Showing papers in "Journal of Family Planning and Reproductive Health Care in 2012"

Prevention of HIV-1 infection with early antiretroviral therapy

Abstract: MS Cohen, YQ Chen, M McCauley N Engl J Med 2011 365:493–505. The exciting evidence generated by this paper – that antiretroviral treatment of HIV-1 infection definitively reduces the risk of onward transmission of the virus by 96% – was rightly dubbed Science magazine's ‘Breakthrough of the Year’ in 2011.1 ,2 It has long been known that the probability of sexual transmission of HIV is strongly correlated with concentrations of HIV in blood and genital fluids.3 ,4 Effective antiretroviral therapy (ART) produces prolonged and sustained suppression of HIV replication in these compartments, reducing the amount of free virus.5 ,6 Thus, there has long been a …

Overall efficacy of HPV-16/18 AS04-adjuvanted vaccine against grade 3 or greater cervical intraepithelial neoplasia: 4-year end-of-study analysis of the randomised, double-blind PATRICIA trial

Abstract: Lehtinen M, Paavonen J, Wheeler CM, et al. Lancet Oncol 2012;13:89–99[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Cross-protective efficacy of HPV-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by non-vaccine oncogenic HPV types: 4-year end-of-study analysis of the randomised, double-blind PATRICIA trial. Wheeler CM, Castellsague X, Garland SM, et al. Lancet Oncol 2012;13:100–110[OpenUrl][5][CrossRef][6][PubMed][7][Web of Science][8] Persistent infection with high-risk (HR) human papillomavirus (HPV) is the underlying cause of cervical cancer. … [1]: {openurl}?query=rft.jtitle%253DThe%2Blancet%2Boncology%26rft.stitle%253DLancet%2BOncol%26rft.aulast%253DLehtinen%26rft.auinit1%253DM.%26rft.volume%253D13%26rft.issue%253D1%26rft.spage%253D89%26rft.epage%253D99%26rft.atitle%253DOverall%2Befficacy%2Bof%2BHPV-16%252F18%2BAS04-adjuvanted%2Bvaccine%2Bagainst%2Bgrade%2B3%2Bor%2Bgreater%2Bcervical%2Bintraepithelial%2Bneoplasia%253A%2B4-year%2Bend-of-study%2Banalysis%2Bof%2Bthe%2Brandomised%252C%2Bdouble-blind%2BPATRICIA%2Btrial.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS1470-2045%252811%252970286-8%26rft_id%253Dinfo%253Apmid%252F22075171%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1016/S1470-2045(11)70286-8&link_type=DOI [3]: /lookup/external-ref?access_num=22075171&link_type=MED&atom=%2Ffamilyplanning%2F38%2F2%2F72.atom [4]: /lookup/external-ref?access_num=000299014500048&link_type=ISI [5]: {openurl}?query=rft.jtitle%253DThe%2Blancet%2Boncology%26rft.stitle%253DLancet%2BOncol%26rft.aulast%253DWheeler%26rft.auinit1%253DC.%2BM.%26rft.volume%253D13%26rft.issue%253D1%26rft.spage%253D100%26rft.epage%253D110%26rft.atitle%253DCross-protective%2Befficacy%2Bof%2BHPV-16%252F18%2BAS04-adjuvanted%2Bvaccine%2Bagainst%2Bcervical%2Binfection%2Band%2Bprecancer%2Bcaused%2Bby%2Bnon-vaccine%2Boncogenic%2BHPV%2Btypes%253A%2B4-year%2Bend-of-study%2Banalysis%2Bof%2Bthe%2Brandomised%252C%2Bdouble-blind%2BPATRICIA%2Btrial.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS1470-2045%252811%252970287-X%26rft_id%253Dinfo%253Apmid%252F22075170%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [6]: /lookup/external-ref?access_num=10.1016/S1470-2045(11)70287-X&link_type=DOI [7]: /lookup/external-ref?access_num=22075170&link_type=MED&atom=%2Ffamilyplanning%2F38%2F2%2F72.atom [8]: /lookup/external-ref?access_num=000299014500049&link_type=ISI

Immunogenicity and safety of the HPV-16/18 AS04-adjuvanted vaccine administered as a 2-dose schedule compared with the licensed 3-dose schedule: results from a randomized study

Abstract: B Romanowski, TF Schwarz, LM Ferguson. Hum Vaccin 2012;7:1374–1386. Good news – it would appear that two doses of the bivalent human papillomavirus (HPV) vaccine elicit “non-inferior” levels of antibodies in young women compared to three doses. Romanowski et al. compared the licensed formulation/schedule of three doses of 20 µg antigen per dose at 0, 1 and 6 months with three two-dose strategies: (1) two doses of 20 µg at months 0 and 6, (2) two doses of 40 µg at months 0 and 6 and (3) two doses of 40 µg at months 0 and 2. Performance of the strategies was measured by quantifying geometric mean antibody titre 1 month after the final dose and at 24 months, …

Barriers to cervical screening in women who have experienced sexual abuse: an exploratory study

Abstract: Objectives To explore self-reported cervical screening history and barriers to attendance among women who have been sexually abused and to identify measures to improve the experience of cervical screening for these women. Methods Women visiting the website of the National Association for People Abused in Childhood (NAPAC), who had been sexually abused, were invited to complete a survey of their views and experiences of cervical screening. This included closed questions on demographic characteristics and cervical screening attendance, open questions on barriers to screening, and the opportunity to submit suggestions to improve this experience for women who have been sexually abused. Content analysis was used to code responses to the open questions. Four women also participated in a discussion group. Results Overall, 135 women completed the closed questions and 124 provided open-ended responses. 77.5% of responding women who were eligible for cervical screening in England had ever attended, 48.5% at least once in the previous 5 years, but 42.1% of women aged 25–49 within 3 years. A total of nine higher order themes were identified related to barriers to screening, one related to intention to attend screening and five related to suggestions to improve screening. Conclusions This study supports the idea that women who have experienced sexual abuse are less likely to attend for regular cervical screening, with under half screened in the last 5 years compared to the National Health Service Cervical Screening Programme figure of 78.6%. Suggestions to improve the experience for abused women focused on communication, safety, trust and sharing control. Further research in this area is warranted to ensure that this at-risk population is appropriately served by cervical screening.

Ovarian and cervical cancer awareness: development of two validated measurement tools.

Abstract: Background The aim of the study was to develop and validate measures of awareness of symptoms and risk factors for ovarian and cervical cancer (Ovarian and Cervical Cancer Awareness Measures). Methods Potentially relevant items were extracted from the literature and generated by experts. Four validation studies were carried out to establish reliability and validity. Women aged 21–67 years ( n =146) and ovarian and cervical cancer experts ( n =32) were included in the studies. Internal reliability was assessed psychometrically. Test-retest reliability was assessed over a 1-week interval. To establish construct validity, Cancer Awareness Measure (CAM) scores of cancer experts were compared with equally well-educated comparison groups. Sensitivity to change was tested by randomly assigning participants to read either a leaflet giving information about ovarian/cervical cancer or a leaflet with control information, and then completing the ovarian/cervical CAM. Results Internal reliability (Cronbach9s α=0.88 for the ovarian CAM and α=0.84 for the cervical CAM) and test-retest reliability ( r =0.84 and r =0.77 for the ovarian and cervical CAMs, respectively) were both high. Validity was demonstrated with cancer experts achieving higher scores than controls [ovarian CAM: t (36)= –5.6, p t (38)= –3.7, p =0.001], and volunteers who were randomised to read a cancer leaflet scored higher than those who received a control leaflet [ovarian CAM: t (49)=7.5, p t (48)= –5.5, p Conclusions This study demonstrates the psychometric properties of the ovarian and cervical CAMs and supports their utility in assessing ovarian and cervical cancer awareness in the general population.

Contraceptive efficacy and tolerability of ethinylestradiol 20 µg/drospirenone 3 mg in a flexible extended regimen: an open-label, multicentre, randomised, controlled study

Abstract: Background The contraceptive efficacy and tolerability of a new flexible extended regimen of ethinylestradiol (EE) 20 μg/drospirenone (DRSP) 3 mg to extend the menstrual cycle and enable management of intracyclic (breakthrough) bleeding (flexible MIB ) was investigated and the bleeding pattern compared with a conventional 28-day regimen and a fixed extended 124-day regimen. Study design This Phase III, 2-year, multicentre, open-label study randomly (4:1:1) allocated women (aged 18–35 years) to the following regimens: flexible MIB (24–120 days9 active hormonal intake with 4-day tablet-free intervals); conventional (24 days9 active hormonal intake followed by a 4-day hormone-free interval); or fixed extended (120 days9 uninterrupted active hormonal intake followed by a 4-day tablet-free interval). Primary outcomes included the number of bleeding/spotting days during Year 1 (all regimens) and the number of observed unintended pregnancies over 2 years (flexible MIB only). Results Results were analysed in 1067 women (full analysis set). The mean number of bleeding/spotting days was lower with the flexible MIB vs the conventional regimen [41.0±29.1 (95% CI 38.8–43.3) vs 65.8±27.0 (95% CI 62.2–69.4) days, p MIB regimen was 0.64 (95% CI 0.28–1.26). All regimens had comparable tolerability profiles. Conclusions EE 20 μg/DRSP 3 mg administered as a flexible extended regimen with MIB is effective, well tolerated and is associated with statistically significantly fewer bleeding/spotting days and fewer withdrawal bleeding episodes vs EE/DRSP in a conventional 28-day regimen. The flexible MIB also provided statistically significantly fewer spotting days vs EE/DRSP in a fixed extended 124-day regimen ( post hoc evaluation). The flexible MIB regimen allows women to extend their menstrual cycle and manage their intracyclic (breakthrough) bleeding.

Cervical screening among migrant women: a qualitative study of Polish, Slovak and Romanian women in London, UK.

Abstract: Objective To explore awareness of and participation in cervical screening services in women from Poland, Slovakia and Romania living in London, UK. Methods Three qualitative studies were carried out in London in 2008–2009: an interview study of professionals working with Central and Eastern European migrants ( n =11); a focus group study including three Polish, one Slovak and one Romanian focus group; and an interview study of Polish ( n =11), Slovak ( n =7) and Romanian ( n =2) women. Results Awareness of the cervical screening programme was good, but understanding of the purpose of screening was sometimes limited. Some women were fully engaged with the UK screening programme; others used screening both in the UK and their countries of origin; and a third group only had screening in their home countries. Women welcomed the fact that screening is free and that reminders are sent, but some were concerned about the screening interval and the age of the first invitation. Conclusions Migrant women from Poland, Slovakia and Romania living in London vary in their level of participation in the National Health Service Cervical Screening Programme. More needs to be done to address concerns regarding screening services, and to ensure that language is not a barrier to participation.

Combined oral contraceptives, venous thromboembolism, and the problem of interpreting large but incomplete datasets.

Abstract: In 2009, Lidegaard et al. 1 published findings in the British Medical Journal , derived from a Danish retrospective cohort study of the risk of venous thromboembolism (VTE) associated with the use of combined oral contraceptives (COCs). Their analysis was based on data derived from national health registries, and they concluded that “oral contraceptives with desogestrel, gestodene, or drospirenone were associated with a significantly higher risk of VTE than oral contraceptives with levonorgestrel”. That report has previously been reviewed in this Journal2 and at an international workshop.3 Subsequently, because of methodological limitations in the Danish study, the European Medicines Agency (EMA) requested a re-analysis. The conduct of the re-analysis was overseen by an independent three-member steering committee [KJ Rothman (Chairman), FE Skjeldestad (nominated by Lidegaard, and a co-author of the published re-analysis)4 and S Shapiro (nominated by Bayer Schering, and a co-author of this commentary)]. The completed re-analysis, together with a commentary by the steering committee, an additional commentary by S Shapiro, and an audit requested by the steering committee, was submitted to the EMA, and an abbreviated version of the EMA submission has recently been published.4 Here we review the publication of the re-analysis submitted to the EMA. The publication manuscript was not submitted to the steering committee for review before publication. In the published re-analysis4 the authors claim to have confirmed the conclusions reached in the original analysis:1 if anything, the risk estimates were even higher than the original estimates. A difficulty, however, is that several numbers reported in the publication differ from those mentioned in the re-analysis submitted to EMA (one example is given below). Since the mid-1990s there has been heated debate regarding the risk of VTE associated with the use of different progestogens, and those who have followed the …

Does hormone replacement therapy cause breast cancer? An application of causal principles to three studies: Part 4. The Million Women Study

Abstract: Background Based principally on findings in three studies, the collaborative reanalysis (CR), the Women9s Health Initiative (WHI) and the Million Women Study (MWS), it is claimed that hormone replacement therapy (HRT) with estrogen plus progestogen (E+P) is now an established cause of breast cancer; the CR and MWS investigators claim that unopposed estrogen therapy (ET) also increases the risk, but to a lesser degree than does E+P. The authors have previously reviewed the findings in the CR and WHI (Parts 1–3). Objective To evaluate the evidence for causality in the MWS. Methods Using generally accepted causal criteria, in this article (Part 4) the authors evaluate the findings in the MWS for E+P and for ET. Results Despite the massive size of the MWS the findings for E+P and for ET did not adequately satisfy the criteria of time order, information bias, detection bias, confounding, statistical stability and strength of association, duration-response, internal consistency, external consistency or biological plausibility. Had detection bias resulted in the identification in women aged 50–55 years of 0.3 additional cases of breast cancer in ET users per 1000 per year, or 1.2 in E+P users, it would have nullified the apparent risks reported. Conclusion HRT may or may not increase the risk of breast cancer, but the MWS did not establish that it does.

Long-term tolerability of ethinylestradiol 20 μg/drospirenone 3 mg in a flexible extended regimen: results from a randomised, controlled, multicentre study.

Abstract: Background This study was designed to assess the long-term safety and tolerability of a new flexible extended regimen of ethinylestradiol (EE) 20 μg/drospirenone (DRSP) 3 mg, which allows management of intracyclic (breakthrough) bleeding [flexible management of intracyclic (breakthrough) bleeding (MIB)], in comparison to conventional 28-day and fixed extended regimens. Study design In this Phase III, multicentre, open-label study, women (aged 18–35 years) were randomised to EE/DRSP in the following regimens: flexible MIB (24–120 days9 active hormonal intake followed by a 4-day tablet-free interval), conventional 28-day (24 days9 active hormonal intake followed by a 4-day hormone-free interval) or fixed extended (120 days9 uninterrupted active hormonal intake followed by a 4-day tablet-free interval) during a 1-year comparative phase. Thereafter, women entered a 1-year safety extension phase in which the majority received the flexible MIB regimen. Safety/tolerability outcomes were measured over 2 years. A separate analysis of certain safety parameters (endometrial, hormonal, lipid, haemostatic and metabolic variables) was conducted at two of the study centres. Results Results were analysed in 1067 and 783 women in the comparative and safety extension phases. Overall, 56.3% of women experienced ≥1 adverse event (AE) in the safety extension phase. Serious AEs occurred in 3.0%, 1.4% and 3.3% of women receiving the flexible MIB , conventional and fixed extended regimens, respectively. No unexpected endometrial, hormonal, lipid, haemostatic or metabolic findings occurred with any of the three regimens. Conclusions EE/DRSP in a flexible extended regimen with management of intracyclic (breakthrough) bleeding is well-tolerated and, when administered for up to 2 years, has a good safety profile comparable to other estrogen/progestogen oral contraceptives.

The investigation and management of hirsutism.

Abstract: Excess male-pattern body hair in women is a very common and psychologically damaging condition. Although its cause is usually a chronic and benign disorder (most commonly polycystic ovary syndrome) it may rarely be an indication of a more serious endocrine disease such as Cushing syndrome or an androgen-secreting tumour. Investigations do not usually need to be extensive, but effective management is important, irrespective of cause, for what can be a debilitating symptom. Specific treatment of any underlying disease is important but in most cases treatment is empirical; it may simply involve physical hair removal, ideally by electrolysis or laser treatment. However, endocrine therapy to suppress androgen production and/or action is desirable in many, if not most, cases.

Efficacy of ethinylestradiol 20 µg/drospirenone 3 mg in a flexible extended regimen in women with moderate-to-severe primary dysmenorrhoea: an open-label, multicentre, randomised, controlled study

Abstract: Objectives The aim of this Phase III, multicentre, open-label, randomised study was to compare the efficacy and safety of ethinylestradiol (EE)/drospirenone (DRSP) in a new flexible extended regimen that allowed the management of intracyclic (breakthrough) bleeding (MIB) with that of EE/DRSP in a conventional 28-day regimen in women with moderate-to-severe primary dysmenorrhoea. Methods Women (aged 18–40 years) with moderate-to-severe primary dysmenorrhoea-related pain received a flexible extended regimen with MIB (flexible MIB ; minimum 24, maximum 120 days of continuous tablet intake for a flexible number of cycles to reach a treatment duration of at least 140 days with 4-day breaks between cycles) or a conventional 28-day regimen (24 active and four placebo tablets for five cycles) of EE/DRSP. The primary outcome was the number of days with dysmenorrhoeic pain over 140 days. Secondary outcomes included other dysmenorrhoea-related pain outcomes, bleeding profile, satisfaction and safety. Results Overall, 223 patients received study medication. There were significantly fewer days with dysmenorrhoeic pain with the flexible MIB regimen than the conventional regimen (difference −4.2 days, 95% CI −6.5 to −2.0; p =0.0003), as well as considerably fewer days with at least moderate dysmenorrhoeic pain (difference −2.5 days, 95% CI −3.7 to −1.3), dysmenorrhoeic pain that interfered with daily activities (difference −2.2 days, 95% CI −4.2 to −0.1) and pelvic pain (difference −3.4 days, 95% CI −5.9 to −0.9). Adverse events were similar with both regimens. Conclusions Compared with the conventional regimen, the flexible extended regimen of EE/DRSP with MIB was associated with a significantly greater reduction in days with dysmenorrhoeic pain in women with moderate-to-severe primary dysmenorrhoea. The flexible MIB regimen was also associated with greater improvements in dysmenorrhea according to the Clinical Global Impression rating scale and was generally well tolerated.

Unmet need for effective family planning in HIV-infected individuals: results from a survey in rural Uganda

Abstract: Background and methodology This study determined the unmet need for family planning among HIV-positive and HIV-negative individuals living in western Uganda. Semi-structured interviews were conducted with individuals who were randomly selected from HIV testing lists. Of those individuals, further analysis was conducted on a subset of 206 participants who did not desire more children and were not using a highly effective method of contraception. Descriptive, bivariate and multivariate methods were performed to assess the relationship between HIV status and unmet need for effective family planning. Results The unmet need for effective family planning was much greater in HIV-infected individuals compared to HIV-negative individuals [75.0% vs 33.8%, adjusted odds ratio (OR) 3.97, 95% confidence interval (CI) 1.97–8.03, p Discussion and conclusions There is high unmet need for effective family planning in HIV-positive study participants in a region of western Uganda, which should be of concern. This suggests that HIV-infected individuals do not want to use family planning or encounter barriers to accessing and utilising family planning services. Family planning programmes and HIV care and prevention services have to work together more effectively to create services conducive to clients from both programmes.

Using a simulated patient to assess referral for abortion services in the USA

Abstract: Background Women seeking abortion services need to access services in a timely fashion. Quick and appropriate referrals to abortion providers are critical to this process. Methods The objective of this study was to determine the quality and quantity of referrals for abortion services from reproductive health care facilities that do not provide abortion services. USA states were ranked by restrictiveness of abortion, and a simulated patient made calls to the five most and six least restrictive states. Referrals were considered direct if the name or telephone number of a facility that provided abortion services was given; indirect when Planned Parenthood was suggested without additional details; and inappropriate if the referral did not provide abortion services. Results Of 142 calls, 77 (52.4%) were made to least restrictive states and 62 (45.8%) were made to most restrictive states. Among all calls, even after prompting staff members for a referral, 45.8% resulted in a direct referral, 19.0% resulted in an indirect referral, 8.5% resulted in an inappropriate referral and 26.8% resulted in no referral. Facilities in least restrictive states were significantly more likely to provide unprompted direct referrals ( p =0.006) and significantly less likely to provide no referral ( p Conclusions A simulated patient received a direct referral for abortion services less than half the time, even after prompting a staff member to provide one. All facilities providing women9s health care should have appropriate referrals readily available for patients seeking abortion services.

Relationship satisfaction and outcome in women who meet their partner while using oral contraception

Abstract: Roberts SC, Klapilova K, Little AC, et al. Proc Roy Soc B doi:doi:10.1098/rspb.2011.1647[OpenUrl][1][Abstract/FREE Full Text][2] Oral contraception (OC) – ‘the pill’ – has been available for over 60 years and continues to be a cause celebre. This latest study addresses relationship satisfaction and outcomes while using OC and suggests that its use influences the type of partner a woman chooses. The research looked at 2519 parous women; 1514 using no form of hormonal contraception and 1005 women using the combined pill. Both groups … [1]: {openurl}?query=rft.jtitle%253DProc%2BRoy%2BSoc%2BB%26rft_id%253Dinfo%253Adoi%252F10.1098%252Frspb.2011.1647%26rft_id%253Dinfo%253Apmid%252F21993500%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=royprsb&resid=279/1732/1430&atom=%2Ffamilyplanning%2F38%2F1%2F29.atom

Assessment of a fast-track referral service for intrauterine contraception following early medical abortion.

Abstract: Background A ‘fast-track’ referral system for intrauterine contraception was established in 2007 between the medical abortion service at the Royal Infirmary of Edinburgh and the principal family planning clinic (FPC) in Edinburgh. Methods Case note review of women fast-tracked for intrauterine contraception after medical abortion between January 2007 and June 2009. Main outcome measures were numbers of women referred, attendance rates, interval to insertion, devices chosen and known complication rates. Results Of the 237 women referred, 126 (53%) attended for intrauterine contraception insertion. Attenders were slightly but significantly older than non-attenders (mean ages of 30 and 27 years, respectively; p =0.003), less likely to live in an area of deprivation ( p =0.045) and were significantly more likely to have attended the FPC in the past ( p n =113) proceeded to have an intrauterine method inserted; 57% ( n =64) chose the levonorgestrel intrauterine system and 43% ( n =49) chose a copper intrauterine device. The median interval to insertion was 21 (range 0–54) days. Of those women ( n =55) who attended for routine follow-up 6 weeks later (49%), there were four (7.2%) cases of expulsion, two (3.6%) requests for removal and four (7.2%) cases of suspected infection. Conclusions Only half the women fast-tracked for intrauterine contraception actually attended and these tended to be women who were pre-existing clients of the FPC. Consideration should therefore be given to provision of immediate insertion where possible.

Doulas as facilitators: the expanded role of doulas into abortion care.

Abstract: The involvement of a lay support person, known as a doula, in the labour process is a long-standing practice across different cultures and traditions. A great body of literature exists evaluating the effect of a support layperson within the labour process on maternal and neonatal outcomes. This literature demonstrates a positive association between doula support and decreased labour time, oxytocin utilisation, Caesarean section rates and need for epidural/anaesthesia.1 Given the varied benefits afforded to women through doula support at the time of labour, the authors believe that women's health providers should consider the potential role that continuous lay person support could play at other physically and emotionally challenging moments in women's lives. One such setting in which doula support would be highly beneficial is in abortion care. Abortion is a stressful event regardless of a woman's circumstances. Unlike pregnancy in which women can accustom themselves for the forthcoming delivery over a period of time, the decision to terminate pregnancy often leaves little time for reflection. Also unlike pregnancy, women often obtain abortion services from medical caregivers with whom they have had no prior relationship. While these and other differences clearly exist between labour and pregnancy termination, many benefits afforded by the presence of a doula during labour would likely translate well into abortion care. One example of the way in which doula involvement would naturally benefit …

Abortion pills: under whose control?

Abstract: We owe a lot to scientists such as Baulieu1 in Paris who developed the progesterone receptor modulator mifepristone and Bygdeman2 in Stockholm who conducted early trials of its use in combination with a prostaglandin. Many others have contributed to the development of this drug and to finessing optimal combinations, visit intervals, dosages and routes of administration.3 This has given women an entirely new and safe option when requesting an abortion. Novel ways of providing early medical abortion have been developed, especially using non-medical personnel such as nurses or midwives,4 5 or doctors who are not on the premises.6 Early medical abortion has a key role to play in reducing unsafe abortion around the world, particularly in resource-poor settings where inadequate surgical services for abortion entail a high risk of infection and reproductive tract injury.7 An important signal went out in July 2005, when the regimen of mifepristone and misoprostol was included on the World Health Organization's WHO Model List of Essential Medicines .7 The Concept Foundation (http://www.conceptfoundation.org/medical-abortion.php) has registered Medabon® in Cambodia, India and Nepal; this is the first product to package mifepristone and misoprostol together. The Medabon introduction programme aims to launch this dedicated combination pack in 26 low- and middle-income countries. The Economic Covenant,8 Article 15(1)(b), recognises the right of everyone to enjoy the benefits of scientific progress and its applications. With regard to early medical abortion, this must include access to mifepristone and misoprostol. Who should be involved in controlling these drugs? Health professionals, drug regulators, customs officials, the courts or women themselves? In the UK, inducing an abortion surgically or medically comes under the criminal law. This is the same as in most other countries in the world apart from Canada and two Australian states (Australian Capital …

Safer prescribing of therapeutic norethisterone for women at risk of venous thromboembolism

Abstract: More than 794 000 prescriptions are written for therapeutic (as opposed to contraceptive) use of norethisterone (or its synonym norethindrone) in the UK each year (data on file, Bayer plc). Although its licensed indications include “metropathia haemorrhagica, premenstrual syndrome, postponement of menstruation, endometriosis, menorrhagia and dysmenorrhea”1 most clinicians prescribe it to stop an episode of heavy menstrual bleeding or use it ‘off-label’ to help regulate irregular bleeding associated with hormonal contraception such as progestogen-only implants or injectables.2 In these situations, the dose prescribed is generally 10–20 mg per day, compared to the 0.5–1 mg per day in contraceptive formulations. Some have called therapeutic norethisterone a ‘lifestyle’ drug as its seasonal prescribing peaks during the UK summer months suggest an increased use solely for delaying menstruation during holidays.3 High-dose (therapeutic) norethisterone was thought to be free of serious adverse effects. Doubts, however, first started to emerge in 1999 when two studies4 ,5 reported an increased incidence of venous thromboembolism (VTE) in women taking high-dose oral progestogens for therapeutic indications. No particular progestogen was named but the authors cautioned …

Continued use of the Standard Days Method.

Abstract: Objective To examine the long-term effectiveness and continuation of the Standard Days Method (SDM)®, a fertility awareness-based method of family planning that identifies Days 8–19 (inclusive) of the cycle as the fertile window. On these days users avoid unprotected sexual intercourse to prevent pregnancy. The method works best for women with cycles that are usually in the range of 26–32 days, which is an important reason for method discontinuation in the first year of use. The authors determine if this continues to be an issue in the second and third years of method use. Methods Participants in an earlier efficacy study (478 women in three countries) and method introduction studies (1181 women in four countries) were followed for 2 years beyond the original 1-year study period, to determine their continued use of the method, intended and unintended pregnancies, and reasons for discontinuation. Life-tables were used to approximate typical use pregnancy rates. Results The method continues to be effective in the second and third years of use, and compares favourably to other user-directed family planning methods. Women with no more than two cycles outside the 26–32-day range within a year are likely to continue having cycles within this range. Conclusions Women who complete the first year of SDM use are likely to continue to be able to use the method successfully and effectively. The method presents a viable longer-term option for women who prefer this approach to family planning.

The Marriage Plot

Abstract: Jeffrey Eugenides. London, UK: Fourth Estate, 2011. ISBN-13: 978-0-007-44130-3. Price: £8.99. Pages: 416 (paperback) The Marriage Plot is a richly woven book set in the early 1980s. Its story begins at the graduation weekend of an Ivy League university, with the three principal characters in a state of distress and uncertainty amidst the end of studies festivities. It is 1982, and punk rock and feminism are still strong amongst female students. This is the year that Columbia University admits its first female undergraduates. Madeleine, however, has a passion for the past and for romantic 19th century literature and a liking for orderly things. Up …

Questions about intimate partner violence should be part of contraceptive counselling: findings from a community-based longitudinal study in Nicaragua

Abstract: Background and methodology The study aim was to examine whether exposure to intimate partner violence (IPV) was associated with reversible contraceptive use in ever-pregnant partnered women. The authors conducted a longitudinal panel study in Leon municipality, Nicaragua. At baseline (2002–2003), 478 pregnant women were interviewed and 398 were available for questioning about contraceptive use 40–47 months after childbirth. IPV was assessed at baseline and follow-up, with women classified as never abused, ending abuse, continued abuse or new abuse. Reversible contraceptive use was defined as women using any form of contraception apart from sterilisation. Adjusted odds ratios (AORs) were used to assess the association between reversible contraceptive use, IPV patterns and IPV exposures at follow-up. Results Eighty percent of the women were not pregnant and with a partner at follow-up. Half were using reversible contraceptives and 28% were sterilised. Women exposed to a continued abuse pattern (AOR 2.50, 95% CI 11.04–5.99), and those exposed to emotional (AOR 2.80, 95% CI 1.32–5.95), physical (AOR 3.60, 95% CI 1.15–11.10) or any IPV at follow-up (AOR 2.59, 95% CI 1.24–5.40) had higher odds of reversible contraceptive use than those not exposed, even after adjusting for demographic factors. No significant differences in the type of reversible contraceptive used were found between women exposed or not to IPV. Discussion and conclusions IPV exposure was associated with more reversible contraceptive use. Abuse inquiring at health facilities providing contraceptives should be implemented to identify women exposed to IPV and provide adequate support.

Oral contraceptive use in girls and alcohol consumption in boys are associated with increased blood pressure in late adolescence

Abstract: Le-Ha C, Beilin LJ, Burrows S, et al. Eur J Prevent Cardiol 2012, doi: 10.1177/2047487312452966 This paper reports on a cross-sectional study of around 1250 17-year-old Australian teenagers, the aim of which was to examine associations between lifestyle factors and blood pressure (BP). The teenagers’ BPs and body mass indices (BMIs) were measured, and details on oral contraceptive (OC) use and lifestyle factors, such as diet and exercise, were recorded. The main findings were that, in …

Comparison of unscheduled re-attendance and contraception at discharge, among women having the final stage of early medical abortion at home and those remaining in hospital

Abstract: Introduction Throughout Great Britain, increasing numbers of women having an early medical abortion are choosing to go home soon after administration of misoprostol, to expel the pregnancy at home (early medical discharge, EMD), rather than remain upon the hospital premises (day case). However, data are lacking on how this impacts upon an abortion service in terms of unscheduled re-attendance rates and contraception provision at discharge. Methods A retrospective audit was carried out of women undergoing medical abortion (up to 64 days9 gestation) over 9 months at a National Health Service hospital in Scotland, to determine (1) unscheduled re-attendance rates within 6 weeks of the procedure for an abortion-related complication and (2) method of contraception provided at discharge. Results Over the audit period 1128 women had an early medical abortion of whom 590 (52%) chose EMD. There was no significant difference in unscheduled re-attendance rates between EMD ( n =23, 4%) and day case groups ( n =20, 4%). There was no significant difference in the proportion of women in each group who left hospital with an effective method of contraception ( n =362, 61% and n =355, 60% for EMD and day case groups, respectively). Conclusions Women undergoing early medical abortion who choose to expel the pregnancy at home are no more likely to re-attend hospital with a post-abortal complication and are just as likely to receive effective contraception than those who remain on hospital premises.

Limitations of current definitions of miscarriage using mean gestational sac diameter and crown–rump length measurements: a multicenter observational study

Abstract: Abdallah Y, Daemen A, Kirk E, et al. Ultrasound Obstet Gynecol 2011;38:497–502[OpenUrl][1][PubMed][2] It is very important that a timely and accurate diagnosis of miscarriage is made to avoid unnecessarily prolonged periods of uncertainty for the couple involved. However it is absolutely vital that a potentially ongoing pregnancy is definitely excluded. Guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG) have helped standardise the ultrasound criteria that can be used to accurately diagnose an … [1]: {openurl}?query=rft.jtitle%253DUltrasound%2Bin%2Bobstetrics%2B%2526%2Bgynecology%2B%253A%2B%2Bthe%2Bofficial%2Bjournal%2Bof%2Bthe%2BInternational%2BSociety%2Bof%2BUltrasound%2Bin%2BObstetrics%2Band%2BGynecology%26rft.stitle%253DUltrasound%2BObstet%2BGynecol%26rft.aulast%253DAbdallah%26rft.auinit1%253DY.%26rft.volume%253D38%26rft.issue%253D5%26rft.spage%253D497%26rft.epage%253D502%26rft.atitle%253DLimitations%2Bof%2Bcurrent%2Bdefinitions%2Bof%2Bmiscarriage%2Busing%2Bmean%2Bgestational%2Bsac%2Bdiameter%2Band%2Bcrown-rump%2Blength%2Bmeasurements%253A%2Ba%2Bmulticenter%2Bobservational%2Bstudy.%26rft_id%253Dinfo%253Apmid%252F21997898%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=21997898&link_type=MED&atom=%2Ffamilyplanning%2F38%2F1%2F22.atom

The Plight of Nuns: Hazards of nulliparity

Abstract: Britt K, Short R. Lancet online 7 December 2011. http://dx.doi.org/10.1016/S0140-6736(11)61746-7 [accessed 7 February 2012] This comment,1 published in The Lancet , has evoked a plethora of response in the popular press and revisits the contentious issue of the Catholic Church and the combined oral contraceptive pill (COCP). It focuses on the increased risks of breast, ovarian and uterine cancers in Catholic nuns, the …

Allergy to Nexplanon

Abstract: A 32-year-old woman presented requiring contraception. She had previously had an Implanon® inserted, but this had been removed to allow her to become pregnant. Following her pregnancy she wished to use a long-term contraceptive method and requested another Implanon. Following insertion of a Nexplanon® within 24 hours the site was red and inflamed. The redness was <0.5 mm around the outline of the subdermal Nexplanon. Antibiotics and antihistamines were …

Ethnic differences in disease presentation of uterine cancer in New Zealand women.

Abstract: Objectives Little is known about the ethnic differences in disease presentation of uterine cancer in New Zealand women. The objectives of this study were two-fold: (1) to estimate the incidence and mortality of uterine cancer among women in New Zealand and (2) to examine the association of ethnicity and socioeconomic status with tumour stage and grade, at presentation of uterine cancer. Methods Retrospective survey of cancer cases identified from the New Zealand Cancer Registry. The authors analysed all 3203 uterine cancer cases registered with the New Zealand Cancer Registry during the period 1 January 1997 to 31 December 2006. Ethnic groups were defined based on the self-identified ethnicity recorded on the cancer registry: Ma–ori, Pacific and non-M–aori non-Pacific women. Socioeconomic status was categorised as quintiles of the New Zealand Deprivation Index 2006. The mortality to incidence ratio was used as a measure of prognosis. Logistic regression was used to estimate age, ethnic and deprivation adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results Pacific and M–aori women have higher incidence (32.4 and 17.7 per 100 000 women, respectively) and mortality rates of uterine cancer (12.1 and 7.4 per 100 000 women, respectively). Women in the most deprived areas are more likely to present with an advanced stage of uterine cancer (OR 1.64, 95% CI 1.09–2.48). M–aori and Pacific women are less likely to present with well-differentiated tumours (OR 0.69, 95% CI 0.52–0.92 and OR 0.72, 95% CI 0.52–0.99, respectively). Conclusions M–aori and Pacific women, and those from lower socioeconomic areas, are more likely to present with advanced uterine cancer.

The Standard Days Method ® : an addition to the arsenal of family planning method choice in Ethiopia

Abstract: Background and methodology The Standard Days Method® (SDM) is a fertility awareness-based method of family planning that helps users to identify the fertile days of the reproductive cycle (Days 8–19). To prevent pregnancy users avoid unprotected sexual intercourse during these days. A cross-sectional community-based study was conducted from December 2007 to June 2008 in four operational areas of Pathfinder International Ethiopia. A total of 184 SDM users were included in the study. Quantitative and qualitative methods of data collection were used. The aim of the study was to examine the experience of introducing the SDM at community level in Ethiopia. Results Of the 184 participants, 80.4% were still using the SDM at the time of the survey, with 35% having used it for between 6 and 12 months, while 42% had used it for more than a year. The majority (83%) knew that a woman is most likely to conceive halfway through her menstrual cycle, and nearly 91% correctly said that the SDM does not confer protection from sexually transmitted infections/AIDS. A substantial majority (75%) had correctly identified what each colour-coded bead represents in the CycleBeads®, and an aggregate of 90.5% of women practised all the elements of correct use. Discussion and conclusions This study demonstrates the importance of the SDM in increasing the availability and accessibility of family planning, and the potential to improve family planning method choice and method mix by expanding use of the SDM.

Routine intrauterine device checks: are they advisable?

Abstract: Background Patients using the intrauterine contraceptive device (IUD) were previously advised to undergo routine checks; in 2004, the National Institute for Health and Clinical Excellence stated the practice was unnecessary. This study was conducted to examine the evidence for this advice. Methods A retrospective examination of case records of patients of Whitehall Medical Practice, Rugby, UK who had used an IUD for a minimum of 2 years was performed. Data were extracted concerning demographic details, types of IUD used, dates of their use and of any checks, defaults from checks and side effects. Kaplan–Meier survival analysis was performed to compare outcomes in frequent and infrequent attenders, and in frequent and infrequent defaulters from checks. Results The study population comprised 272 individuals using a total of 423 devices. Frequent check attenders showed adverse events earlier, or at no significant time difference, to infrequent attenders. Conclusions Considering patients who use an IUD for a minimum of 2 years, this study found no evidence of harm occurring in those who attended infrequently compared to frequent attenders. If these data from a single practice are generalisable, after an initial check following insertion, women can be asked to attend as needed and only be recalled for smears and at the end of the life of the IUD.