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A bitter pill-scare

The thromboembolic risks associated with combined oral contraceptives are well known, but may not always be communicated effectively to potential pill users. In a cautionary tale about communication, consent, medicine and the media, Lucy Cox traces the French response to Marion Larat's successful lawsuit for damages following a pill-related embolic event. An initial over-response in France gave way to greater calm and clearer guidelines from the European Medicines Agency, but many French women remain wary of oral contraception. Meanwhile, Larat continues her campaign against the medical profession and against third- and fourth-generation pills. This offers a sharp reminder that preventing harms, maintaining trust, and containing costs require honest, evidence-based communication. See page 81

What is ‘sensitive’ disposal of fetal tissue after abortion?

Do you know what happens to the ‘products of conception' after abortion? In the UK, regulations on managing fetal tissue after pregnancy loss are underpinned by the concept of ‘sensitive disposal,' and include discussion of possible cremation and religious or other ceremonies. But surveying women who had undergone abortion, Myers and colleagues found that women themselves often had little knowledge of the fate of fetal tissue, or desire to be involved in decisions about its disposal. Particular anxiety was expressed by women undergoing medical abortion at home. The authors argue that policy and guidelines may need to be revised to reflect women's views. See page 84

Waiting for a yolk sac before TOP may be unnecessary

The high sensitivity of pregnancy tests enables women to seek termination soon after a missed period, and before a yolk sac – the gold standard of confirmed intrauterine pregnancy – is visible on ultrasound. This often results in repeat scans and delays for those seeking abortion. This audit of 1155 women provides early evidence that the combination of an eccentrically placed gestation sac, a decidual reaction, and the absence of risk factors or signs or symptoms of ectopic pregnancy, may be sufficient indicators to proceed to medical termination of pregnancy (TOP) without further delay. If confirmed in larger studies, these criteria could reduce waiting times and need for repeated scans in women seeking termination at very early gestation. See page 90

Contraceptive advice for UK women with sickle cell disease: improving but still not good

Pregnancy in women with sickle cell disease is associated with high maternal and fetal mortality and morbidity. This multicentre, cross-sectional study compared interview responses from 102 women with sickle cell disease in 2010 with those from an earlier 1993 study. The numbers of unplanned pregnancies and of women advised not to become pregnant appear to have declined, associated with with decreased use of combined oral contraceptive pills and increased use of depot medroxyprogesterone acetate and the levonorgestrel intrauterine system. However, over half the pregnancies in the 2010 survey remained unplanned, highlighting the need for further initiatives. See page 96

Female sex workers' reproductive rights should be recognised

Though risks for HIV and pregnancy are intimately intertwined, research on female sex workers (FSWs) has focused almost exclusively on disease prevention and transmission, overlooking these women's reproductive health needs and wants. FSWs are often negatively portrayed as ‘vectors of disease’, and rarely viewed in their role as parents. Shannon et al.'s cross-sectional study of on- and off-street FSWs finds their wishes in respect of motherhood differ little from women with other occupations, and concludes that FSWs' access to integrated sexual health services needs to be improved, and that this will require policy changes. See page 102

Norway may be paying dearly for patchy use of LARC

If you need further evidence regarding the cost-effectiveness of long-acting reversible contraception (LARC), look no further than the cost analysis by Henry et al., who report on the substantial costs of unintended pregnancy in Norway resulting from incorrect and inconsistent use of short-acting reversible contraception. They estimate that imperfect contraceptive adherence accounts for over 60% of unintended pregnancies in women aged 15–44 years and over 80% in the 15–24 years age group. Even a 5% switch to LARC can yield substantial cost savings with benefits for the consumer as well as the provider. See page 109

Levonorgestrel still leads for emergency contraception

The uptake of emergency contraception in a large sexual health service has previously been studied by Baird et al. The same authors revisit the question in this Journal issue following the introduction of revised FSRH guidance. Reviewing the number of clients choosing each of the three available methods, the authors find a significant increase in women being offered and choosing ulipristal acetate (UPA); however, the majority still chose levonorgestrel (LNG). This may have been due to the ability to quick-start or to continue hormonal contraception after LNG. The authors speculate that potential changes in advice on the need for extra contraceptive precautions following UPA could lead to greater acceptance of this method. See page 116

Asylum seekers need culturally competent FP services

Migrant women are often disadvantaged in sexual and reproductive health care. If migrant women are to receive best family planning (FP) support, understanding their sociocultural background is an essential prerequisite. But while Chinese people are amongst the nationalities most frequently receiving asylum in the UK, FP policies in the two countries are vastly different. Interviewing Mandarin speakers from mainland China in the West Midlands, Verran et al. identified practical and cultural challenges facing these women and their health care providers. Key issues include missing contraceptive cover during the journey from the country of origin, urgent need for services on arrival, ignorance about conception in unmarried women, expectations of mandatory contraception after childbirth, and fears relating to the effects of contraception on menstrual bleeding. Chinese asylum seekers saw postnatal care and Chinese friends as key sources of information, while primary health care support was deemed inadequate to support individual decision-making. See page 122

Abortion services should ask all women about domestic abuse

NICE guidelines require all antenatal services to ask about domestic abuse, and to be prepared to offer and provide women with support. Motta et al.'s study, undertaken in a large abortion service, complements studies of women who proceed with their pregnancy in reporting significant risks of domestic abuse during these early pregnancies. No characteristics are reliably associated with domestic abuse, indicating that all women should be asked about this problem. Three-quarters of respondents said they would welcome this. See page 128

Factors affecting absorption of information about HPV

Testing for human papillomavirus (HPV) infection is now integral to cervical screening programmes, but uptake of information can vary. Interviewing women to investigate barriers to their accessing and absorbing information about HPV, O'Connor et al. identified factors which affected how well these women's information needs were met. These included perceptions of medical professionals' attitudes, and being overwhelmed with information, while factors influencing their information needs included concerns about abnormal cytology and awareness of the sexually transmitted nature of HPV. While this study was conducted in a colposcopy setting, its findings invite wider reflection on provision of information within cervical screening services. See page 134

WHOMEC app is welcomed by clinicians

Have you ever struggled to recall whether a contraceptive method carries risks for your patient? You may pull up the UK or WHO Medical Eligibility Criteria (MEC) on your desktop computer, but now Castelo-Branco and colleagues in Barcelona have created an app for smartphones or tablets that computes the safety category of any contraceptive method when you input a patient's characteristics and medical conditions. It uses the WHOMEC, as distinct from UKMEC. The app was evaluated by 54 health care providers, of whom 96% were very satisfied. See page 142

Performance-based incentives may increase FP uptake

Performance-based incentives (PBIs), such as schemes where community distributors are offered financial incentives to recruit more users of contraception, have been explored as a strategy for improving FP uptake in several countries. A non-systematic review of both published and grey literature examining the use of PBIs in community-based FP programmes conducted in April 2013 finds some evidence of benefit. Of 28 community-based family planning programmes in 21 countries identified as having used PBIs, most used a sales commission model, while some used a referral payment model for long-term methods. Overall, the evidence for efficacy is mixed, but easy-to-understand PBIs can, it appears, increase the use of FP at the community level. But it is essential to consider the ethics of incentivising FP, and to ensure that PBIs enhance choice and not coercion, argue the authors. See page 146

Showcasing sexology

Would you spend a day at an exhibition about sex? Our Consumer Correspondent offers a brief guide to the Wellcome Trust's ‘The Institute of Sexology’ showcase, on in London until September 2015. From Freud to Krafft-Ebing, Masters and Johnson to Marie Stopes, this exhibition chronicles the science of sex and the achievements of its pioneers. Many struggled with opposition or even persecution, and deserve our gratitude. See page 152

Pills, plays, and philanthropy: a tribute to the maker of norethisterone

Hailed by many as the “father of the pill” because of his 1951 synthesis of norethindrone (norethisterone), Carl Djerassi was also known as an art collector, novelist, playwright and philanthropist. Norethisterone, whose synthesis was the initial step in the development of oral contraceptives, remains the mainstay for the progestogen component of oral contraceptives (other progestogens used for contraception resulted from minor chemical modifications). Lindsay Edouard's appreciation highlights the life of an extraordinary polymath, chemist, pharmacologist and humanitarian, playwright and art collector, who crossed the barriers between science and the arts, commerce and philanthropy.

His 1200-acre San Francisco cattle ranch named SMIP: “Steroids Made It Possible” and the Djerassi Resident Artists Program he founded are a testament to the breadth of Djerassi's vision. Whether the posthumous creation of a memorial monument on the National Mall in Washington DC named ‘Djerassic Park’ is to be realised, remains to be seen. See page 158

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