65 e-Letters

  • Implementation details deserve attention

    I am delighted to see the psychometrically validated Desire to Avoid Pregnancy (DAP) scale assessed for clinical use. A low DAP score from the 14-item scale was known to be highly predictive of future pregnancy, and this study adds information on the predictive value of single DAP questions and groups of 2, 3, 4, or 6 DAP questions, which could be more clinically feasible than the 14-item scale. I agree with the authors’ conclusion that these shortened DAP-based strategies are worth studying for their clinical acceptability. I write to make a plea for attention to implementation details.

    There are many available clinical tools to support reproductive health assessment and counseling, and I would challenge the authors’ statement that One Key Question (OKQ) is frequently the least favored option and that it is not feasible in the UK. There is more research on how OKQ performs when implemented in practice (especially in primary care) than other tools. My colleagues and I published a systematic review of English-language preconception, interconception, and reproductive health screening tools that could be applied in US clinical practice (1). We found 22 tools or standardized approaches from which clinicians can choose, and there are potential pros and cons of each. Studies have explored patient and clinician preferences, perceptions of feasibility and acceptability, and a few have examined if or how care and outcomes change when clinicians implement these tools. The th...

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  • Early telemedical abortion, safeguarding, and under 18s

    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...

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  • Re Article in January 22 BMJ SRH

    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...

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  • Policy for all early pregnancy loss

    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.

  • Author response to 'Concerns about high grade HPV results on routine smear tests'.

    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...

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  • Concerns about high grade HPV results on routine smear tests.

    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...

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  • Supplementary vs Table 2 data

    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.

  • Regular Contraception user requests declined over the 5 years - another reflection of reduced access to sexual health clinics and GPS?

    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.

  • A better way to judge fertility awareness, and the need for a better app

    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...

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