We write in response to the article in the July 2012 issue of this
Journal by Shelley Mehigan and Janice Burnett entitled 'An innovative
training for nurses in sexual health'[1]. We agree wholeheartedly that a
nationally recognised, standardised training for nurses in sexual and
reproductive health is needed and that the best way forward may be for the
Faculty of Sexual and Reproductive Healthcare (FSRH) to accredit nurse...
We write in response to the article in the July 2012 issue of this
Journal by Shelley Mehigan and Janice Burnett entitled 'An innovative
training for nurses in sexual health'[1]. We agree wholeheartedly that a
nationally recognised, standardised training for nurses in sexual and
reproductive health is needed and that the best way forward may be for the
Faculty of Sexual and Reproductive Healthcare (FSRH) to accredit nurses or
to open up the Faculty Diploma (DFSRH) to nurses. Mehigan and Burnett warn
of the dangers of reinventing lots of different wheels. In Hull this is
exactly what we have done.
Previous training initiatives to increase the numbers of long-active
reversible contraception (LARC) providers within primary care proved
unsuccessful due to low numbers of nurses with the prerequisite
qualifications (i.e. a family planning qualification) necessary to access
LARC training. In addition, a training needs assessment demonstrated lack
of interest in undertaking a lengthy academic pathway to achieve family
planning status. To overcome these problems we worked in partnership with
commissioners and York St John University to develop a fast-track
contraceptive course with 30 credits at degree level to enable nurses to
counsel clients about all methods of contraception and to fit and remove
subdermal implants.
We do, however, disagree with Mehigan and Burnett about the value of
working with a university to ensure that the programme has academic
accreditation. Even if the Faculty does eventually accredit nurses and we
have a nationally recognised qualification thus standardising training
across the UK this will not help nurses with their career pathway in the
way that transferable academic credit can do. Nursing is now a degree and
masters level profession and any training and education needs to reflect I
the academic level of the knowledge and skills development involved.
Nurses within our service in Hull have undergone much training, which has
equipped them well in providing safe and effective care for their clients
but has left them short on academic qualifications and the credibility
which this brings. Working in true collaboration with a local university
to achieve academic accreditation has enabled us to maintain ownership of
our essentially practical skills-based course, but also given us access to
the expertise of educationalists in a higher educational institution to
ensure that our assessment processes are rigorous and appropriate. The
university, always needing to update its own practices, has benefitted
from the opportunity to work with practitioners who are at the forefront
of service enhancement. Without accreditation we would not have obtained
funding and approval from commissioners to provide this training, which we
anticipate will make a real difference to the high unplanned pregnancy
rates in our local area and demonstrate a tangible return on investment
for all stakeholders.
We are more than willing to work with Mehigan and Burnett or indeed
anyone else out there who is trying to reinvent wheels, but to do this
effectively we believe that it is important to share practice with
academic colleagues and avoid working in silos.
Reference
1. Mehigan S, Burnett J. An innovative training for nurses in sexual
health. J Fam Plann Reprod Health Care 2012;38:194-195.
May I congratulate the authors of the commentary describing
contraceptive options for women with systemic lupus erythematosis
(SLE).[1] This was a comprehensive summary and I was interested in their
views regarding the suitability of progestogen-only methods in women with
antiphospholipid antibodies. The authors felt these methods were unsafe in
such women (World Health Organization Medical Eligibility Criteria for
Contr...
May I congratulate the authors of the commentary describing
contraceptive options for women with systemic lupus erythematosis
(SLE).[1] This was a comprehensive summary and I was interested in their
views regarding the suitability of progestogen-only methods in women with
antiphospholipid antibodies. The authors felt these methods were unsafe in
such women (World Health Organization Medical Eligibility Criteria for
Contraceptive Use Category 3 - generally risks outweigh the benefits of
use). As up to 42% of women with SLE will be positive for these
antibodies[2] the authors are reducing contraceptive choice to barrier
methods, copper intrauterine devices or sterilisation.
About one-third of women with antiphospholipid antibodies develop a
venous thromboembolism (VTE) in their lifetime and this risk is further
increased in pregnancy and the puerperium.[2] Maternal mortality in women
suffering from SLE is thought to be 2-3%.[3] We now have good evidence
that progestogen-only contraceptive methods such as the levonorgestrel-
releasing intrauterine system and desogestrel pill do not increase the
risk of VTE in the general population.[4] A recent study also suggested
that oral pregnane progestogen contraceptives appear to have little effect
on the development of VTE in women with SLE (where 29.4% of 187 women had
detectable antiphospholipid antibodies).[5]
Perhaps the authors would like to provide an additional comment?
References
1 Culwell KR, Curtis KM. Contraception for women with systemic lupus
erythematosus. J Fam Plann Reprod Health Care 2013; 39:9-11.
2 Al-Homood IA. Thrombosis in systemic lupus erythematosus: a review
article. ISRN Rheumatol 2012;2012:428269. Epub 2012 Jul 30.
3 Iozza I, Cianci S, Di Natale A, Garofalo G, Giacobbe AM, Giorgio E,
De Oronzo MA, Politi S. Update on systemic lupus erythematosus pregnancy.
J Prenat Med 2010; 4(4):67-73.
4 Lidegaard O, Lokkegaard E, Svendsen AL, Agger C. Hormonal
contraception and risk of venous thromboembolism: national follow-up
study. BMJ 2009 Aug 13;339:b2890. doi: 10.1136/bmj.b2890.
5 Chabbert-Buffet N, Amoura Z, Scarabin PY, Frances C, Levy DP,
Galicier L, Wechsler B, Bletry O, Piette JC, Gompel A. Pregnane progestin
contraception in systemic lupus erythematosus: a longitudinal study of 187
patients. Contraception 2011;83:229-237.
Conflict of Interest:
The author has received financial support to attend pharmaceutical advisory board meetings, undertake research studies, speak at educational meetings and conferences along with travel grants from Astellas, Bayer, Consilient Healthcare, HRA Pharma, Merck, Pfizer and Vifor Pharma.
We thank Dr Mansour for her interest in our article[1] and for her
provocative questioning of the recommendations for use of progestogen-only
contraceptives by women with systemic lupus erythematosus (SLE) who test
positive for anti-phospholipid antibodies.[2] We are sensitive to any
reductions in choice of contraceptive methods, particularly for women in
whom pregnancy has significant health consequences, such as women w...
We thank Dr Mansour for her interest in our article[1] and for her
provocative questioning of the recommendations for use of progestogen-only
contraceptives by women with systemic lupus erythematosus (SLE) who test
positive for anti-phospholipid antibodies.[2] We are sensitive to any
reductions in choice of contraceptive methods, particularly for women in
whom pregnancy has significant health consequences, such as women with
SLE. As mentioned in our article, any considerations of contraceptive use
in women with SLE must be weighed against the alternative of pregnancy,
which brings many risks, particularly in women with active disease or
those with positive anti-phospholipid antibodies.
We would first like to clarify an apparent misunderstanding by Dr
Mansour that we believe that use of progestogen-only methods by women with
SLE and positive anti-phospholipid antibodies is "unsafe". The
recommendations included in our article are those which are in the World
Health Organization (WHO) Medical Eligibility Criteria for Contraceptive
Use (MEC)[3] and subsequent adaptations by the UK and USA. In these
recommendations, progestogen-only contraceptives, including progestogen-
only pills (POPs), injectables, implants and the levonorgestrel-releasing
intrauterine system (LNG IUS) are given a Category 3 rating, meaning the
risks usually outweigh the benefits. However, a Category 3 rating does not
automatically mean that this method should not be used in any
circumstance. The introduction to the 4th edition of the WHO MEC states:
"However, provision of a method to a woman with a condition classified as
Category 3 requires careful clinical judgement and access to clinical
services; for such a woman, the severity of the condition and the
availability, practicality, and acceptability of alternative methods
should be taken into account. For a method/condition classified as
Category 3, use of that method is not usually recommended unless other
more appropriate methods are not available or acceptable. Careful follow-
up will be required". In practice, this means that a woman with SLE and
positive anti-phospholipid antibodies could be offered progestogen-only
methods if more appropriate alternatives, such as a copper intrauterine
device (IUD), are unavailable or unacceptable to her. The decision about
which method is optimal for a particular woman would best be made through
consultation with a specialist, such as a family planning specialist
and/or a rheumatologist after thorough counselling regarding the potential
risks and benefits and careful follow-up. The WHO MEC goes on to say (p.
10): "Where resources for clinical judgement are limited, such as in
community-based services, the four category classification framework can
be simplified into two categories. With this simplification, a
classification of Category 3 indicates that a woman is not medically
eligible to use the method".
While we know that progestogen only methods don't carry the same risk
of thromboembolism as do methods containing estrogen, such as combined
oral contraceptives (COCs), the evidence is insufficient to conclude that
there is no risk of thromboembolism with progestogen-only methods. A
recent meta-analysis of eight observational trials found that evidence on
risk of venous thromboembolism (VTE) with use of progestogen-only methods
was limited but that there appeared to be no increased risk with POPs or
the LNG IUS, while there may be an increased risk with progestogen-only
injectables.[4] In addition, these studies were generally conducted among
healthy women without other risk factors for VTE. The only evidence we
have of use of progestogen-only methods by women with SLE is from the
randomised controlled trial by Sanchez-Guerrero et al., included in our
review, in which women were randomised to COC, POP or copper IUD use.[5]
There were four episodes of thromboembolism in the study, two in the COC
group and two in the POP group, with none in the group assigned to copper
IUD. All four of these patients were reported to have positive anti-
phospholipid antibodies. The incidence of thromboembolism was therefore
4.75/100 woman-years in the COC group and 5.44/100 woman-years in the POP
group. This study was not powered to detect a difference in the outcome of
thromboembolism between the groups.
Based on the best available evidence, we agree with the WHO MEC
recommendations of a Category 3 for use of progestogen-only contraceptives
for women with SLE and positive anti-phospholipid antibodies, but also
would agree that clinical judgment might lead to the use of progestogen-
only methods in these women following adequate counselling regarding the
risks, benefits and alternatives, including the alternative of non-use of
contraception and subsequent pregnancy.
References
1 Culwell KR, Curtis KM. Contraception for women with systemic lupus
erythematosus. J Fam Plann Reprod Health Care 2013;39:9-11.
2 Mansour D. Contraceptive options for women with SLE [Letter]. J Fam
Plann Reprod Health Care 2013; 8 January 2013 [Epub ahead of print].
3 World Health Organization. Medical Eligibility for Contraceptive
Use (4th edn). 2009.
http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf [accessed
19 December 2012].
4 Mantha S, Karp R, Raghavan V, et al. Assessing the risk of venous
thromboembolic events in women taking progestin-only contraception: a meta
-analysis. BMJ 2012. 345: e4944.
5 Sanchez-Guerrero J, Uribe AG, Jimenez-Santana L, et al. A trial of
contraceptive methods in women with systemic lupus erythematosus. N Engl J
Med 2005. 353:2539-2549.
Conflict of Interest:
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
The commentary by Horga et al.[1] on the consequences of Ceausescu's
attempt to ban abortion in Romania is a stark reminder of what happens
when women are prevented from accessing safe and legal means to end
problem pregnancies. In short, they end their pregnancies using means that
are unlawful and/or unsafe, sometimes with tragic consequences.
Although it is difficult to compare any country today with the
repre...
The commentary by Horga et al.[1] on the consequences of Ceausescu's
attempt to ban abortion in Romania is a stark reminder of what happens
when women are prevented from accessing safe and legal means to end
problem pregnancies. In short, they end their pregnancies using means that
are unlawful and/or unsafe, sometimes with tragic consequences.
Although it is difficult to compare any country today with the
repressive, restrictive climate of Romania in the 1960s and 1970s, a
reminder of the contribution that adequate birth control, including
abortion, makes to women's health is important. Politicians in Ireland -
and the UK, since abortion is still outlawed in the Northern Ireland
counties that it governs - would do well to take note.
The recent death of a woman who was denied a pregnancy termination in
Ireland[2] has focused international attention on its abortion ban. One
might ask why, when one considers Romania, there have not been more deaths
in Ireland? The answer is simple. Although abortion is unlawful in
Ireland, Irish women have found their own ways of accessing services.
For thousands of Irish women, the path to an abortion involves a
relatively cheap flight to Britain and treatment provided by a not-for-profit clinic run by a charity. At British Pregnancy Advisory Service
(bpas) clinics, especially in Liverpool, Birmingham and London, Irish
visitors are so 'normal' that a special range of literature is provided,
explaining how to care for themselves as they travel home.
Other women rely on the internet to obtain medicines that are safe
for them to use but illegal to obtain. Clearly, there are risks with
internet supply, not least that the medication may not be authentic, and
could even be harmful. Internet sites such as 'Women on Web'
(https://www.womenonweb.org/) have become a vital source of safe
medication for women living where safe, legal abortion is unavailable. And
the widespread availability of the abortifacient misoprostol as treatment
for gastric ulcers is another lifeline, especially where it is available
in local pharmacies.
Women still die from abortion bans. International agencies publish
estimates routinely. Governments record their horror and pledge to make
motherhood safer. At the London Summit on Family Planning in July 2012,
the Prime Minister responded to estimates that an unplanned pregnancy is
conceived every 10 seconds by announcing £500 million in aid to increase
international access to contraceptives.[3] He told government
representatives from around the world: "Women should be able to decide
freely, and for themselves, whether, when and how many children they have
... When a woman is prevented from choosing when to have children it's not
just a violation of her human rights, it can fundamentally compromise her
chances in life, and the opportunities for her children."[4]
Yet in Northern Ireland and Ireland, women are denied that choice
because they are denied access to abortion. European politicians find it
easy to understand the importance of safe contraception and abortion in
countries far away; they find it less easy to understand the importance of
reproductive choice in their own countries. Romania is a good European
example of why abortion bans should be regarded as being as perverse and
as archaic as the rest of Ceausescu's policies.
References
1 Horga M, Gerdts C, Potts M. The remarkable story of Romanian
women's struggle to manage their fertility. J Fam Plann Reprod Health Care
2013;39:2-4.
2 Houston M. Investigations begin into death of woman who was refused
an abortion. BMJ 2012;345:e7824.
3 Prime Minister's Speech on Family Planning. 11 July 2012.
http://www.number10.gov.uk/news/prime-ministers-speech-on-family-planning/
[accessed 15 January 2013].
4 Tran M. Rich countries pledge $2.6bn for family planning in global
south. 11 July 2012. http://www.guardian.co.uk/global-
development/2012/jul/11/rich-countries-pledge-family-planning-women
[accessed 15 January 2013].
I read with interest Dr MacGregor's letter[1] regarding the unusual
shape of a Mirena intrauterine system (IUS) following removal. From the
photograph it would appear that the capsule has become displaced and the
arms of the device enclosed within it.
We have seen a case of complete detachment of the capsule from the
frame, with unrecognised retention of the capsule within the uterine
cavity. This was only reco...
I read with interest Dr MacGregor's letter[1] regarding the unusual
shape of a Mirena intrauterine system (IUS) following removal. From the
photograph it would appear that the capsule has become displaced and the
arms of the device enclosed within it.
We have seen a case of complete detachment of the capsule from the
frame, with unrecognised retention of the capsule within the uterine
cavity. This was only recognised at hysteroscopy for investigation of
subsequent infertility.
This was described in the form of a letter to the British Journal of
Obstetrics and Gynaecology in 2008.[2]
It would seem prudent to check the integrity of the IUS at removal.
References
1 MacGregor A. An unusual shaped IUS. J Fam Plann Reprod Health Care
2013;39:64.
2 Forrest A, Amarakone I, Lord J. Retained hormone release capsule
following removal of Mirena intrauterine system. BJOG 2008;115:130-131.
I read the article by Briggs and colleagues[1] with interest as it
is, to my knowledge, the only study to assess the impact of the
implementation of the UK Medical Eligibility Criteria on general practice
prescribing of combined hormonal contraceptives (CHCs) in the UK. However,
I have a study limitation.
As the authors have stated, oral contraception can be accessed on
prescription from a general practitioner (...
I read the article by Briggs and colleagues[1] with interest as it
is, to my knowledge, the only study to assess the impact of the
implementation of the UK Medical Eligibility Criteria on general practice
prescribing of combined hormonal contraceptives (CHCs) in the UK. However,
I have a study limitation.
As the authors have stated, oral contraception can be accessed on
prescription from a general practitioner (GP) and these data are captured
in the therapy table in the General Practice Research Database (GPRD) -
the data source used by the investigators. However, CHCs can also be
obtained from National Health Service contraception clinics and these data
are not recorded in a patient's prescription history in GPRD. Women
registered with GPRD who have obtained their CHC from contraception
clinics will therefore not be identified as CHC users as part of this
study, leading to an underestimation in the number of CHC users aged 15-49
years. An estimated 413 000 women in England and 20 000 women in Wales
received oral contraception from a contraceptive clinic in 2011/2012 and
2010/2011 respectively.[2][3] Although these figures are not specifically
for CHCs, they illustrate that community contraceptive clinics play a
substantial role in the provision of contraception to women of
childbearing age.
In addition, those patients prescribed CHCs by their GP, and
therefore included in the study, are not likely to be sufficiently
representative of those patients who are prescribed CHCs from clinics. The
National Statistics Opinion Survey conducted during 2008/2009 showed that
during the 5 years prior to interview, a higher percentage of patients
aged 16-19 years accessed contraception through a community contraception
clinic rather than their GP or community practice nurse.[4] Conversely, a
larger percentage of older women obtained family planning services from
their GP.[4] As the patients accessing community contraceptive services
are in general younger, they may also be less likely to have certain
Category 3 or 4 risk factors (e.g. current smokers and previous smokers
aged 35 years or over). Furthermore, patients with risk factors such as
hypertension, migraine, stroke, ischaemic heart disease, dyslipidaemia and
migraine may be more likely to obtain contraception from their GP while
being monitored for these conditions.
The impact of this limitation is likely to have influenced the
estimation of the number of women using a CHC with a Category 3 or 4 risk
factor in the whole UK population.
References
1. Briggs PE, Praet CA, Humphreys SC, Zhao C. Impact of UK Medical
Eligibility Criteria implementation on prescribing of combined hormonal
contraceptives. J Fam Plann Reprod Health Care 2013;00:1-7.
doi:10.1136/jfprhc-2012-100376 [published Online First 7 January 2013].
2. Health and Social Care Information Centre, Lifestyles Statistics.
NHS Contraceptive Services: England 2011/12 Community Contraceptive
Clinics. Leeds, UK: NHS, 2012. http://www.ic.nhs.uk/article/2021/Website-
Search?productid=9063&q=NHS+Contraceptive+Services%3a+England&sort=Relevance&size=10&page=1&area=both#top
[accessed 12 January 2013].
3. Statistics for Wales. NHS Community Contraceptive Services in
Wales, 2011-12. Cardiff, UK: Welsh Government, 2012.
http://wales.gov.uk/topics/statistics/headlines/health2012/121129/?lang=en
[accessed 12 January 2013].
4. Lader D. Opinions Survey Report No. 41. Contraception and Sexual
Health, 2008/09. Newport, UK: Office for National Statistics; 2009.
http://www.statistics.gov.uk [accessed 12 January 2013].
Conflict of Interest:
The author is currently in receipt of a PhD Studentship from Cardiff University and is employed as a pharmacist researcher by a research consultancy that receives funding from pharmaceutical companies. In addition, the author is currently employed on a part-time basis as a community pharmacist for a large health and beauty group.
I read the letter on 'Early implant removal: an ethical dilemma' by
Bari et al.[1] in the January 2013 issue of the Journal with interest, a
great feeling of disappointment and I shared the feelings of alarm with
the authors. The piece reported a 29-year-old woman who was so
dissatisfied with her subdermal implant that she attempted removal herself
without anaesthetic and she broke the device. She had requested removal
f...
I read the letter on 'Early implant removal: an ethical dilemma' by
Bari et al.[1] in the January 2013 issue of the Journal with interest, a
great feeling of disappointment and I shared the feelings of alarm with
the authors. The piece reported a 29-year-old woman who was so
dissatisfied with her subdermal implant that she attempted removal herself
without anaesthetic and she broke the device. She had requested removal
from "several sexual health clinics" but had been turned away.
Refusing removal in this way will surely destroy the reputation of
this method and do great harm to the population of contraceptive seekers,
as well as the distressed user.
Some years back I worked in Indonesia (and several South Asian
countries) where women were often refused early cessation of a
contraceptive method. Consequently, in Indonesia especially, Norplant
developed a reputation for causing a high level of unwanted bleeding and
other undesirable side effects and uptake fell. Surely we must not make
the same mistake again here in Britain?
Reference
1. Bari S, Kulkarni U, Robinson G. Early implant removal: an ethical
dilemma. J Fam Plann Reprod Health Care 2013;39:64.
Conflict of Interest:
None disclosed, although the author does fit subdermal implants and intrauterine devices in general practice in England
On behalf of all the authors I would like to thank Sarah Holden for
her comments[1] on our recently published article.[2]
When designing the study, we recognised that the majority of women
receive their contraception from their general practitioner (GP). Our
study compares the prescribing habits of GPs in 2005 pre-UK Medical
Eligibility Criteria (pre-UKMEC) to those in 2010 (post-UKMEC).
On behalf of all the authors I would like to thank Sarah Holden for
her comments[1] on our recently published article.[2]
When designing the study, we recognised that the majority of women
receive their contraception from their general practitioner (GP). Our
study compares the prescribing habits of GPs in 2005 pre-UK Medical
Eligibility Criteria (pre-UKMEC) to those in 2010 (post-UKMEC).
Whilst the authors realise that this does not reflect total
contraceptive usage in the UK, it does compare women prescribed combined
hormonal contraceptives (CHCs) by their GPs in 2005 to a similar group of
women in 2010. Consequently we presume that we are comparing 'apples' with
'apples' and therefore our conclusion that there was "a reduction in
prescribing of CHCs to higher-risk women after publication of UKMEC, a
large number of women with Category 3 or 4 risk factors are still
prescribed CHCs" is valid and is worth publicising to the reproductive
health clinical community.
References
1. Holden SE. Comment on 'Impact of UK Medical Eligibility Criteria
implementation on prescribing of combined hormonal contraceptives'. J Fam
Plann Reprod Health Care 2013;00:1. doi:10.1136/jfprhc-2013-100627.
2. Briggs PE, Praet CA, Humphreys SC, et al. Impact of UK Medical
Eligibility Criteria implementation on prescribing of combined hormonal
contraceptives. J Fam Plann Reprod Health Care 2013;39:1-7. Published
Online First 7 January 2013. doi:10.1136/jfprhc-2012-100376.
I read with interest Anne MacGregor's letter in the January 2013
issue of the Journal describing the removal of an unusually shaped
intrauterine system (IUS) and asking if others have had similar
experiences.[1]
A couple of years ago I too was alarmed as I removed an IUS through a
slightly tight cervical os and noted an odd shape. On closer inspection
the device was removed intact but as in Dr MacGregor's case t...
I read with interest Anne MacGregor's letter in the January 2013
issue of the Journal describing the removal of an unusually shaped
intrauterine system (IUS) and asking if others have had similar
experiences.[1]
A couple of years ago I too was alarmed as I removed an IUS through a
slightly tight cervical os and noted an odd shape. On closer inspection
the device was removed intact but as in Dr MacGregor's case the hormonal
sheath bad slipped down the plastic shank thus folding in the arms. In
this case, the sheath had actually come much closer to being totally
detached.
At the time I was looking through some back journal issues and
fortuitously came across a letter in the Faculty Journal[2] written in
2009 by Emma Torbe et al. describing two other similar events. Since these
events occurred years apart it cannot be assumed that this was just one
faulty batch of devices, and it would appear that it is something that one
needs to be aware does occasionally happen. It highlights the importance
of examining the device when it is removed and knowing what the original
device was. I have removed quite a few Nova-Ts that have been in situ for
too long and have become 'denuded' of copper. The appearance would be very
similar to a 'denuded' IUS. The difference is important since no action
would be needed in the case of the Nova-T, however further investigation
to locate the missing sheath would be necessary in the case of an IUS.
I have kept the misshapen IUS in a specimen bottle as a training aid!
References
1. MacGregor A. An unusual shaped IUS. J Fam Plann Reprod Health
Care 2013;39:64.
2. Torbe EJV, Eddowes H, Aston K. Missing IUS arms? J Fam Plann
Reprod Health Care 2009;35:131.
As with McKay and Gilbert[1] in Cambridge, UK, we also developed an
emergency contraception (EC) algorithm following the introduction of
ulipristal acetate (UPA), likewise recognising that fitting an
intrauterine device (IUD) was the 'gold standard'. Our ongoing experience
is rather different, however, in that our rates of emergency IUD fitting
have increased since the introduction of our algorithm from 6% to at least
9%...
As with McKay and Gilbert[1] in Cambridge, UK, we also developed an
emergency contraception (EC) algorithm following the introduction of
ulipristal acetate (UPA), likewise recognising that fitting an
intrauterine device (IUD) was the 'gold standard'. Our ongoing experience
is rather different, however, in that our rates of emergency IUD fitting
have increased since the introduction of our algorithm from 6% to at least
9%.
Within the Department of Sexual and Reproductive Healthcare in
Aneurin Bevan Health Board (South Wales), 6% (17/270) of clients leaving
the clinic with a method of EC in 2011 had an IUD fitted. Our service is
different to the one in Cambridge in that our clients can usually have an
IUD fitted on the day of presentation providing there is an IUD fitter in
clinic. Thus a second appointment is not needed.
Although there is no recognised standard for the percentage of
emergency IUDs fitted, Schwarz et al.[2] found that 12% of women attending
a walk-in clinic for either pregnancy testing or EC would consider same-day fitting of an IUD, and a further 22% expressed interest in having
further information about the IUD, suggesting that our emergency IUD
insertion rates could be improved. We therefore ran a teaching session in
January 2012 to emphasise the efficacy and benefits of emergency IUDs to
nursing staff, and between March and May 2012 introduced our algorithm for
EC, including the use of UPA. Our algorithm is similar to that used in
Cambridge but we consider the high risk time for conception to be Days 10-15 of the cycle, and our algorithm is designed so that staff must record
that they have discussed the emergency IUD. In the 3 months following the
intensive teaching programme our rate of emergency IUD use increased to
11.8%. Disappointingly, however, for the 9 months to the end of 2012 the
rate dropped to an average of 9%.
We audited the notes of all clients given EC between May and July
2012 and found that 31% of clients had been inaccurately recorded as
unsuitable for the IUD. In a further 11% of cases we could not assess
suitability for an IUD from the information provided. Consequently,
further teaching was undertaken to explain to staff when clients may have
an emergency IUD fitted, and the clinical proforma was amended so that
staff had to give reasons why the client was unsuitable for an IUD.
An audit for the first 3 months of 2013 demonstrates a small increase
in emergency IUD use to 10.5%. As well as being encouraging, this suggests
that clinician advice to clients is influential in their choice of EC. As
many of our clients have little or no knowledge of the emergency IUD[3,4]
and a possibly inflated estimate of the effectiveness of oral EC,[5] it is
also incumbent upon the clinician to give appropriate risk management
advice.[6]
In summary, our experience of introducing a new EC pathway that
includes UPA has been an increase in the rate of clients using emergency
IUD contraception from 6% to at least 9%. It is noteworthy that our
initial rate of emergency IUD use was initially far lower than in
Cambridge but our current endpoint is similar. We will continue auditing
emergency IUD use to see if we can sustain, or improve on, our current
usage. If this small effect were to be replicated nationally, this would
constitute a clinically important increase in long-acting reversible
contraception use and more cost-effective contraception[7] - a definite
bonus in these financially stretched times.
References
1. McKay RJ, Gilbert L. An emergency contraception algorithm based on
risk assessment: changes in clinicians' practice and patients' choices. J
Fam Plann Reprod Health Care 2013:39:1-7. doi.10.1136/jfprhc-2012-100495.
2. Schwarz EB, Kavanaugh M, Douglas E, et al. Interest in
intrauterine contraception among seekers of emergency contraception and
pregnancy testing. Obstet Gynecol 2009;113:833-839.
3. Wright RL, Frost CJ, Turok DK. A qualitative exploration of
emergency contraception users' willingness to select the copper IUD.
Contraception 2012;85:32-35.
4. Lader D. Opinions Survey Report No. 41, Contraception and Sexual
Health 2008/9. http://www.ons.gov.uk/ons/rel/lifestyles/contraception-and-
sexual-health/2008-09/2008-09.pdf [accessed 24 April 2013].
5. Bharadwaj P, Saxton J, Mann SC, et al. What influences young women
to choose between the emergency contraceptive pill and an intrauterine
device? A qualitative study. Eur J Contracept Reprod Health Care
2011;16:201-209. doi:10.3109/13625187.2001.565891.
6. Braybrook S, Ahmed H, Cogswell C, et al. Communicating risk about
emergency contraception. Gynaecology Forum 2013;(in press).
7. National Institute for Health and Clinical Excellence. Long-acting
Reversible Contraception. 1995.
http://guidance.nice.org.uk/CG30/Guidance/pdf/English [accessed 24 April
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Conflict of Interest:
The Department of Sexual and Reproductive Healthcare in Aneurin Bevan Health Board has received sponsorship for clinical meetings from Durbin, Bayer Healthcare, HRA Pharma and MSD Women's Health. Dr Cogswell has received honoraria from MSD Women's Health and Bayer Healthcare. Dr Lipetz has received honoraria from Bayer Healthcare and MSD Women's Health.
We write in response to the article in the July 2012 issue of this Journal by Shelley Mehigan and Janice Burnett entitled 'An innovative training for nurses in sexual health'[1]. We agree wholeheartedly that a nationally recognised, standardised training for nurses in sexual and reproductive health is needed and that the best way forward may be for the Faculty of Sexual and Reproductive Healthcare (FSRH) to accredit nurse...
May I congratulate the authors of the commentary describing contraceptive options for women with systemic lupus erythematosis (SLE).[1] This was a comprehensive summary and I was interested in their views regarding the suitability of progestogen-only methods in women with antiphospholipid antibodies. The authors felt these methods were unsafe in such women (World Health Organization Medical Eligibility Criteria for Contr...
We thank Dr Mansour for her interest in our article[1] and for her provocative questioning of the recommendations for use of progestogen-only contraceptives by women with systemic lupus erythematosus (SLE) who test positive for anti-phospholipid antibodies.[2] We are sensitive to any reductions in choice of contraceptive methods, particularly for women in whom pregnancy has significant health consequences, such as women w...
The commentary by Horga et al.[1] on the consequences of Ceausescu's attempt to ban abortion in Romania is a stark reminder of what happens when women are prevented from accessing safe and legal means to end problem pregnancies. In short, they end their pregnancies using means that are unlawful and/or unsafe, sometimes with tragic consequences.
Although it is difficult to compare any country today with the repre...
I read with interest Dr MacGregor's letter[1] regarding the unusual shape of a Mirena intrauterine system (IUS) following removal. From the photograph it would appear that the capsule has become displaced and the arms of the device enclosed within it.
We have seen a case of complete detachment of the capsule from the frame, with unrecognised retention of the capsule within the uterine cavity. This was only reco...
I read the article by Briggs and colleagues[1] with interest as it is, to my knowledge, the only study to assess the impact of the implementation of the UK Medical Eligibility Criteria on general practice prescribing of combined hormonal contraceptives (CHCs) in the UK. However, I have a study limitation.
As the authors have stated, oral contraception can be accessed on prescription from a general practitioner (...
I read the letter on 'Early implant removal: an ethical dilemma' by Bari et al.[1] in the January 2013 issue of the Journal with interest, a great feeling of disappointment and I shared the feelings of alarm with the authors. The piece reported a 29-year-old woman who was so dissatisfied with her subdermal implant that she attempted removal herself without anaesthetic and she broke the device. She had requested removal f...
On behalf of all the authors I would like to thank Sarah Holden for her comments[1] on our recently published article.[2]
When designing the study, we recognised that the majority of women receive their contraception from their general practitioner (GP). Our study compares the prescribing habits of GPs in 2005 pre-UK Medical Eligibility Criteria (pre-UKMEC) to those in 2010 (post-UKMEC).
Whilst the aut...
I read with interest Anne MacGregor's letter in the January 2013 issue of the Journal describing the removal of an unusually shaped intrauterine system (IUS) and asking if others have had similar experiences.[1]
A couple of years ago I too was alarmed as I removed an IUS through a slightly tight cervical os and noted an odd shape. On closer inspection the device was removed intact but as in Dr MacGregor's case t...
As with McKay and Gilbert[1] in Cambridge, UK, we also developed an emergency contraception (EC) algorithm following the introduction of ulipristal acetate (UPA), likewise recognising that fitting an intrauterine device (IUD) was the 'gold standard'. Our ongoing experience is rather different, however, in that our rates of emergency IUD fitting have increased since the introduction of our algorithm from 6% to at least 9%...
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