The following Online Firsts have been published

Does a full bladder assist insertion of intrauterine contraception?: a randomised trial (Cameron, Glasier, Cooper,  Johnstone)

Cameron and colleagues set out to answer a simple question: does a full bladder assist insertion of intrauterine contraception? In the world of assisted conception a full bladder had been shown to aid intrauterine catheter insertion for embryo transfer, but could this knowledge be transferred usefully to the world of contraception? This simple question was answered in a simple and elegant way with a properly constructed and conducted randomised trial, which showed that we needn’t ask our clients requesting IUD/IUS insertion to arrive bursting – a fact for which both they and clinic staff will be duly grateful.

Impact of UK Medical Eligibility Criteria implementation on prescribing of combined hormonal contraceptives (Briggs, Praet, Humphreys, Zhao)

Briggs et al. have assessed the effect of the UKMEC on prescribing of combined hormonal contraceptives (CHC). Sadly, although there has been a small decrease in the proportion of higher-risk women being prescribed CHCs, their results suggest that in 2010 7.3% of CHC users had Category 3 or 4 risk factors, particularly BMI ≥35. The authors point out that it is likely many of these women were being placed at an unnecessarily high risk of cardiovascular events, given the availability of lower risk alternatives.

Understanding barriers to sexual health service access among substance-misusing women on the South East coast of England (Edelman, Patel, Glasper, Bogen-Johnston)

This interesting article explores why substance-abusing women have problems accessing SRH services in Hastings, UK. Drug use, low self-esteem and previous traumatic experiences all combine prevent women accessing help. This is a qualitative interview study and provides important insights into the care of these women; there are no easy answers but the authors have provided some suggestions as to how practitioners may make the service more accessible.

Coping after recurrent miscarriage: uncertainty and bracing for the worst (Ockhuijsen, Boivin, van den Hoogen, Macklon)

Pregnancy loss is a significant trauma for women, the more so if repeated.  In their study, Ockhuijsen and her colleagues investigated the ways in which women coped in the time after single and recurrent miscarriages and in the difficult period soon after conception while waiting for ongoing pregnancy to be confirmed. They found that coping strategies differed between the two groups of women and they investigated the use of a simple psychological support tool, the Positive Reappraisal Coping Intervention, that may be of help, particularly to those with greater concern for the future following recurrent miscarriage.

The role of ambulatory hysteroscopy in reproduction (Robinson, Cooper, Clark)

The relatively recent introduction of outpatient operative hysteroscopy enables investigation and treatment previously carried out in the operating theatre to be performed in the clinic setting without the need for general anaesthesia. A ‘see and treat’ style of management is being adopted, which is changing how we configure our gynaecological services. This review summarises the role for ambulatory hysteroscopy in the diagnosis of conditions contributing to reproductive failure and in sterilisation.

The use of local anaesthesia for intrauterine device insertion by health professionals in the UK (Akintomide, Sewell, Stephenson)

What to do now? How women with breast cancer make fertility preservation decisions (Snyder, Tate)

A service-based approach to nurse training in sexual and reproductive health care (Shawe, Cox, Penny, White, Wilkinson)

Increasing male participation in the uptake of vasectomy services (Singh, Mishra, Alam, Pandey)

Correlates of unprotected sexual intercourse among women who inject drugs or who have sexual partners who inject drugs in St Petersburg, Russia
(Abdala, Hansen, Toussova, Krasnoselskikh, Verevochkin, Kozlov, Heimer)

Plus Organisation Factfiles on Tommys and the College of Sexual and Relationship Therapists (COSRT) by Susan Quilliam and a letter to the editor “Learning from Romanian women’s struggle to manage their fertility” by Ann Furedi following the article in the January Journal

Risk of Unwanted Pregnancies with Morning After Pill Conscience Clause

This article is published in the Journal of Medical Ethics today – “The Fox and the grapes: an Anglo-Irish perspective on conscientious objection to the supply of emergency hormonal contraception without prescription”

Conscience clauses, which allow pharmacists to opt out of providing the “morning after pill” without a prescription, risk unwanted pregnancies and undermine the principle of universal healthcare in the NHS, say pharmacists in the Journal of Medical Ethics.  These clauses should either be banned or enhanced so that pharmacists and patients know exactly where they stand, rather than the current “fudge”, which serves nobody well, the authors conclude. Emergency contraception without a prescription became available from UK pharmacies in 2001 and the Republic of Ireland in 2011.  Built-in conscience clauses allow pharmacists to opt-out of provision on moral or religious grounds, providing they refer patients to other providers willing to prescribe the product.

Cuts to services set to saddle UK with a £136.7 billion NHS and welfare burden by 2020

A new report from the UK’s leading sexual health charities, Brook and FPA, has revealed for the first time the economic and social impact of NHS cuts to contraception and other sexual health services. Cuts are resulting in these services been reduced or restricted and this can already be seen across the UK today. The report looks at what happens if these restrictions to services continue unabated. The key findings of the report reveal:

-          A significant rise in the number of NHS abortions and STI rates by 2020

-          An additional cost burden on the NHS of £612.8 million as a consequence of increasing numbers of unintended pregnancies and STIs

-          An increase in wider public spending of up to £124.7 billion – equivalent to 10% of all welfare spending – by 2020

Anne Connolly, GP in Bradford, and Chair of the Primary Care Women’s Health Forum, said; “There is a clear danger that imminent changes to commissioning could significantly undermine the good work that professionals are doing. Maintaining progress requires investment and if we are brave enough to invest money at a time when there is pressure to disinvest there are massive cost savings as well as quality of life savings to be made, as this report clearly illustrates.”

In response to reports of restrictions to contraception across the UK Brook and FPA joined forces earlier this year to launch XES – We Can’t Go Backwards, a major awareness campaign. Brook and FPA are calling on people in the UK to join the campaign and rate and share their experiences of contraception services, good and bad, through the UK’s only interactive online sexual health map www.wecantgobackwards.org.uk

Education for Choice hightlights misleading pregnancy counselling

Education for Choice support young people’s right to informed choice on abortion. They report that Feminist Action Cambridge held a demo in Cambridge city centre to raise awareness of local ‘crisis pregnancy centres’ which they feel are ‘using emotionally manipulative techniques’ and misinformation ‘in order to increase the guilt women might feel at having an abortion.’ They sent mystery shoppers to three counselling centres in Cambridgeshire and found that, at each one, women were being given some kind of false information about abortion and/or subjected to ‘counselling’ which was biased and often based on personal anecdotes.

New NICE Clinical Guideline: Ectopic pregnancy and miscarriage

This clinical guideline offers evidence-based advice on the diagnosis and management of ectopic pregnancy and miscarriage in early pregnancy and is available from NICE at: http://www.nice.org.uk/guidance/index.jsp?action=byID&o=14000

The Morning After: A Cross Party Inquiry into Unplanned Pregnancy

2020Health.Org report that “Over half of unplanned pregnancies happen because people are not using sufficient contraception, according to a survey by a Cross-Party Parliamentary Inquiry.

Th inquiry, supported by 2020health, into unwanted pregnancies, highlights three main findings:
1.That a large proportion of unwanted pregnancies are happening because people are not using sufficient contraception;
2. That there is inadequate Sex and Relationship Education in schools; and
3. That there is a lack of access to contraception for over 25s.

http://www.2020health.org/2020health/Press/latest-news/Unplanned-Pregnancy-Report.html

ICEC has relaunched its website with easily accessible information on all aspects of emergency contraception worldwide. The map of registration status of EC pills is particularly interesting as is the status and availability database

New IUS launched

Skyla, has gained FDA approval and is due to be launched in the USA next month – the first new device to come to market in 12 years.  Skyla contains 13.5 mg of Levonorgestrel and differs from Mirena in that it prevents pregnancy for 3 years rather than 5 and appears to be aimed at younger women who have not had children.

MEDFASH eBulletin

Read all the latest SRH news here

As mentioned in the previous blog this remarkable story (Editor’s choice in this month’s Journal) documents what can happen when access to abortion is restricted. I include here the graph, from the paper, which shows this so well.

Anne Furedi, Chief Executive of BPAS, writes, in response to the article,

The commentary by Horga et al.[1] on the consequences of Ceausescu’s attempt to ban abortion in Romania is a stark reminder of what happens when women are prevented from accessing safe and legal means to end problem pregnancies. continue at:http://jfprhc.bmj.com/letters

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

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

The financial costs to patients of diagnosing and excluding ectopic pregnancy (Unger et al)

In their article, Unger and his colleagues in Edinburgh report on their assessment of an area of patient experience that is not often considered when assessing medical interventions. The financial impact on patients’ lives of the need to seek medical attention can be considerable and may become more significant as economic hardship increases. This paper describes a well-conducted questionnaire study on the costs that patients themselves incurred in attending their general practitioners and a hospital clinic with a suspected ectopic pregnancy. The authors argue that such costs need to be factored into decisions regarding the cost-effectiveness of medical procedures. from David Horwell, Advisory Editor

Despite the best intentions: a reflection on low client numbers for a pilot telemedicine sexual health service (Garrett & Kirkman)

This “Better Way of Working” article describes the outcome of a pilot of a telemedicine sexual health service for rural youth in Victoria, Australia. Despite expecting high client numbers, few used the service. This article explores the reasons for the disappointing usage, and concludes that clinicians’ expertise and passion for improving access to health care may not be enough to guarantee successful design and implementation of the most appropriate service. from Gillian Robinson,  Associate Editor

Uptake and continuation rates of the intrauterine system in a university student general practice population in the UK (Armitage et al)

This is a very simple real-life observational study of a cohort of young nulliparous women in a university-based general practice choosing and continuing with LARCs as their first line method of contraception. This paper compels the reader to offer this ‘fit and forget’ method of contraceptive to our younger population, of course along with all other forms of contraception, as a matter of routine. from Scott Wilkes, Associate Editor

Removal of a fractured Nexplanon^® (Elliman)

In a letter to the editor Alyson Elliman describes removal of a partially fractured, curved implant with no obvious cause and asks if other clinicians have observed anything similar.

NICE Good Practice Guidance: Patient Group Directions is now under development.

This guidance is now in development and due to be published in April 2013

Stakeholder registration is now open.  To register your organisation as a stakeholder* send registration details (name of contact, name of organisation, email address) to pgd@nice.org.uk using the subject heading Patient group directions GPG stakeholder registration 2012/13

*for the purposes of this guidance stakeholders are:

• national patient and carer organisations that directly or indirectly represent the interests of people whose care is covered by the guidance
• national organisations that represent the healthcare professionals who provide the services described in the guidance
• companies that manufacture the medicines or devices used in the area covered by the guidance and whose interests may be significantly affected by the guidance
• providers and commissioners of health services in England, Wales and Northern Ireland
• statutory organisations including the Department of Health, the Welsh Assembly Government, NHS Quality Improvement Scotland, the Healthcare Commission and the National Patient Safety Agency
• research organisations that have done nationally recognised research in the area

See http://www.nice.org.uk/mpc/goodpracticeguidance/PatientGroupDirections.jsp for further information.

Philippine Government finally passes Reproductive Health Bill after 14 years.

This is a huge victory in the Philippines for access to maternal health services, family planning, and sex education. The reproductive health bill gives the national government the mandate to make reproductive health services accessible to poor families through information and education and the provision of free contraceptives.

Branded, generics or branded generics? Do you know the difference?

When a branded, or proprietary, drug comes ‘off patent’ it is common for other companies to apply for marketing authorisation and we are, increasingly, seeing this in sexual health. This can be for generic versions or for branded generics. Branded generics are simply generic equivalent drugs with a brand name given by the particular company. When a pharmacist dispenses a proprietary drug or branded generic they are obliged to dispense the named product, if a pure generic is prescribed they can give any product containing the generic compound/s but this is reimbursed at the current generic rate.

To give an example in contraception Microgynon 30 & Ovranette are proprietary brands and Levest & Rigevidon are branded generic equivalents.

MeReC bulletin summarises:

• Generic medicines are, overall, much less expensive to the NHS. Their appropriate use instead of branded medicines delivers considerable cost savings. In England about 5% of medicines are still prescribed by their brand name when generic equivalents are available.
• List prices for some ‘branded generics’ may be lower than the reimbursement price for equivalent generics. However, any cost savings achieved by their use may be unsustainable by the manufacturer and may not necessarily be cheaper, or in the best interests of the NHS overall.

This may be because many companies marketing branded generics negotiate a fixed price for a fixed period for their products with pharmacies or clinics which are lower than, even, generic alternatives – however generic drug prices are subject to fluctuation due to market forces and may fall over time meaning this would no longer be the case.

The MeReC bulletin also signposts the UK Medicines Information (UKMi) Q & A document “Which medicines are not suitable for generic prescribing in primary care?” This lists medicines that may be considered suitable to prescribe by specific manufacturer’s product (branded or generic). These include:

– multiple ingredient products
– ensuring adherence to long-term medications, where differences in appearance between manufacturer’s products might cause confusion and anxiety

In contraception, over the years, we have probably not noticed when this has happened and the first of the reasons above, as well as the fact that there were not many generic versions available, may explain this. The second may be more pertinent in the future.

There are a number of reasons why these issues are currently topical in sexual health:

• cost saving – not only perceived savings on generics vs brands but increased bulk/group purchasing to afford greater savings within Trusts
• more companies are making and marketing branded generics than in the past
• more medicines used in sexual health are due to come off patent now or in the next year including: sildenafil, many HIV drugs, desogestrel and mifepristone
• increased use of paperless IT systems with built-in drug data bases, as in general practice, where generic equivalents are often highlighted
• different ordering capabilities of independent pharmacies vs large national companies/chains

There are potentially more likely to be problems with contraceptive pills prescribed in general practice than in clinics as clinics generally see women at each visit and can explain any differences there may be in dispensed products. A woman taking an FP10 to a pharmacy (if it is prescribed generically) may be given a different product from previously without the prescriber being aware that this could occur. And this may happen even if she goes to the same pharmacy as last time. Clinicians will be aware of the issues that arise if women are given different pills and the anxiety this may cause followed by increased clinician time required for extra appointments to handle any problems. This is always assuming the woman doesn’t just stop her pills if she is unable to access help in a timely fashion. Food for thought.

ella-One® black triangle removed

The MHRA has removed the black triangle from ella-One®. The black triangle will be removed from all company materials over the next few months and EC providers may need to update some documentation.

The Faculty of Sexual & Reproductive Healthcare has, today, announced that it will offer training and a qualification in sexual health for nurses. This is something nurses have been requesting for some time and should improve access and service delivery. It is part of a wider project to review training in SRH in light of the Peile Report. The project is being managed by MEDFASH in partnership with FSRH, BASHH and RCGP and is expected to extend the current well evaluated and highly regarded training and make it more flexible and accessible in the UK and internationally. see www.fsrh.org

“Getting to Zero: Zero new HIV infections. Zero deaths from AIDS-related illness. Zero discrimination” is the theme of World AIDS Day 2012 on 1 December. Life-saving antiretrovirals have reduced new HIV infections and deaths. The 2015 target of 15 million HIV-infected people on antiretroviral medicines worldwide looks more achievable now than ever before.

World AIDS Day – BMJ special promotion 

The BMJ Group is putting together a special promotional webpage for World AIDS Day on 1st December that will offer a week’s free access to all relevant content published by our full range of journals. Please click here for access

New resources for young people living with HIV 

To mark World AIDS day on the 1^st of December, the Children and Young People HIV Network, based at leading children’s charity the National Children’s Bureau, is sending a message of support to young people with HIV by launching a range of materials to support them in managing life with the condition.

The ‘Your Life’ leaflets and the ‘Studying with HIV’ guidance and LifeLinks resources are all available from www.ncb.org.uk/hiv

More than Half of those with HIV in the UK are Overweight:  The Surprising Issues Facing Those Living with HIV

The British Dietetic Association (BDA) will once again be supporting World Aids Day on 1st December. Early data from the BDA’s DHIVA specialist group audit suggests that more than half of people living with HIV in the UK are overweight or obese, with only about one-in-nine being underweight.

In fact by far the most common issues facing HIV dietitians in the outpatient clinic these days are dyslipidaemia, hypertension, diabetes and osteoporosis, with over 75% of HIV patients Vitamin D deficient. Dealing with these issues is not as straightforward as it might seem, with HIV-specific barriers to lifestyle change emerging.

Members report common themes from their patients, including a fear that deliberate weight loss might lead to others guessing their HIV status (“why are you getting thin – you don’t have AIDS do you?”), and a feeling that being overweight is safer (“I remember how ill and thin I was before starting ARVs and I don’t want to go back there again”). from Alastair Duncan, Chairman of the BDA’s DHIVA (Dietitians in HIV/Aids) specialist group.

UNITAID welcomed the good news this World AIDS Day that the number of children newly infected with HIV continues to decline but urges the international community to step up efforts for those children already living with the disease. more from the website

    2012 UNAIDS World AIDS Day Report

The Medical Foundation for HIV and Sexual Health is 25 yrs old (rebranded as MEDFASH). Established in 1987 by the BMA, as an independent foundation, with the aim of improving knowledge and understanding of HIV among health professionals it has grown and spread to encompass all aspects of sexual health.

As part of this celebration the foundation has a new website and has launched its Sexual Health & HIV Policy eBulletin.  MEDFASH Chief Executive, Ruth Lowbury, introduces the eBulletin: it is designed with local sexual health and HIV commissioners and providers in mind. It will give a concise and regular round-up of emerging policy developments, relevant evidence updates and available tools and resources across the field of sexual and reproductive health and HIV. It will also consider the impact the change agenda is having on this area of healthcare through a series of eFeature articles and interviews with those working at both national and local levels. This is particularly useful now at a time when service delivery is changing and many of us will be involved with new (and possibly challenging) ways of working and new communication channels.

Amonst other things the first issue includes: transfer of sexual heath services to local authorities; local transition arrangements; re-tendering of GUM services; Healthwatch England (the new consumer champion for health and care in England); HIV treatment for overseas visitors.