family planning services. Understanding the underlying reasons for this inequitable provision, and developing appropriate marketing strategies and materials, is key to developing more sensitive service provision. See page 29

Disruptive events among women having abortions in the USA

We are all aware that poverty is associated with abortion but how many of us knew that bad (or disruptive) life events also play a major role? Research by Jones et al. demonstrated that more than half of the women seeking abortion had experienced a disruptive life event in the preceding 12 months. Women are making decisions about their abortion whilst in the midst of complex life events. The authors’ suggestions for changes in policy may not be directly relevant in the UK; however, the study findings are of wider significance. See page 36

Impact of freedom on fertility decline

Campbell et al. propose that education of women is not the most important factor in reducing family size; access to family planning is critical. Education and wealth can make the adoption of family planning easier, but they are not prerequisites for fertility decline. By contrast, access to family planning itself can accelerate economic development and the spread of education. See page 44

Arguments for abortion

This year’s Margaret Jackson Prize Essay winner, John Reynolds-Wright, has produced a fascinating and provocative review of the moral and philosophical importance of abortion. The prize, awarded by the FSRH, is open to medical students and is named after one of the British pioneers of family planning. The standard of this year’s entries was very high and covered the whole field of sexual and reproductive health care, making the judges’ choice a difficult one. We are sure that readers will be stimulated by the positive arguments that the author presents. Letters to the Editor are always welcome and the correspondence may be lively! See page 51

and finally

Fifty Shades of a phenomenon

Few of us will have failed to notice the erotica phenomenon, Fifty Shades of Grey. The Journal’s Consumer Correspondent, Susan Quilliam, explains what lies behind the trilogy and reports on worldwide reaction to it. See page 56

By coincidence, the publication of this season’s Journal occurred at the same time as the mushrooming revelations around Jimmy Savile’s abuse of many of his fans over many years. The press are currently talking about 50 or 60 people but he must have come into contact with thousands of vulnerable young, star-struck youngsters in his time. The abuse appears to have been well masked (or ignored) because of the money he was then able to donate to many good causes.

The Commentary and Lead Article in the Journal demonstrate one of the many serious outcomes for future health that childhood abuse can have using attitude to cervical screening in later life as an example. These also highlight the value of one particular organisation who are likely to be inundated with more calls for help and support.

NAPAC is the only UK national charity that supports adult survivors of all forms of childhood abuse. Founded in 1997, NAPAC runs Britain’s only free phone support line for adult survivors and is accredited by the Helplines Association. The support line is staffed entirely by volunteers some of whom are survivors themselves. The organisation was profiled in the Journal in 2011 by our consumer correspondent Susan Quilliam.  The organisation can be contacted at www.napac.org.uk, email at: support@napac.org.uk or the freephone Support Line on 0800 085 3330.

To learn more about the work of NAPAC follow this link to the podcast featuring Sarah Kelly, Training and Development Manager: http://podcasts.bmj.com/jfprhc/

There is still time to register for FIAPAC 2012 in Edinburgh – October 19th-20th

- Unwanted Pregnancy: A fact of life

ESC – Global Conference – Call for Papers

The First global conference on contraception, reproductive and sexual health will be held in Copenhagen from 22-25th May 2013. The closing date for submission of papers is 15th December. Further information is available from the website or using the QR-code below.

Two articles from The Obstetrician and Gynaecologist, July 2012 edition:

• Domestic Violence: a clinical guide for women’s healthcare providers by Amy Gottlieb and
• Female genital cosmetic surgery: how can clinicians act in women’s best interests by Lina Michala, Lih-Mei Liao and Sarah M Creighton

Rape Axe

In a controversial, but fascinating, story we hear about a nurse in Zimbabwe who invented a vaginal device that is full of hooks that inbed into the penis of a rapist and can only be removed by surgical intervention! More information from the website where women share their experiences and with links to support organisations.

not to be confused with

Medical Device turns sex toy

which claims to be the first sex toy to strengthen pelvic floor muscles. It was developed from a device used to help women with incontinence which was found to induce pleasure and orgasm in consumer trials

WHO – 40 years of innovation in sexual and reproductive health

A comment piece in The Lancet by past and present directors of WHO’s Human Reproduction Programme (HRP) discusses the achievements of the Programme since it was established in 1972.

Online First – Evaluation of a community pharmacy delivered oral contraception service

“Anything for the weekend … and beyond, madam?” Community pharmacies increase oral contraceptive uptake

Parsons et al.’s evaluation of a community pharmacy delivered oral contraceptive (OC) service is of particular interest, as it demonstrates the value of providing OCs via this service outlet, especially for women who would not otherwise access long-term contraception. Between 2009 and 2011, seven specially trained pharmacists at five pharmacies in South-East London provided OCs under a Patient Group Direction (PGD) during 741 client consultations. The evaluation showed that trained pharmacists were clinically competent to provide OCs according to a PGD, and that the service was successful in attracting the population identified as most in need. Nearly half of all consultations occurred following emergency hormonal contraception supply, and nearly half of clients receiving an initial supply of OCs were first-time Pill users. Based on satisfaction questionnaires from a small sub-group, most clients valued this service, were happy about privacy, and would recommend it. Although the primary aim was to reduce teenage pregnancy , and nearly a quarter of clients were aged <20 years, the study shows that women aged 20+ years also require this service and should not be overlooked when formulating policies for service provision.
summary by Walli Bounds, Associate editor

Infertility: Survey shows nearly half of all GPs lack knowledge

Results of a comprehensive patient survey by the National Infertility Awareness Campaign (NIAC) shows that GPs need to be better informed about infertility treatment, including IVF, and the options available when the commissioning of IVF switches to local commissioning groups next year. The NIAC survey found that nearly 50% of GPs lacked the necessary knowledge of infertility and the treatment options available to provide an effective service. This could explain why some patients with fertility issues perceived their GPs as unsympathetic.

Calling All Baby Boomers: Get Your Hepatitis C Test

A report issued by the U.S. Centers for Disease Control and Prevention (CDC) recommended that all Americans born between 1945 and 1965 be tested for the hepatitis C virus (HCV). An estimated 2.7 million to 3.9 million people in the United States are infected with this liver-damaging—and sometimes lethal—virus, and many do not know they carry it. CDC calculates that roughly 75% of those infected are baby boomers: 3.25% of people born in that “birth cohort” test positive for HCV, which is five times higher than the rate in adults born before 1945 or after 1965. CDC has determined that universal testing of baby boomers is the most cost-effective strategy for detecting undiagnosed HCV infections.  As reported in Science

New lab for HIV research

The Indian Government has opened the new $12 million HIV Vaccine Translational Research Laboratory in New Delhi. The new Laboratory will aim to recruit around 30 scientists with the goal of creating a new vaccine against HIV, and will work in collaboration with the International AIDS Vaccine Initiative.  As reported in Science

The following papers have been published this month at http://jfprhc.bmj.com/content/early/recent

More than poverty: disruptive events among women having abortions in the USA (Jones)

We are all aware that poverty is associated with abortion but how many of us knew that bad (or disruptive) life events also play a major role? The research by Jones et al. demonstrates that more than half of the women seeking abortion had experienced a disruptive life event in the preceding 12 months. Women are making decisions about their abortion whilst in the midst of complex life events. The authors’ suggestions for changes in policy may not be directly relevant in the UK; however, the study findings are of wider significance. from Gillian Robinson,  Associate Editor

Psycho-social factors affect semen quality (Cao)

Semen quality appears to be declining and this cross-sectional study in China casts light upon some factors that may be associated with that decline. The research team analysed the semen of 1346 healthy 20-40-year-old Chinese men, capturing their psychological, social and behaviour profiles via questionnaire. It appears that stress, social class and underwear made from man-made fibres all play a significant part in declining semen quality. from Scott Wilkes,  Associate Editor

Young people and chlamydia – peer led strategies to increase the uptake of screening (Horner)

The major burden of Chlamydia trachomatis infection is borne in individuals under 25 years of age. Complications of untreated infection are manifold and encompass pelvic inflammatory disease, sub-fertility, epididymo-orchitis, urethritis, arthritis, conjunctivitis and proctitis. Despite high hopes, uptake of the English National Chlamydia Screening Programme has been lower than expected. As a result, the expected decline in chlamydia prevalence has not been observed. Paddy Horner’s group have investigated the use of a peer-led approach to increase screening and examine the feasibility and acceptability of this strategy in young people. Interestingly, although this is a relatively small proof of principle study, women peer-led screening was more successful than male in recruiting peers to participate in the programme. from Rachael Jones,  Associate Editor

Inequity in family planning provision in urban Nigeria: a providers’ perspective (Herbert)

In Nigeria contraceptive use is low: used by only 10% of married women and with 20% of women estimated to have an unmet need. Provision needs to improve, and understanding the roles and perspective of the mixed economy of contraceptive providers is a key step in designing better services. A qualitative study from the Nigerian Urban Reproductive Health Initiative explores the experiences and challenges faced by a range of providers in two urban Nigerian areas. Using structured in-depth interviews and checklists, researchers identified need for further training and support for all providers to empower them to provide a wider range of contraception. Few providers engaged in meaningful promotional activities for their products or services. Vulnerable groups, likely to have high needs for contraceptive advice and provision, were routinely excluded from family planning services: adolescents, married women and those seeking post-abortion care. Understanding the underlying reasons for this inequitable provision, and developing appropriate marketing strategies and materials will indeed be key to developing more sensitive service provision. from Imogen Stephens,  Associate Editor

New female condom, the ‘Woman’s Condom’ – will the Chinese go for it? (Coffey)

The need for products that simultaneously protect against unwanted pregnancy and STIs, including HIV, has prompted interest in the development of Multipurpose Prevention Technologies (MPTs), including new variants of the female condom. In this issue, Coffey and colleagues describe their survey of initial reactions to the ‘Woman’s Condom’ (which obtained marketing approval in China in 2010) by potential user groups in Shanghai. Their study demonstrates the importance of assessing the potential acceptability of new products in a range of populations, with differing expectations, needs and culture-specific influences. Their findings are of particular value to programme/service providers, in order to identify most likely adopters of this new type of female condom. from Walli Bounds,  Associate Editor

The European Consortium for Emergency contraception (ECEC) was launched in Athens on June 21^st at the 12th Congress of the European Society for Contraception and Reproductive Health.

Why a European Consortium on EC, now?

• Access to emergency contraception (EC) is unequal across the region.
• Absence of a harmonised evidence-based approach to EC recommendations.
• Current changes in the EC landscape are likely to lead to further inequalities in access to reliable EC options.
• The International Consortium for Emergency Contraception (ICEC) works to expand access to EC worldwide, but focuses on the developing world.
• ICEC and partners identified a need to develop a regional platform to serve as an authoritative source of information, and a voice for more equitable access to EC in Europe.

ECEC mission:

To expand knowledge about and access to EC in European countries, and to promote the standardisation of EC services delivery in the European context, to ensure equitable access within the region. (not only with the 27 EU countries, but with all countries considered Europe by the EU and the WHO.)

ECEC objectives:

KNOWLEDGE – Generate knowledge and serve as an information-sharing platform.
RESEARCH – Promote high quality research on EC issues.
ADVOCACY – Disseminate research findings and promote use of evidence-based information for policy and program development.
QUALITY OF CARE – Reduce access inequalities by promoting the standardization of quality of care of EC services across the region.
IEC – Develop and disseminate information, education and training materials.

How to become a member?

Individual membership – Email info@ec-ec.org and join or via http://knowledge-gateway.org/ICEC/Global/ecec

Institutional membership (terms under development).

Other ESC News

The Congress in Athens was well attended (1400 delegates) despite the reduction in drug company support, most notably for UK clinicians.

At the General Assembly the venue for the 2016 Congress was voted for and won by Basle in Switzerland, which is also the base of the current president – Johannes Bitzer.

•  In case you hadn’t heard there is an extra Congress next year – the first Global Congress – in Copenhagen. An outline programme, information and calls for papers are available from the website: www.escrh.eu. The abstract submission deadline is 15 December 2012. Why not send something in? You may win an award: best poster, best free communication and for the under 35s, best Young Scientist.
• The next biennial Congress is in 2014 and will be in Lisbon.

At the Board meeting Professor Kristina Gemzell-Danielsson, from the Karolinska Institute in Sweden, was elected Vice President.

Highlights from this issue include:

Norethisterone and VTE risk

Diana Mansour’s article previewed at online first and in the 15th June blog. See page 148

Helping women with hirsutism

Editor’s Choice article – Stephen Franks provides useful guidance for helping women with this common and often distressing condition. See page 182

US administration’s attitude to family planning

The winner of the 2010 Margaret Jackson Prize Essay for undergraduate medical students has looked at the differences between the Bush and Obama administrations’ attitudes to family planning and abortion. See page 187

Avoiding a shocking experience with intrauterine contraceptive procedures.

Aisling Baird et al. make a compelling case for adherence to the current Faculty and UK Resuscitation Council guidelines. The last time this issue was raised, in the January 2011 edition of the journal, a flood of letters followed. See page 191

Nurse Training in the UK

Shelley Mehigan & Janice Burnett describe and discuss the Berkshire training programme for nurses which mimics the DFSRH. See page 194

The SDM: a realistic option for longer-term use

A report on the experience of nearly 500 women who used the Standard Days Method for between 2 and 3 years. See page 150

CycleBeads: the latest in ‘contraceptive jewellery’!

Describes CycleBeads®, a colour-coded string of beads, that are a visual tool that helps women use the SDM correctly. See page 157

Ovarian and cervical cancer: better awareness, earlier recognition, improved outcome?

Simon and colleagues developed and validated reliable disease-specific Cancer Awareness Measurement tools for both forms of cancer, testing them in matched comparison groups. See page 167

Encouraging IUD uptake after medical TOP

Sharon Cameron and colleagues in Edinburgh created a fast-track referral service so that women who had undergone early medical abortion & wished to use intrauterine contraception afterwards could be seen promptly for fitting. See page 175

Psychosexual therapists speak out

Psychosexual therapy can seem like one of the dark arts, but in this issue Consumer Correspondent Susan Quilliam brings us the therapists’ own stories. See page 196