JFPRHC launches two new sections

As well as the usual mix of science, information, reflection and discussion, we welcome in this issue two new regular journal sections: Venus and Person in Practice, both of which are introduced more fully in an accompanying editorial (page 167). You will find Venus, a new digest of sexual health literature, at the very end of the journal (page 236). Named for the Roman goddess of love, Venus is inspired by her wise counterpart at the BMJ: Minerva. Our goddess will be combining an eye for compelling evidence with an eye for good gossip. Meanwhile, our new columnist from primary care, Dr Abi Berger, will be challenging us with reflections, sometimes candid, on the role of the doctor as a person in the consultation, and on how the personal can affect practice. In her inaugural article, Abi reflects on her personal menopause journey (page 226).

Sandy Goldbeck-Wood

Editor-in-Chief

New NICE menopause guideline recommends an individualised approach, with some changes to previous recommendations

Women experience menopause in individual and widely differing ways, and a key theme of the new National Institute for Health and Care Excellence (NICE) guideline, summarised in an editorial in this issue, is individualisation at all stages of the diagnosis, investigation and management. Notable changes from previous guidance include the advice that clinicians should avoid routine use of follicle-stimulating hormone levels to diagnose menopause, and that hormone replacement therapy (HRT) is a first-line option for most women. HRT's efficacy as a treatment for low mood in menopause is confirmed, as is the appropriateness of continuing treatment of vaginal symptoms with topical estrogens. See page 168

DMPA is associated with postnatal depression and delayed return to sexual activity

The only previous randomised controlled trial (RCT) looking at the effect of injectable progestogens on postnatal depression studied norethisterone and found an increased risk if it is injected within 48 hours of childbirth. In this issue we publish a single-blind RCT comparing depotmedroxyprogesterone acetate (DMPA) and the copper intrauterine device (IUD). Conducted in South Africa, where injectable progestogens can be given immediately post-delivery, the trial found that DMPA was associated with a higher rate of postnatal depression, and that women using the method resumed intercourse later than those using a copper IUD. See page 171

Young parents seeking help with their children want easy access to respectful help, not stigma

The attitudes of health professionals to young parenthood can be stigmatising, and at odds with the experiences of young parents themselves. This qualitative, semi-structured interview study examined the views of 10 young parents in Newcastle, UK. Several highlighted seeing themselves as ‘first-time parents’ rather than just ‘young’. Themes emerged such as power imbalances between young parents and professionals, particularly when the former were seeking help for their children. Access to help was found to be a particular concern when the parent intuitively knew there was something wrong. Midwives were rated more favourably than health visitors and general practitioners. These findings suggest that if this vulnerable group is to be empowered and not alienated, services should be designed so as to allow parents easy ad hoc access to help, and staff need skills in listening and empathy. See page 179

Postpartum implant administration does not affect the duration of lochia

Etonogestrel implants provide highly effective long-acting contraception and they are therefore an attractive choice for the prevention of early unwanted pregnancy following childbirth. In Hobart, Tasmania, implants have been offered to newly-delivered women for over 7 years, with increasing popularity, but little is known about their impact on the duration or quantity of postpartum bleeding. This issue is important as unscheduled bleeding is one of the recognised drawbacks of this method of contraception. In their study of 79 women who had early postpartum Implanon^® insertion and 73 matched controls, Dobromilsky and colleagues found no significant difference between the groups in the duration of bleeding – information that will be of great help in advising women considering implants as their method of postpartum contraception. See page 187

A DVD can be used to inform patients about Nexplanon^®

Providing detailed patient information about a contraceptive method takes time if done well and many health care providers have limited consultation time. This pilot RCT randomised 50 women attending a clinic in Scotland to either receive information face-to-face or via a DVD developed using Faculty of Sexual & Reproductive Healthcare (FSRH) guidance. Structured interviews were conducted immediately following the consultation to assess accuracy of knowledge recall and acceptability of using a DVD to give information. Interviews were repeated 3 months later by telephone. Women who watched the DVD felt it was helpful and easy to understand, and the study concluded that use of a DVD to provide patient information on Nexplanon was acceptable and informative, and may enhance patient consultations. See page 194

Most Irish medical students believe abortion is justified in extreme circumstances

Abortion remains a controversial issue worldwide. In the Republic of Ireland, abortion remains illegal except in very limited circumstances. O'Grady et al. offered a questionnaire to almost 1000 Cork University medical students, over 500 of whom responded. They stratified the respondents by their mode of entry to medical school, whether as undergraduates or as graduates, as well as by other factors such as age, country of origin and religious affiliation. The majority of students, regardless of mode of entry, believed that abortion was justified where there was a real risk to the life of the mother (including risk of suicide) or in cases of fetal non-viability. The most significant determinant of students' beliefs was religious adherence. This very large study suggests that future doctors' attitudes to abortion are moulded at an early stage in their careers. See page 201

Pharmacy workers, whose role in medical termination of pregnancy in Kenya is key, lack relevant knowledge

Unsafe abortion accounts for 35% of maternal deaths in Kenya. Pharmacy workers are in an ideal position to provide information and dispense drugs with a prescription. This study used interview and mystery shoppers to assess pharmacy workers' understanding, knowledge and provision of abortion information to women. Knowledge of drugs was patchy and there were gaps in the information given to women. Pharmacy workers are a valuable resource and with training could improve access to safe abortion. See page 208

Some simple strategies can help us communicate risk better to patients in SRH settings

Presenting risk information to patients is an important part of clinical encounters and good risk communication improves patient satisfaction with their care. A review article in this issue offers clinicians concrete strategies to improve patients' understanding of risks. These include providing personalised rather than just population risks, using decision aids, and presenting information in a variety of structured, tailored and/or interactive formats. To quantify risk, it is more effective to use numbers rather than words. Event rates or natural frequencies are often more helpful than probabilities or relative risk reduction, and absolute risks are more useful than relative risks. See page 213

TV can be a useful distraction for patients during SRH procedures

Television (TV) screens were introduced in three clinical rooms in a busy inner-city practice and made available as a diversion when patients were undergoing SRH procedures. A questionnaire-based survey was performed with 63 patients and 30 staff 2 months prior to, and 45 patients and 24 staff 8 months after, this intervention. A large majority of patients appreciated the TV and no adverse comments were made. Some 59% of staff were ambivalent prior to the TV installation but all felt it was positive afterwards, with one specific comment that it was not as distracting to staff as had been anticipated. The authors recommend considering this cheap intervention as a support for patients, and observe that it is unlikely to contribute to adverse events related to the distraction of staff. See page 220

Part 1 MFSRH Examination now comprises a new Single Best Answer paper

Examinations to assess progress in medical training have become increasingly robust over recent years. They should be as reliable and valid as possible, both to satisfy the requirements of medical regulatory bodies and the concerns of the general public. In this article, the Chair of the FSRH Examinations Committee introduces the new Single Best Answer paper that now constitutes the Faculty's Part 1 Membership examination. This is a multiple-choice examination in a style that has been shown to be a better test of candidates' knowledge of basic sciences and clinical medicine than previous multiple-choice formats. The article explains how tests of validity now applied in setting and reviewing medical examinations ensure that this examination (and others like it) is fair, valid and reliable. See page 222

While condemning FGM, Western media collude in other forms of non-medical vulval manipulation

Who shapes expectations of what women should look like? The media seems to have a lot to answer for. The line between free choice and powerlessness is unclear, when it comes to genital cosmetic surgery, while alteration of the genitals in female genital mutilation (FGM) is clearly illegal. This Personal View article reflects on media pressure to alter the vulva to conform to an ideal ‘normal’, and the insecurities of women who are ignorant about its function. The author points out that while FGM is acknowledged as a coercive situation like child abuse and sexual violence, Western society is silent and collusive on the subject of vulval alteration in pursuit of an unrealistic, air-brushed notion of normality. We need more of the relevant kinds of research – including investigating the psychosexual consequences of such surgery – the author of this article argues. See page 226

Sexpression:UK meets a need for information about sex among young people

Young people want and are entitled to receive information about sex and relationships that is both reliable and relevant. The Organisation Factfile article in this issue highlights a much-needed service run by volunteer students at universities across the UK that delivers sex and relationship education to young people in the community. See page 230