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Online condoms and lubes provider the Freedoms Shop (Central & North West London NHS Foundation Trust) has teamed up with Terrence Higgins Trust to launch the Summer Lovin’ campaign – urging gay men across London to use condoms – with a new online health resource. The downloadable resource brings together stacks of health and sexual safety information, presented in a cheeky, accessible way, while Freedoms is providing a half price condoms
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
From the New England Journal of Medicine: A large (7486 paticipants) prospective cohort study, by researchers at Washington University School of Medicine in St. Louis, to evaluate contraceptive methods has found dramatic differences in their effectiveness. Women who used pills, the patch or vaginal ring were 20 times more likely to have an unintended pregnancy than those who used longer-acting forms such as an intrauterine device (IUD) or implant.
And from the American Journal of Obstetrics & Gynecology
The purpose of this study in Colorado was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant insertion and showed excellent continuation 1 year after delivery; rapid repeat pregnancy was significantly decreased compared with control participants.
The objective of the study from South Carolina was to improve the understanding of long-acting reversible contraception (LARC) use patterns among unmarried, young adults at risk of unintended pregnancy. LARC use was associated with older age, high IUD knowledge, and earlier onset of sexual activity and concluded that increasing knowledge of IUD among certain groups may improve LARC use among young, unmarried adults and in turn decrease unintended pregnancy.
The number of women of childbearing age who are active-duty service members or veterans of the US military is increasing. These women may seek reproductive health care at medical facilities operated by the military, in the civilian sector, or through the Department of Veterans Affairs. This article reviews the current data on unintended pregnancy and prevalence of and barriers to contraceptive use among active-duty and veteran women. Active-duty servicewomen have high rates of unintended pregnancy and low contraceptive use, which may be due to official prohibition of sexual activity in the military, logistic difficulties faced by deployed women, and limited patient and provider knowledge of available contraceptives. In comparison, little is known about rates of unintended pregnancy and contraceptive use among women veterans. Based on this review, research recommendations to address these issues are provided.
The study aimed to determine whether clinics that serve indigent patients demonstrate equal compliance with sexually transmitted infection testing guidelines when compared with private clinics in North Carolina. They concluded that clinics serving indigent patient populations had a higher compliance with required testing compared to private clinics. HIV testing in the third trimester remains the greatest need for improvement for all practice types.
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.
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
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?
The latest edition of FSRH News is available on the website.
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)
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 firstname.lastname@example.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 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:
Advances in intrauterine technique training (Connolly)
This article describes an innovative new way for doctors and nurses to be able to learn how to fit intrauterine devices and systems with realistic simulation, which is much better than a ‘Zoe’. This should increase their confidence and make the first encounter with the ‘live’ patient less stressful for all concerned. Anne Szarewski (Editor in Chief, jfprhc)
US Administration’s attitude to family planning (Joseph)
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. It is taking a long time to reverse the damaging initiatives put in place by the Bush administration: we can only hope that the Right Wing does not triumph in the next election. Anne Szarewski (Editor in Chief, jfprhc)
The following Museum piece was spottedby Toni Belfield (Specialist in sexual health information): The Phallus Museum in Iceland!
The Icelandic Phallological Museum has the collection of penises of all animals whether on land, sea or air….. They have plans for a future specimen belonging to Homo sapiens……as reported in The Times 15th November 2011.
and not to forget the more conventional:
Museum of contraception and Abortion (based in Vienna)
(Sexual Health Out Loud) is a website based on a partnership between Terrence Higgins Trust, FPA, African Health Policy Network, National AIDS Trust, MedFASH and Brook. It aims to provide information about sexual health by geographical area. It is conducting 2 surveys, one for service users and one for service providers with the aim of monitoring changes in service delivery in light of funding difficulties.
Did you see the on-line poll on the front page of the Journal website? It asked for your views on the hot topic of whether to routinely offer local anaesthesia to women undergoing IUD/IUS insertions. Though many people have accessed the page not many took the time to answer the question. This issue has caused much discussion as you may have seen in the last 3 issues since the original letter from Dr Sam Hutt in January. To answer now, please click on the image to the left.
Sexual and Reproductive Health Activity Dataset,
aka SHRAD replaced the KT31 which is/are due to ‘retire’ in 2013. How are you coping with the new way of collecting our activity data? The latest edition of the SHRAD newsletter (no 5) is now available via the Faculty website.
And in the News
The GMC has announced a consultation on 2 future pillars of medical professionalism: CPD and revalidation. More info and access to the consultation on the GMC website.
The newly published Journal includes a number of articles related to abortion: a book review; a commentary on medical abortion in Ethiopia – for which there is also a podcast; an Israeli view of the status of a foetus; HIV testing in clinics and repeat attendance in Britain.
In addition there is a profile of FIAPAC, the international organisation for abortion providers who have their next biennial Congress in Edinburgh in October 2012.
In Letters to the Editor there is continuing correspondence discussing the emotive subject of the use of cervical analgesia for IUD/IUS fitting which seems to have polarised opinion more than any other issue for some time.
The printed journal was accompanied by the most recently published Faculty Guidance on Emergency Contraception (2011), available electronically from: http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf. This updates the previous guidance from 2006, includes the new oral preparation, ulipristal acetate, a progesterone receptor modulator licensed for use up to 5 days after unprotected sex and refers to the guidance for Quick Starting Contraception (2010) which details how to ‘quick start’ after use of emergency contraception.
This Guidance follows neatly on from the CEU Statement on Missed Pill Recommendations (May 2011), which accompanied the last edition of theJournal which also included a commentary by Dr Diana Mansour; Revision of the ‘missed pill’ rules, which details the background to the changes. The statement was published after the MHRA asked the Faculty Clinical Effectiveness Unit to review its previous guidance (2005), with a view to producing harmonised guidance. This the CEU subsequently did and the new guidance has been endorsed and adopted by the MHRA, fpa and BNF although unfortunately not by the pharmaceutical industry.
BNF 62 includes the amended instructions for starting and switching combined hormonal contraception to take into account the above recommendations. Continuing the initiative of working closely with the Clinical Effectiveness Committee the BNF section on Contraception (7.3) is up to date and in line with FSRH guidance. This makes it an accurate resource particularly for GPs and Practice Nurses who use it more than any other group of clinicians.
The latest Faculty Presidents Newsletter, which also accompanied the print journal, highlights the need for all services and clinicians to dispose of and not use any of the old training CD ROMs for IUDs, implants and EC. Trainees should only use the up-to-date training modules from the e-learning website: www.e-lfh.org.uk.
My aim is to bring you news, views and information in the field of contraception and sexual health – some of which you may have seen and some not. I hope that as well as highlighting articles and issues from our journal this will signpost current issues and initiatives from the UK and around the world.
It has been an eventful year in contraception with a number of changes for clinical practice and over the coming weeks I will revisit the most important of these.
A round-up of some recent news items includes:
Mary Robinson calls for more funds for Family Planning.
As world leaders collected at the UN in New York last week Mary Robinson, the first woman president of Ireland (1990-1997), UN High Commissioner for Human Rights from 1997-2002, and chairwoman of the Global Leaders Council for Reproductive Health called for them to make good on their promise of17 years ago at the UN International Conference on Population and Development in Cairo, when they agreed to make contraceptive services available for women all over the world by 2015. http://www.newsday.com/opinion/oped/robinson-more-funds-for-family-planning-1.3187083
WHO Medical Eligibility Criteria for Contraceptive Use 4th ed wins first prize in the BMA Book Awards (O&G category).
The WHO MEC are the basis from which the UK MEC were developed and underpin clinical practice in contraception and sexual health. The most recent version of the UKMEC was published 2009:http://www.fsrh.org/pdfs/UKMEC2009.pdf
Medscape Education Clinical Briefs report a pooled analysis of 2 studies which seem to demonstrate that Intrauterine Devices Lower Cervical Cancer Risk. This involved 10 case-control studies done in 8 countries, and 16 studies of HPV prevalence from 16 countries looking at risks for cancer of the cervix and HPV in IUD users. http://www.medscape.org/viewarticle/749724?src=cmemp
InRwanda, Africa’s most densely populated country,men are being encouraged to have vasectomies. The no-scalpel procedure is being offered for free according to a report in the Independent Newspaper on 7th September.