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Revision of the ‘missed pill’ rules – at last

We have waited 6 years for this moment; the rules put forward for missed pills in 2005 have finally been revised by the Medicines and Healthcare products Regulatory Agency (MHRA) – more or less back to the rules we had before. Diana Mansour assesses the current rules and looks at the increasing recognition of the importance of the pill-free interval in pill failures.

See page 128

VTE and the Pill – again

This commentary by Klaas and Lothar Heinemann looks critically at the two papers by the Jick group recently published in the British Medical Journal. They explain the problems inherent in database studies of this kind and conclude that these papers do not add anything useful to the literature on this topic.

See page 132

Early marriage in India and its effect on women's reproductive health

Data from the third wave of the National Family Health Survey (2005–2006) was used to examine the effects of early marriage on the reproductive health status of women and on the well-being of the children. Early age at marriage has a detrimental effect on a woman's reproductive health status. Women married at an early age are exposed to frequent childbearing, unplanned motherhood and abortions. Children belonging to mothers with poor reproductive health have lower chances of survival and a higher likelihood of stunting, wasting and being underweight. The authors conclude that programmes are required to delay entry into motherhood and to meet the needs of poor adolescent mothers.

See page 136

Bridging emergency contraceptive users to more effective methods

Emergency contraceptive pills (ECPs) were introduced to prevent unwanted pregnancy in ‘emergency’ situations, such as non-use or incorrect use of a ‘regular’ contraceptive method. Much effort has gone into educating the public about this addition to our contraceptive options and to making the method more readily accessible to consumers (e.g. via over-the-counter purchases from pharmacies). While it was initially assumed that women would use ECPs only for rare ‘emergencies’ and that they would adopt/revert to the use of ongoing longer-term methods thereafter, this study by L’Engle et al. shows that this is not always so. Their study of Ghanaian women, who purchased ECPs from pharmacies, shows that the majority used ECPs as their regular method to avoid pregnancy, with more than half of the 24 study subjects having used it between four and seven times in the preceding 12 months. Ignorance and misconceptions about modern contraceptives, like pills and long-acting methods, and fear of side effects emerged as the main deterrents to adopting such methods. Future interventions need to focus on basic contraceptive education.

See page 146

Accessing GUM services in the UK

Sexual health remains a national priority but across the UK, the provision of sexual health services is not evenly distributed. What are the barriers to accessing care? While great improvement in timely access was observed following the introduction of the ‘48 hour’ target, there has been little focus on the geographical barriers to sexual health provision. This study investigates the physical aspect of accessibility, assessing how long it takes for individuals to reach their local sexual health clinic. In areas where access is challenging, the resultant impact on allied services (e.g. primary care) may be significant.

See page 152

Injection drug-using women and contraception and unplanned pregnancies

The issue of intravenous drug use in Russia remains a major concern, with women comprising up to 40% of the drug-using population. As yet, there has been little focus on the reproductive health needs of this vulnerable population. In this small study, over two-thirds of respondents had undergone an abortion. Following termination of pregnancy, none were using hormonal contraception or intrauterine devices. This finding highlights the need for greater pregnancy prevention strategies, delivered in combination with HIV/sexually transmitted infection avoidance policies, in this neglected group.

See page 158

Does HRT cause breast cancer? Part 2. The Women's Health Initiative: estrogen plus progestogen

Shapiro and colleagues continue their review of HRT and breast cancer studies, turning their attention to the Women's Health Initiative (WHI) results for combined therapy. They conclude that although it started out at as a double-blind randomised trial, this part of the WHI in effect became an observational study. By the end of the study just over 40% of women in the combined therapy arm of the trial had been ‘unblinded’ because of side effects, and the discontinuation rates were around 40%. They conclude that while it remains possible that the use of estrogen plus a progestogen may increase the risk of breast cancer, the WHI studies have not demonstrated that it does.

See page 165

Learning disability and contraceptive decision-making

Have you ever felt your heart sink when people with learning disability attend your service? This article in Sam Rowlands' occasional legal series gives a practical approach to operating within the new legal framework that governs those without mental capacity. Both testing for mental capacity and best interests are covered. Two cases are used to illustrate features of learning disability, taking into account possible interactions with the sexual partner. A table has been compiled to demonstrate how the courts view the so-called restrictiveness of different contraceptive methods. After reading this article you should feel better equipped when seeing women with learning disability.

See page 173

Mills and Boon versus the FPA?

While most women receive perhaps a few hours of formal sex education, the reader of romantic fiction can average one such book every 2 days. This means that our female clients in the consulting room are more likely to have been informed and inspired by Mills and Boon than by the Family Planning Association. In her latest article, the Journal's Consumer Correspondent, Susan Quilliam, examines the romantic fiction genre and what impact it has on female clients and hence on sexual health work in general. She argues that this genre is far less stereotyped than may first appear, but that below the surface it may well be doing more harm than good.

See page 179