We welcome research about safeguarding under-18s in early telemedical abortions. Telemedicine can be a useful adjunct to in-person care. The Royal College of Paediatrics and Child Health safeguarding guidance for under-18s accessing early medical abortions[1] requires that providers aim to see under-18s in-person ‘at some point in the EMA care pathway’. This guidance will be included in the new NHS Standard Contract from April 2023.
Romanis and Parsons[2] don’t address the prevention of mid-term abortions (the central reason why under-18s should be seen in-person) focusing their analysis on abortion care providers’ views of access to abortion care.
Abortion deliveries beyond 10 weeks are inevitable if not preceded by clinical examination and/or ultrasound scans,[3-5] and the psychological consequences of a mid- or late-trimester home delivery can be severe.[6,7] Under-18s lack brain maturity[8-10] and are more vulnerable to effects of trauma.[11,12] The law imposes particular responsibility to prevent foreseeable trauma in this age group.[13,14]
Under-18s are also vulnerable to child sexual exploitation and abuse. Virtual consultations enable unseen and unheard coercive adults to overhear and intercept the patient's conversations.[15,16] Ensuring they are seen in-person enables rapport and guarantees privacy. Following no-test medical abortions, under-20s, compared to others are more likely to report wanting a face-to-face abortion in the future...
We welcome research about safeguarding under-18s in early telemedical abortions. Telemedicine can be a useful adjunct to in-person care. The Royal College of Paediatrics and Child Health safeguarding guidance for under-18s accessing early medical abortions[1] requires that providers aim to see under-18s in-person ‘at some point in the EMA care pathway’. This guidance will be included in the new NHS Standard Contract from April 2023.
Romanis and Parsons[2] don’t address the prevention of mid-term abortions (the central reason why under-18s should be seen in-person) focusing their analysis on abortion care providers’ views of access to abortion care.
Abortion deliveries beyond 10 weeks are inevitable if not preceded by clinical examination and/or ultrasound scans,[3-5] and the psychological consequences of a mid- or late-trimester home delivery can be severe.[6,7] Under-18s lack brain maturity[8-10] and are more vulnerable to effects of trauma.[11,12] The law imposes particular responsibility to prevent foreseeable trauma in this age group.[13,14]
Under-18s are also vulnerable to child sexual exploitation and abuse. Virtual consultations enable unseen and unheard coercive adults to overhear and intercept the patient's conversations.[15,16] Ensuring they are seen in-person enables rapport and guarantees privacy. Following no-test medical abortions, under-20s, compared to others are more likely to report wanting a face-to-face abortion in the future.[17]
Access difficulties for in-person assessment should be addressed by service design such as outreach or transport provision rather than forgoing in-person assessment with the significant consequences this could have for young people.
The debate around safeguarding in abortion care has become polarised including suggestions that those who raise concerns about child safeguarding are doing this from an anti-abortion standpoint. Whilst we respect all viewpoints, we are not anti-abortion and in our many plenary discussions no members of the National Network of Designated Healthcare Professionals for children have expressed anti-abortion views.
2 Romanis, EC. and Parsons, JA. (2023) Early telemedical abortion, safeguarding, and Under 18s: A qualitative study with care providers in England and Wales, BMJ Sexual & Reproductive Health. British Medical Journal Publishing Group. 27/01/2023 doi 10.1136/bmjsrh-2022-201762
3 Raymond EG, Grossman D, Mark A, et al. Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond. Contraception. 2020;101(6):361-366.
4 Royal College of Obstetricians and Gynaecologists (RCOG). Coronavirus (COVID-19) infection and abortion care. Information for healthcare professionals. V3.1. Royal College of Obstetricians and Gynaecologists, 2020. Available at: https://www.rcog.org.uk/media/bbhpl2qa/2020-07-31-coronavirus-covid-19-i... (Accessed: February 5 2023)
5 Aiken A, Lohr PA, Lord J, et al. Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: a national cohort study. BJOG. 2021;128(9):1464-74
6 Raymond EG, Bracken H. Early medical abortion without prior ultrasound. Contraception. 2015;92(3):212-214.
7 Kirkland F. Clinics call for at home abortions to continue. BBC News [Internet]. 2022 Mar 30. Available at: https://www.bbc.co.uk/news/health-60912656 (Accessed: February 5 2023)
8 Steinberg L. Commentary: A behavioral scientist Looks at the science of adolescent brain development. Brain Cogn. 2010 February ; 72(1): 160–164.
9 Cohen AO, Breiner K et al. When is an adolescent an adult? Assessing cognitive control in emotional and non-emotional contexts. Psychological Science 2016;27: 549–562.
10 Diekema DS, Adolescent Brain Development and Medical Decision-making. Pediatrics 2020; 146:S18
11 Miller AB, Prinstein MJ Adolescent Suicide as a Failure of Acute Stress-Response Systems. Annual Review of Clinical Psychology 2019;15(1):425-50
12 Eiland L, Romeo RD. Stress and the developing adolescent brain. Neuroscience 2013;249:162–71
15 Bateson DJ, Lohr PA, Norman WV, et al The impact of COVID-19 on contraception and abortion care policy and practice: experiences from selected countries. Editorial. BMJ Sexual & Reproductive Health 2020;46:241-243.
17 Porter Erlank C, Lord J, Church K. Acceptability of no-test medical abortion provided via telemedicine during Covid-19: analysis of patient-reported outcomes. BMJ Sex Reprod Health. 2021;47(4):261-268.
When you support healthy blood flow, you can boost the flow of vital nutrients and oxygen to every inch of your body.
And this leads to…
- Increased Sex Drive
- More Energy and Vitality
- Easier Weight Loss and Less Cravings
- A Sharper and Healthier Recall
- Increased Performances and Youthful Stamina for your Love Life
- Supporting Healthy Blood Pressure
- Maintaining Healthy Blood Sugar
- Supporting a Healthy Immune System
Dear Dr.Gilmore ,
I have found the article very informative and was pleased that you have incorporated lifestyle medicine as part of the management of perimenopause. I wanted to mention specifically the area where you mention about complementary therapy and highlight Phytoestrogens like soya should be avoided in women with hormone dependent cancers or those taking tamoxifen. You have highlighted that the evidence on effect of vasomotor symptoms is conflicting too.
I have been researching this area myself and hence felt it was important to mention that now there is growing evidence that Soya can be beneficial during perimenopause and can be used in women with hormone dependent breast cancer as well as those taking tamoxifen.
Minimally processed soya foods like soya milk, edamame, tofu, tempeh and miso can be beneficial to overall health including during perimenopause.(1) In the case of cancer this study shows benefits for reducing the risk of breast cancer (13% reduction) and ovarian cancer (48% reduction) amongst several others which included prostate, colorectal, lung and endometrial cancers. The only negative impact highlighted in this meta-analysis was the increased risk of gastric cancer amongst men consuming 1-5 cups of miso soup per day. The study has shown the beneficial effect of soya on hot flushes during perimenopause as well.
The misconception of soya being a phytoestrogen comes from classifying it as an endocrine disruptor. However re...
Dear Dr.Gilmore ,
I have found the article very informative and was pleased that you have incorporated lifestyle medicine as part of the management of perimenopause. I wanted to mention specifically the area where you mention about complementary therapy and highlight Phytoestrogens like soya should be avoided in women with hormone dependent cancers or those taking tamoxifen. You have highlighted that the evidence on effect of vasomotor symptoms is conflicting too.
I have been researching this area myself and hence felt it was important to mention that now there is growing evidence that Soya can be beneficial during perimenopause and can be used in women with hormone dependent breast cancer as well as those taking tamoxifen.
Minimally processed soya foods like soya milk, edamame, tofu, tempeh and miso can be beneficial to overall health including during perimenopause.(1) In the case of cancer this study shows benefits for reducing the risk of breast cancer (13% reduction) and ovarian cancer (48% reduction) amongst several others which included prostate, colorectal, lung and endometrial cancers. The only negative impact highlighted in this meta-analysis was the increased risk of gastric cancer amongst men consuming 1-5 cups of miso soup per day. The study has shown the beneficial effect of soya on hot flushes during perimenopause as well.
The misconception of soya being a phytoestrogen comes from classifying it as an endocrine disruptor. However reviewing the data so far, there is no conclusion that intake of isoflavones or soya food has an adverse effect on thyroid hormone, oestrogen or testosterone in both women and men.(2) Phytoestrogens contain isoflavones that can bind to the oestrogen receptors. Research has shown that there are two different types of oestrogen receptors in the human body: alpha and beta. The oestrogen present in humans has a preference to attach on the alpha receptors when the phytoestrogens have a preference for the beta receptors. Soya phytoestrogen is known as a ‘selective oestrogen receptor modulator’(SERM) as it has pro oestrogenic as well as anti-oestrogenic effect, depending on the type of tissue it attaches to. On the breast tissue phytoestrogen have an anti-oestrogenic effect which inhibits cellular proliferation. This is how consumption of soya has been shown to be beneficial in reducing the risk of breast cancer. (3)
The oestrogenic effect of isoflavones present in soya have raised concerns for its use in women with oestrogen dependent cancer. However, it has been seen that there is inverse association between soya intake amongst women with oestrogen receptor positive or negative breast cancer. This effect was seen in both tamoxifen users as well as non-users. (4)
Osteoporosis is a major concern during perimenopause as well as menopause which results from continuous bone resorption. It has been seen that soya isoflavones increase the bone mineral density in women of normal weight as well as reduce bone resorption in women with a high BMI. (5)
There is also growing evidence that soya has a beneficial effect on hot flushes .(6) It can be incorporated as part of a healthy diet, including women who have a history of breast cancer or are on tamoxifen. Overall soya can be beneficial for women during perimenopause and menopause.
Thank you,
Dr.Anni Tripathi
GP and Lifestyle Medicine Physician.
References:
(1)https://pubmed.ncbi.nlm.nih.gov/31584249/ Soy and Isoflavone Consumption and Multiple Health Outcomes: Umbrella Review of Systematic Reviews and Meta-Analyses of Observational Studies and Randomized Trials in Humans
(2)https://pubmed.ncbi.nlm.nih.gov/33775173/ Neither soyfoods nor isoflavones warrant classification as endocrine disruptors: a technical review of the observational and clinical data
I applaud the author’s call for similar policy in the UK.
Miscarriage is the most well known form of early pregnancy loss but other types of pregnancy loss including pregnancy of unknown location (PUL), ectopic pregnancy, gestational trophoblastic disease (GTD) and termination of pregnancy should also fall under the auspices of early pregnancy loss bereavement leave policy.
People and their partners experiencing these less common forms of pregnancy loss already encounter less societal awareness of their type of pregnancy but experience the physical and emotional loss nonetheless, and often the context of traumatic and frightening lifesaving emergency treatment.
Those who have termination of pregnancy may have done so for reasons of foetal abnormality or other personal, social or health reasons but for which they may have continued the pregnancy or may experience unexpected regret or bereavement.
The loss of any pregnancy is something that can be emotionally and physically challenging to those experiencing it and I would urge any UK policy to include all forms of early pregnancy loss.
Thank you for your e-letter 'Concerns about high grade HPV results on routine smear tests' which we read with interest. You highlight some important questions that women have following receipt of an HPV positive result, such as where the infection came from and the consequences of HPV for partners. We identified similar issues in our recently published review exploring the psychosexual impact of testing positive for high-risk HPV (1). We acknowledge the importance of training and advice for all clinicians involved in cervical screening so they are able to confidently support and reassure women who test positive for HPV. Public Health England (PHE) have developed an e-learning module on primary HPV testing to support clinicians (2), and Jo’s Cervical Cancer Trust has information for practice nurses and GPs on HPV and cervical screening (3), which clinicians may find helpful.
(1) Bennett KF , Waller J , Ryan M, Bailey JV & Marlow, LAV (2019). The psychosexual impact of testing positive for high‐risk cervical human papillomavirus (HPV): a systematic review. Psycho-oncology;28:1959–1970. doi.org/10.1002/pon.5198
Thank you for your e-letter 'Concerns about high grade HPV results on routine smear tests' which we read with interest. You highlight some important questions that women have following receipt of an HPV positive result, such as where the infection came from and the consequences of HPV for partners. We identified similar issues in our recently published review exploring the psychosexual impact of testing positive for high-risk HPV (1). We acknowledge the importance of training and advice for all clinicians involved in cervical screening so they are able to confidently support and reassure women who test positive for HPV. Public Health England (PHE) have developed an e-learning module on primary HPV testing to support clinicians (2), and Jo’s Cervical Cancer Trust has information for practice nurses and GPs on HPV and cervical screening (3), which clinicians may find helpful.
(1) Bennett KF , Waller J , Ryan M, Bailey JV & Marlow, LAV (2019). The psychosexual impact of testing positive for high‐risk cervical human papillomavirus (HPV): a systematic review. Psycho-oncology;28:1959–1970. doi.org/10.1002/pon.5198
I read with interest this article. I am a GP with many years of experience in Sexual Health. Our area has over the past months started to implement the HPV screening tagged on to the conventional liquid based cytology. As a GP with interest in SH, I am doing the 'difficult' smears in our practice, either for women who found the smear taking particularly awful - due usually to dryness, and vaginal atrophy, but also for other reasons, such as opportunistic smear taking in women fearful of smears. Recently one of the smears I had taken contained an unexpected high grade HPV infection, in a woman in her early fifties. In the light of this, I felt I had no choice but to take a sexual history - a potential minefield in General Practice. In this particular case, the patient had been in a monogamous relationship for 30 years, having one daughter in her early twenties. This at least told me I won't have to do an HIV and syphilis test (but, maybe she should?). Positive high grade HPV results do bring up of lot sensitive issues, and questions, especially for women, such as, where did this come from? how long have I had it? What are the repercussions in my relationship? Might there be a risk of violence following a result like this? Will women feel they have to keep it secret from their partners for fear of being blamed? What may be the consequence of high grade HPV for the partner? It is no good just ignoring these issues, or doing it off as a perso...
I read with interest this article. I am a GP with many years of experience in Sexual Health. Our area has over the past months started to implement the HPV screening tagged on to the conventional liquid based cytology. As a GP with interest in SH, I am doing the 'difficult' smears in our practice, either for women who found the smear taking particularly awful - due usually to dryness, and vaginal atrophy, but also for other reasons, such as opportunistic smear taking in women fearful of smears. Recently one of the smears I had taken contained an unexpected high grade HPV infection, in a woman in her early fifties. In the light of this, I felt I had no choice but to take a sexual history - a potential minefield in General Practice. In this particular case, the patient had been in a monogamous relationship for 30 years, having one daughter in her early twenties. This at least told me I won't have to do an HIV and syphilis test (but, maybe she should?). Positive high grade HPV results do bring up of lot sensitive issues, and questions, especially for women, such as, where did this come from? how long have I had it? What are the repercussions in my relationship? Might there be a risk of violence following a result like this? Will women feel they have to keep it secret from their partners for fear of being blamed? What may be the consequence of high grade HPV for the partner? It is no good just ignoring these issues, or doing it off as a personal 'decision'. It is important to know what advice to give, how to counsel, and how to move forward... even when I was still working in Sexual Health the answers to a lot of those questions were not clear with regards to HPV infection.
As an interested observer from a different field, I am not an expert in the statistical analysis techniques used in this article. However, it appears from the supplementary data table that the lowest rate of cancer for women is actually for either 1 partner (against which the others are compared and all are >1 OR) or 5-9 partners with an OR of 1.28, based on the categories presented, but the 0 partner case has an OR of 1.81. This supplementary data table therefore does not support the conclusion "A higher lifetime number of sexual partners is associated with increased odds of reported cancer" and does not warrant the comment in the paper that no differences were found.
Thank you for the above article. It was noted that over the 5 year period the percentage of consultations for patients who used regular contraception compared with no regular method reduced by a statistically significant amount ( 44.2% to 33.9% p <0.001). A possible explanation for this could be reduced access to clinics and Primary Care in Wales, as England with pressures on all health services. I would welcome any moves in my area of Wales for CPs to provide oral hormonal contraception.
In their article about Natural Cycles, Hough et al quote a Cochrane Review that dismisses fertility awareness based contraception (natural family planning).
A Cochrane Review is an understandable choice but not an appropriate one. It would be more helpful to quote NHS Choices, the Family Planning Association or Faculty Guidance, which all have a more nuanced approach to the evidence, and say that fertility awareness is up to 99% effective.
Typical use rates are lower but many women achieve high effectiveness thanks to either their own research or appropriate support. Books like “Taking Charge of Your Fertility” by Toni Weschler, websites like Fertility UK and apps such as Kindara, Cycle Beads and Ovuview have helped women to avoid (and plan) pregnancy for years. There is also NHS-funded fertility awareness support in some areas.
Natural Cycles is the new app that is revolutionising fertility awareness thanks to huge amounts of funding for marketing and research and a clean design that removes all judgement from the user (in a similar way to CycleBeads) and simply pronounces a day “red” or “green”.
The accessibility, if not the advertising, of Natural Cycles is welcome. Women need options. But it is not ideal.
Advertising is one issue. As Hough et al describe, because Natural Cycles is not a prescribed product, and because they have substantial financial resources, they are able to bypass health professionals and advertise direct to potential c...
In their article about Natural Cycles, Hough et al quote a Cochrane Review that dismisses fertility awareness based contraception (natural family planning).
A Cochrane Review is an understandable choice but not an appropriate one. It would be more helpful to quote NHS Choices, the Family Planning Association or Faculty Guidance, which all have a more nuanced approach to the evidence, and say that fertility awareness is up to 99% effective.
Typical use rates are lower but many women achieve high effectiveness thanks to either their own research or appropriate support. Books like “Taking Charge of Your Fertility” by Toni Weschler, websites like Fertility UK and apps such as Kindara, Cycle Beads and Ovuview have helped women to avoid (and plan) pregnancy for years. There is also NHS-funded fertility awareness support in some areas.
Natural Cycles is the new app that is revolutionising fertility awareness thanks to huge amounts of funding for marketing and research and a clean design that removes all judgement from the user (in a similar way to CycleBeads) and simply pronounces a day “red” or “green”.
The accessibility, if not the advertising, of Natural Cycles is welcome. Women need options. But it is not ideal.
Advertising is one issue. As Hough et al describe, because Natural Cycles is not a prescribed product, and because they have substantial financial resources, they are able to bypass health professionals and advertise direct to potential clients. They run targeted Facebook and Instagram adverts and get support from trusted social media influencers, favourable press articles and others.
Still, it is worth remembering that prescribed medication is also not free of commercial influence. As Ben Goldacre describes in Bad Pharma, not being able to advertise direct to consumers simply means Big Pharma concentrates on selling direct to trusted health professionals, researchers and influencers through educational events, smooth sales reps, research grants, lobbying and other methods.
Another issue is the lack of transparency about the Natural Cycles algorithm. There has been decades of research about fertility awareness. It is a shame that they are not adding to this in a more meaningful way – or even acknowledging it, simply saying that they have “invented” an algorithm, as if it has come out of thin air and not decades of research about different algorithms.
It is also worrying that their algorithm seems to have a “one-size-fits-all” approach. Fertility is not an on/off switch. There are days on which pregnancy is very likely, days on which it is likely and days on which it is very unlikely or impossible.
Some women use fertility awareness in a very cautious “life or death” way – not having unprotected sex till after ovulation has been and gone.
Others are more willing to push the boundaries – depending on our cycles and on how we feel about unplanned pregnancy – and our age. A woman of 48 might choose to be less cautious than she was aged 38, or even 44.
We also use different fertility indicators. Some of us use temperature and ovulation sticks (in the style of Natural Cycles). Many women find temperature and fluid more convenient, or simply fluid and/or calendar calculations.
A better fertility app would have a transparent algorithm that allows women to choose the approach that suits them. It would also open up the data (in anonymised form) to researchers. This is not only an important contraceptive option, it is important knowledge. We should have an NHS app for this - not a private one.
The move to single visit medical abortion[1] will be a great improvement in convenience to clients. The requirement of two doctors to sign the HSA form results in many attending and sometimes waiting for hours purely to obtain a signed form. This inconvenience could easily be removed by distant signing of such forms. In a service such as ours with an electronic patient record, readily accessed at a remove, the requirement for such attendance seems especially egregious.
Reference
1 Lord J, Regan L, Kasliwal A, et al. Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England. BMJ Sex Reprod Health 2018;44:155–8.
We welcome research about safeguarding under-18s in early telemedical abortions. Telemedicine can be a useful adjunct to in-person care. The Royal College of Paediatrics and Child Health safeguarding guidance for under-18s accessing early medical abortions[1] requires that providers aim to see under-18s in-person ‘at some point in the EMA care pathway’. This guidance will be included in the new NHS Standard Contract from April 2023.
Romanis and Parsons[2] don’t address the prevention of mid-term abortions (the central reason why under-18s should be seen in-person) focusing their analysis on abortion care providers’ views of access to abortion care.
Abortion deliveries beyond 10 weeks are inevitable if not preceded by clinical examination and/or ultrasound scans,[3-5] and the psychological consequences of a mid- or late-trimester home delivery can be severe.[6,7] Under-18s lack brain maturity[8-10] and are more vulnerable to effects of trauma.[11,12] The law imposes particular responsibility to prevent foreseeable trauma in this age group.[13,14]
Under-18s are also vulnerable to child sexual exploitation and abuse. Virtual consultations enable unseen and unheard coercive adults to overhear and intercept the patient's conversations.[15,16] Ensuring they are seen in-person enables rapport and guarantees privacy. Following no-test medical abortions, under-20s, compared to others are more likely to report wanting a face-to-face abortion in the future...
Show MoreWhen you support healthy blood flow, you can boost the flow of vital nutrients and oxygen to every inch of your body.
And this leads to…
- Increased Sex Drive
- More Energy and Vitality
- Easier Weight Loss and Less Cravings
- A Sharper and Healthier Recall
- Increased Performances and Youthful Stamina for your Love Life
- Supporting Healthy Blood Pressure
- Maintaining Healthy Blood Sugar
- Supporting a Healthy Immune System
To get started with Red Boost today, simply copy the link below
https://70de4ldryfdq3paebq-eja8o42.hop.clickbank.net
Dear Dr.Gilmore ,
I have found the article very informative and was pleased that you have incorporated lifestyle medicine as part of the management of perimenopause. I wanted to mention specifically the area where you mention about complementary therapy and highlight Phytoestrogens like soya should be avoided in women with hormone dependent cancers or those taking tamoxifen. You have highlighted that the evidence on effect of vasomotor symptoms is conflicting too.
I have been researching this area myself and hence felt it was important to mention that now there is growing evidence that Soya can be beneficial during perimenopause and can be used in women with hormone dependent breast cancer as well as those taking tamoxifen.
Minimally processed soya foods like soya milk, edamame, tofu, tempeh and miso can be beneficial to overall health including during perimenopause.(1) In the case of cancer this study shows benefits for reducing the risk of breast cancer (13% reduction) and ovarian cancer (48% reduction) amongst several others which included prostate, colorectal, lung and endometrial cancers. The only negative impact highlighted in this meta-analysis was the increased risk of gastric cancer amongst men consuming 1-5 cups of miso soup per day. The study has shown the beneficial effect of soya on hot flushes during perimenopause as well.
Show MoreThe misconception of soya being a phytoestrogen comes from classifying it as an endocrine disruptor. However re...
I applaud the author’s call for similar policy in the UK.
Miscarriage is the most well known form of early pregnancy loss but other types of pregnancy loss including pregnancy of unknown location (PUL), ectopic pregnancy, gestational trophoblastic disease (GTD) and termination of pregnancy should also fall under the auspices of early pregnancy loss bereavement leave policy.
People and their partners experiencing these less common forms of pregnancy loss already encounter less societal awareness of their type of pregnancy but experience the physical and emotional loss nonetheless, and often the context of traumatic and frightening lifesaving emergency treatment.
Those who have termination of pregnancy may have done so for reasons of foetal abnormality or other personal, social or health reasons but for which they may have continued the pregnancy or may experience unexpected regret or bereavement.
The loss of any pregnancy is something that can be emotionally and physically challenging to those experiencing it and I would urge any UK policy to include all forms of early pregnancy loss.
Thank you for your e-letter 'Concerns about high grade HPV results on routine smear tests' which we read with interest. You highlight some important questions that women have following receipt of an HPV positive result, such as where the infection came from and the consequences of HPV for partners. We identified similar issues in our recently published review exploring the psychosexual impact of testing positive for high-risk HPV (1). We acknowledge the importance of training and advice for all clinicians involved in cervical screening so they are able to confidently support and reassure women who test positive for HPV. Public Health England (PHE) have developed an e-learning module on primary HPV testing to support clinicians (2), and Jo’s Cervical Cancer Trust has information for practice nurses and GPs on HPV and cervical screening (3), which clinicians may find helpful.
(1) Bennett KF , Waller J , Ryan M, Bailey JV & Marlow, LAV (2019). The psychosexual impact of testing positive for high‐risk cervical human papillomavirus (HPV): a systematic review. Psycho-oncology;28:1959–1970. doi.org/10.1002/pon.5198
(2) Public Health England (2019). Primary HPV screening training resources launched. Available from: https://phescreening.blog.gov.uk/2019/02/11/primary-hpv-screening-traini...
(3) Jo's Cervical Cancer Trust (2016). Inform...
Show MoreI read with interest this article. I am a GP with many years of experience in Sexual Health. Our area has over the past months started to implement the HPV screening tagged on to the conventional liquid based cytology. As a GP with interest in SH, I am doing the 'difficult' smears in our practice, either for women who found the smear taking particularly awful - due usually to dryness, and vaginal atrophy, but also for other reasons, such as opportunistic smear taking in women fearful of smears. Recently one of the smears I had taken contained an unexpected high grade HPV infection, in a woman in her early fifties. In the light of this, I felt I had no choice but to take a sexual history - a potential minefield in General Practice. In this particular case, the patient had been in a monogamous relationship for 30 years, having one daughter in her early twenties. This at least told me I won't have to do an HIV and syphilis test (but, maybe she should?). Positive high grade HPV results do bring up of lot sensitive issues, and questions, especially for women, such as, where did this come from? how long have I had it? What are the repercussions in my relationship? Might there be a risk of violence following a result like this? Will women feel they have to keep it secret from their partners for fear of being blamed? What may be the consequence of high grade HPV for the partner? It is no good just ignoring these issues, or doing it off as a perso...
Show MoreAs an interested observer from a different field, I am not an expert in the statistical analysis techniques used in this article. However, it appears from the supplementary data table that the lowest rate of cancer for women is actually for either 1 partner (against which the others are compared and all are >1 OR) or 5-9 partners with an OR of 1.28, based on the categories presented, but the 0 partner case has an OR of 1.81. This supplementary data table therefore does not support the conclusion "A higher lifetime number of sexual partners is associated with increased odds of reported cancer" and does not warrant the comment in the paper that no differences were found.
Thank you for the above article. It was noted that over the 5 year period the percentage of consultations for patients who used regular contraception compared with no regular method reduced by a statistically significant amount ( 44.2% to 33.9% p <0.001). A possible explanation for this could be reduced access to clinics and Primary Care in Wales, as England with pressures on all health services. I would welcome any moves in my area of Wales for CPs to provide oral hormonal contraception.
In their article about Natural Cycles, Hough et al quote a Cochrane Review that dismisses fertility awareness based contraception (natural family planning).
Show MoreA Cochrane Review is an understandable choice but not an appropriate one. It would be more helpful to quote NHS Choices, the Family Planning Association or Faculty Guidance, which all have a more nuanced approach to the evidence, and say that fertility awareness is up to 99% effective.
Typical use rates are lower but many women achieve high effectiveness thanks to either their own research or appropriate support. Books like “Taking Charge of Your Fertility” by Toni Weschler, websites like Fertility UK and apps such as Kindara, Cycle Beads and Ovuview have helped women to avoid (and plan) pregnancy for years. There is also NHS-funded fertility awareness support in some areas.
Natural Cycles is the new app that is revolutionising fertility awareness thanks to huge amounts of funding for marketing and research and a clean design that removes all judgement from the user (in a similar way to CycleBeads) and simply pronounces a day “red” or “green”.
The accessibility, if not the advertising, of Natural Cycles is welcome. Women need options. But it is not ideal.
Advertising is one issue. As Hough et al describe, because Natural Cycles is not a prescribed product, and because they have substantial financial resources, they are able to bypass health professionals and advertise direct to potential c...
The move to single visit medical abortion[1] will be a great improvement in convenience to clients. The requirement of two doctors to sign the HSA form results in many attending and sometimes waiting for hours purely to obtain a signed form. This inconvenience could easily be removed by distant signing of such forms. In a service such as ours with an electronic patient record, readily accessed at a remove, the requirement for such attendance seems especially egregious.
Reference
1 Lord J, Regan L, Kasliwal A, et al. Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England. BMJ Sex Reprod Health 2018;44:155–8.
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