eLetters

60 e-Letters

  • 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.

  • Endometrial sampling has been undertaken for many years in some general practices.
    It was very pleasing to see a paper reporting a pilot study of Primary care endometrial sampling1as this was something I have been involved with over the last 25 years, although I was a little disappointed that there was no reference to some of the previous work on this subject in primary care2. I published two papers on the subject in 1998, The first considered the end of the operation Dilatation and Curettage (D & C) which until the 1990s had been the investigation of choice for abnormal uterine bleeding and the emergence of new techniques such as Pipelle sampling3. The second paper I published was entitled Endometrial sampling in general practice and was a case series of 38 women investigated for unexpected vaginal bleeding4. I had introduced the procedure to the Honiton Practice in 1993; having held the qualification for intrauterine techniques for many years and having acquired further training from the local gynaecology department and taken advice from the relevant defence unions. It was not part of General Medical Services then and under new general practice arrangements it was recognized as ‘provision of secondary care within primary care’ and remunerated. It is also important to realize that the current 2 week wait referral procedure did not exist and sometimes women with abnormal bleeding could w...
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  • Second doctor signature on HSA forms

    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.

  • 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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  • Comment on ‘Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England’

    Jonathan Lord, Lesley Regan and colleagues make a strong case for allowing home use of misoprostol in early medical abortion. Indeed it has been obvious for some years ever since the WHO reviewed research trials in various countries. Isn't this really the time to make both abortifacients, mifepristone and misoprostol, available off prescription?

    They are safe, reliable and easy to use. Complications requiring further medical attention after self-administration are only marginally more common than when supervised by medical staff. Dire results are rare. Is this the time to recognise that the present, medically supervised, regulated system has been outflanked by pharmaceutical technology?

    In fact abortion has become so easy that many women obviously prefer it to contraception. In 2017 approximately 74 000 abortions in England & Wales (39% of the total) were for women who had had at least one before. Whether or not repeated abortion by medical means in early pregnancy is undesirable or even harmful does not seem to have been established.

    Pills over the counter would be a popular innovation because it would enable a pregnant woman to achieve a termination more quickly and with greater privacy than now. She would, for example, not need to run the gauntlet of abortion protesters outside clinics.

    Of course there are snags and difficulties. It could not be done without a change in the laws which currently forbid self-induction of abortion and r...

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  • Home use of misoprostol: is it really safe and appreciated?

    Regarding the Scottish decision on home abortion of 26th October 2017, Lord J, Regan L, Kasliwal A, et al. claim that "Home use of misoprostol in Scotland is relatively new. The larger abortion services in Scotland report widescale uptake of home use of misoprostol among women and that it is highly appreciated with no negative impact on services." The Scottish “abortion services” consulted are not named and the reference for the bold claim that home use of misoprostol is “highly appreciated” is “S Cameron [co-author], personal communication 2018”. Such statements do not inspire confidence.

    In response to some other claims made in the article: women having better control over timing in practice will mean less precision in timing, since medical supervision is supposed to guarantee ‘correct’ time between drugs and a ‘correct’ route of administration, whether sublingual, buccal or vaginal. If these are departed from, the effectiveness goes down, and the complications go up. This is well-known.

    As regards travel and onset of bleeding, the Creinin paper [1] referred to by the authors had a bleeding onset median time of 2 hours for the standard (misoprostol taken 24 hours after mifepristone), and 3.7 hours when mifepristone and misoprostol were taken together. Others state that the onset of bleeding with the standard regimen was after 2 hours and meant light to moderate spotting at 4 hours after misoprostol [2]. Depending on the travel time, there m...

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  • Comment on "Barriers and facilitators of access to first-trimester abortion services for women in the developed world: a systematic review"
    Julie Ancian

    The article of Frances Doran and Susan Nancarrow [1] suggests that there is a need for more research about the barriers to access to abortion services in developed countries. I totally agree with this finding, especially for qualitative research, and would like to provide a point of view from France.

    As part of my doctoral research on the social determinants of reproductive health, I attended the trial of Domin...

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