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Journal highlights – April issue

30 Mar, 12 | by shellraine, e-Media Editor

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.




Recent Online First articles (including the Million Women Study critique)

18 Jan, 12 | by BMJ

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:

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”).

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