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...
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 clients. They run targeted Facebook and Instagram adverts and get support from trusted social media influencers, favourable press articles and others.
Still, it is worth remembering that prescribed medication is also not free of commercial influence. As Ben Goldacre describes in Bad Pharma, not being able to advertise direct to consumers simply means Big Pharma concentrates on selling direct to trusted health professionals, researchers and influencers through educational events, smooth sales reps, research grants, lobbying and other methods.
Another issue is the lack of transparency about the Natural Cycles algorithm. There has been decades of research about fertility awareness. It is a shame that they are not adding to this in a more meaningful way – or even acknowledging it, simply saying that they have “invented” an algorithm, as if it has come out of thin air and not decades of research about different algorithms.
It is also worrying that their algorithm seems to have a “one-size-fits-all” approach. Fertility is not an on/off switch. There are days on which pregnancy is very likely, days on which it is likely and days on which it is very unlikely or impossible.
Some women use fertility awareness in a very cautious “life or death” way – not having unprotected sex till after ovulation has been and gone.
Others are more willing to push the boundaries – depending on our cycles and on how we feel about unplanned pregnancy – and our age. A woman of 48 might choose to be less cautious than she was aged 38, or even 44.
We also use different fertility indicators. Some of us use temperature and ovulation sticks (in the style of Natural Cycles). Many women find temperature and fluid more convenient, or simply fluid and/or calendar calculations.
A better fertility app would have a transparent algorithm that allows women to choose the approach that suits them. It would also open up the data (in anonymised form) to researchers. This is not only an important contraceptive option, it is important knowledge. We should have an NHS app for this - not a private one.
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...
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 require each to be approved by two doctors. The control and supervision of this procedure by medical staff would be greatly reduced. Identifying other medical conditions would also be less frequent. A few women might use the drugs in late pregnancy, when the foetus was already viable, but they can do this already. Statisticians, without a medical certificate for every abortion, would have to make estimates.
Making such a radical change in the present parliament would not be easy but it might help British society catch up with the reality that these pills are available fairly cheaply, world-wide, right now. If most women could manage the whole process themselves it would be a further step towards equality with men.
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;44:155–158.
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...
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 may be some women who would begin bleeding on the way home from a clinic. However, 30-40% of women will begin bleeding after mifepristone and before misoprostol in any case, and the chance that the abortion would occur on the way home would normally be slim.
If travel time is greater than a couple of hours, it is surely in any case risky to offer a woman misoprostol to take at home because by the same token she would presumably have difficulty accessing emergency care. Rural women without easy access to emergency care are not candidates for medical abortion. This is so whatever our views about whether abortion more generally is in fact ‘care’ or ‘treatment’ for the woman [3], given that her pregnancy is not a disease. We should also bear in mind that ambivalence in women about the abortion decision is common [4] and associated with regret [5]. Indeed, some women having medical abortions refuse to take misoprostol after mifepristone, whereupon the foetus may be found to be still alive, and born without adverse effects [6].
Nor is it clear as to why there should be better emotional support for a woman who takes misoprostol at home rather than at a clinic. Either way, the abortion will happen at home, and if, for example, a partner or family are going to provide emotional support at all to the woman as she loses the baby, there are multiple ways that they can do so. If misoprostol is taken at home, we must face the fact that not only will some women get no support at all but the ‘support’ they will get may be pressure to abort (bearing in mind the strong link between abortion and intimate partner violence ) [7].
A Scottish trial in 2010 surveyed women’s responses and experience of returning home immediately after the administration of misoprostol to abort. 100 out of 145 women answered the survey (making one wonder why 45 did not respond). 12 of the 100 responded that they were extremely upset by the experience. 8 out of 100 were home alone at the time of the abortion [8].
Removing a second visit to take misoprostol, with an increase in complications and side effects, could have a significant impact on resources because of the severity of some of the complications.
It is somewhat ironic that the authors refer to the paper by Lohr et al , which highlights the increased risk of complications when women take mifepristone and misoprostol simultaneously. Lord et al. [9]claim that because 85% of women choose to take misoprostol and mifepristone at the same time at the clinic, this demonstrates “how much of a barrier access is for many women.” Instead, we think it shows two different things. First, that BPAS is prepared to offer a less effective and more risky regimen that they know significantly increases harm to women (perhaps as a wedge to use in campaigning for home abortions?) And second, rather than choosing simultaneous drug taking because of access barriers, we think it just as likely that women choose simultaneous use because all they want is for the horrible process to be over sooner.
The experience is clearly unpleasant with high percentages of women experiencing a lot of pain, excess bleeding, cramps, chills, vomiting, diarrhoea, nausea, dizziness, weakness, fever, and headache. Some figures for these from the three key US trials are as follows: listed as very common (>10%) by the manufacturer of Mifegymiso (mifepristone plus misoprostol) include nausea (30.7 - 69.2%), vomiting (22.3 - 34.1%), diarrhea (31.8 - 58.6%), pain (91.6%), fever (21.3 – 44.3%), chills (36.5 – 44.3%), headache (12.3 – 42%), dizziness 13.1 – 45.5%), and weakness (19.2 – 56.6%). We wonder how many women undergoing this ordeal, many of whom would have been emotionally conflicted about the abortion, were offered help at any stage to have their baby.
I am grateful to Dr Greg Pike for the use of his research materials.
[1] Creinin M et al. (2007) Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion. A randomized controlled trial. Obstet. Gynecol. 109(4):885-894.
[2] Sitruk-Ware R (2006) Mifepristone and misoprostol sequential regimen side effects, complications and safety. Contraception 74:48-55.
[3] McCarthy A (2018). Abortion Matters. Philos Educational Publications.
[4] Kero A, Högberg U, Jacobsson L & Lalos A (2001) Legal abortion: a painful necessity. Social Science and Medicine 53:1481-1490.
[5] Kero A, Högberg U & Lalos A (2004); Wellbeing and mental growth – long-term effects of legal abortion. Social Science and Medicine 58:2559- 2569.
[6] Delgado G et al. (2018) A case series detailing the successful reversal of the effects of mifepristone using progesterone. Issues in Law & Medicine.33(1): 1-12.
[7] Pallitto CC, García-Moreno C, Jansen HAFM, Heise L, Ellsberg M & Watts C (2013) Intimate partner violence, abortion, and unintended pregnancy: results from the WHO Multi-country Study on Women’s Health and Domestic Violence. Int J Gynecology Obstetrics 120:3-9.
[8] Cameron S et al. (2010) Women’s experiences of the final stage of early medical abortion at home: results of a pilot survey. J Fam Plann Reprod Health Care 36(4): 213–216.
[9] Lohr PA, Wade J, Riley, et al. Women’s opinions on the home management of early medical abortion in the UK. J Fam Plann Reprod Health Care 2010; 36:21-5.
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...
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 Dominique Cottrez, a woman
who killed eight of her newborns and was jailed for 9 years on July 3rd in
Douai (North of France). This kind of child homicide has to be referred to
as neonaticide, which is characterized by an unwanted and concealed
pregnancy, solitary delivery and without prior mental illness [2].
Recognizing the specificities of neonaticide allows us to situate
these acts in connection with the issue of fertility control. From a
sociological perspective, neonaticide constitutes an illuminating case to
analyze reproductive behaviours by the margins. Dominique Cottrez has
herself explained that her crimes were a means of birth control. She
discussed her phobia of doctors, due to both her obesity and the traumatic
experience during the birth of her first child at the hospital, because
the caregivers were chiding and hurtful to her. A phobia that prevented
her from consulting for contraception or abortion.
In other cases of neonaticide, the women I interviewed also explained
that they had encountered barriers to access abortion: difficulties to
organize or afford a travel to the health facilities, fear to confront the
medical staff, lack of information on the existence of family planning
services and also lack of availability to organize a consultation within
the legal deadlines. The burden of daily housework for women, especially
single mothers in rural areas, with limited health literacy, appears to be
a barrier to abortion.
These obstacles are well known and documented in many developing
countries [3]. However, in developed countries, or at least in France, the
idea prevails that universal access to contraception and abortion allows
any women to make their own reproductive choices [4]. Further research
therefore appears necessary to specifically study the upstream constraints
on women's autonomy in decision-making for reproductive matters, well
before the entry into the health system.
References :
1. Doran F, Nancarrow S. Barriers and facilitators of access to first
-trimester abortion services for women in the developed world: a
systematic review. J Fam Plann Reprod Health Care 2015; 41:170-180.
2. Friedman S. H, McCue Horwitz S, Resnick P. J. Child murder by
mothers: A critical analysis of the current state of knowledge and a
research agenda. Am J Psychiatry 2005; 162:1578-1587.
3. WHO, Social determinants of sexual and reproductive health:
Informing future research and programme implementation, Geneva, 2010.
4. Bajos N, Ferrand M. De l'interdiction au controle: les enjeux
contemporains de la legalisation de l'avortement. Revue francaise des
affaires sociales 2011; 1:42-60.
Counseling is voluntary by definition. A person being 'counseled' can
leave at any time and without any consequences. If 'counseling' is
mandatory it becomes in fact a state ordered instruction. Like for example
in the case of obligatory military service.
We as society should at least have the courage to name things with their
correct terminology. And not pretend to 'counsel' women if in fact we
force them to listen to an...
Counseling is voluntary by definition. A person being 'counseled' can
leave at any time and without any consequences. If 'counseling' is
mandatory it becomes in fact a state ordered instruction. Like for example
in the case of obligatory military service.
We as society should at least have the courage to name things with their
correct terminology. And not pretend to 'counsel' women if in fact we
force them to listen to an instruction, simply because they do not act
according to the social expectation.
It was interesting to read Sharon Moses' thoughtful commentary
questioning the role of an 'express' contraceptive service in a community
sexual health clinic and advocating improving contraceptive provision in
primary care, the primary provider of contraception in the UK.[1] My
colleagues in Newcastle, however, support this service innovation as they
feel that women in their late teens and early twenties have been
overl...
It was interesting to read Sharon Moses' thoughtful commentary
questioning the role of an 'express' contraceptive service in a community
sexual health clinic and advocating improving contraceptive provision in
primary care, the primary provider of contraception in the UK.[1] My
colleagues in Newcastle, however, support this service innovation as they
feel that women in their late teens and early twenties have been
overlooked in the process of sexual health service integration and are at
risk of unplanned pregnancy. A number of women attending our sexual health
walk-in clinics had had to wait several hours to receive further pills or
their injection. Given an 'express' service for asymptomatic sexually
transmitted infection (STI) screening, is it not reasonable to offer a
similar service for those needing further contraceptive supplies?
The separation of sexual health commissioning in England has led to
women aged 20+ years finding it difficult to access 'same-day'
contraceptive help. Due to the increase in primary care workload, many
women report being unable to see their general practitioner (GP) or
practice nurse for several days and then are provided with unsuitable
appointment times. A growing number of GP practices are no longer
providing comprehensive contraceptive care due to pressure of work and
withdrawal of long-acting reversible contraception (LARC) contracts.
Integration of sexual health services may work for the young, those
at risk of STIs and some vulnerable groups but not those who work, have
young children, are from a number of the black and minority ethnic
communities, or at low risk of STIs and are requesting further
contraceptive supplies. In Newcastle we have a protected number of
'contraceptive' appointments otherwise we would be overrun with those
requesting help with 'STI issues' that frequently are not STI-related but
fall into the category of 'primary care' urology, dermatology and
gynaecology problems. Patients are quick to learn that sexual health
services provide walk-in clinics where patients can be seen that day and
treatment is dispensed free of charge for 'STI' problems.
The setting up of an 'express' contraceptive clinic[2] is not
'dumbing down' of a service or failing to provide high-level 'sexual
health provision' as these services will identify those who would benefit
from STI testing and meet the needs of those who are being failed by the
current pressures placed on our National Health Service.
References
1. Moses S. Mini-Commentary on 'Would an exclusive contraceptive
clinic help meet the needs of patients attending an integrated sexual
health clinic?' J Fam Plann Reprod Health Care 2015;41:312-313.
2. Percy LA. Would an exclusively contraceptive clinic help meet the
needs of patients attending an integrated sexual health service? J Fam
Plann Reprod Health Care 2015;41:309-311.
Conflict of Interest:
Dr Mansour has received financial support to attend pharmaceutical advisory board meetings, undertake research studies, speak at educational meetings and conferences, and travel grants from Astellas, Bayer, Consilient Healthcare, HRA Pharma, Merck, Pfizer and Vifor Pharma.
We thank Dr Kell and Ms McMahon for their comments[1] on our
article[2] and for sharing their experience of running an abortion service
from a community setting. It is reassuring to learn that both staff and
patients welcomed this service and that contraceptive provision and
sexually transmitted infection diagnosis have improved as a result. We
hope other clinicians providing abortion care services may be encouraged
to c...
We thank Dr Kell and Ms McMahon for their comments[1] on our
article[2] and for sharing their experience of running an abortion service
from a community setting. It is reassuring to learn that both staff and
patients welcomed this service and that contraceptive provision and
sexually transmitted infection diagnosis have improved as a result. We
hope other clinicians providing abortion care services may be encouraged
to consider the potential benefits of providing such services from a
community setting.
References
1. Kell P, McMahon K. Comment on 'Abortion care services delivered
from a community sexual and reproductive health setting: views of health
care professionals'. J Fam Plann Reprod Health Care
2014;doi:10.1136/jfprhc-2013-100863.
2. Michie L, Cameron ST, Glasier A. Abortion care services delivered
from a community sexual and reproductive health setting: views of health
care professionals. J Fam Plann Reprod Health Care 2013;39:270-275.
We thank to Dr Pillai for her letter[1] about our review article
entitled "Practical advice of pain associated with insertion of
intrauterine contraceptives".[2] We would like to make the following
comments regarding the specific points Dr Pillai raised in her letter.
1. Dr Pillai suggests that clinicians may wish to sit on a stool with
wheels at the side of the couch rather than with the woman at the end of
the...
We thank to Dr Pillai for her letter[1] about our review article
entitled "Practical advice of pain associated with insertion of
intrauterine contraceptives".[2] We would like to make the following
comments regarding the specific points Dr Pillai raised in her letter.
1. Dr Pillai suggests that clinicians may wish to sit on a stool with
wheels at the side of the couch rather than with the woman at the end of
the couch. This still means that clinicians need to sit at the side of the
couch, thereby twisting their backs when fitting an intrauterine
contraceptive (IUC). This may be personal preference for some but not
ideal for others. Many healthcare professionals (HCP) prefer to sit in
front of the woman for the reasons given in our review and electric
lithotomy couches are not available in many clinics.
2. We are aware that some HCPs do not to use tenaculums to stabilise
the cervix when fitting IUCs, however it is standard practice to recommend
their use to avoid uterine perforation. However, using a tenaculum may
induce pain, which could be avoided by an experienced HCP in cases where
the cervix presents easily and the cervical canal is open and thus does
not present a resistance for IUC insertion. We are also unaware of
evidence supporting the routine use of ultrasound scanning when fitting
IUCs with many HCPs unable to access this facility and, if implemented,
would greatly increase costs and reduce access to IUCs.
3. We described atraumatic tenaculums that gently grip rather than
puncturing the cervix. This can be achieved by gently holding the forceps
rather than locking the handles together. Additionally we also suggested
the use of Judd-Allis forceps.
4. We agree with Dr Pillai's approach to finding the cervical canal
but reiterate that routine use of ultrasound is not possible for many
HCPs.
5. We also agree with Dr Pillai's use of the os finder to open a
partially stenosed external os and the suggestion to use tapered dilators
to help dilate the internal os if available.
6. We describe both intracervical and paracervical blocks in our
review2 along with the advantages of using a dental syringe and needle. We
agree that the latter could be given laterally at the base of the cervix
or via the cervical canal. There is no strong evidence that lidocaine gel
or intrauterine infusion of lidocaine works and we reference the key
studies. Dr Pillai's advice regarding filling the uterine cavity with
anaesthetic gel following IUC removal and prior to inserting a new one is
interesting and requires further study.
References
1. Pillai M. Comment on 'Practical advice for avoidance of pain
associated with insertion of intrauterine contraceptives'. J Fam Plann
Reprod Health Care 2014;doi:10.1136/jfprhc-2013-100848.
2. Bahamondes L, Mansour D, Fiala C, Kaunitz AM, Gemzell-Danielsson
K. Practical advice for avoidance of pain associated with insertion of
intrauterine contraceptives. J Fam Plann Reprod Health Care 2014;40:54-60.
Congratulations are due to the authors for producing much needed
guidelines.[1] These are necessarily a consensus owing to the lack of
quality studies on pharmacological interventions. Since 2009 I have
provided a referral service for intrauterine device (IUD) problems, and
currently manage 400-500 referrals per year for failed insertion or
removal, or a history of severe pain and/or vasovagal syncope (VVS). Women
referr...
Congratulations are due to the authors for producing much needed
guidelines.[1] These are necessarily a consensus owing to the lack of
quality studies on pharmacological interventions. Since 2009 I have
provided a referral service for intrauterine device (IUD) problems, and
currently manage 400-500 referrals per year for failed insertion or
removal, or a history of severe pain and/or vasovagal syncope (VVS). Women
referred are motivated to persevere with this method despite a bad
experience. There are no data to indicate how many women are put off by a
poor experience and rule out this method of contraception and/or menstrual
control. In my experience, concerns around the fitting are the main
barrier to improving the overall low uptake of intrauterine methods in the
UK. I would strongly echo the consensus that the setting, confidence and
technique of the provider, and particularly the presence of an assistant
skilled at addressing anxiety, are key to the overall experience.
There are six points where I differ from Bahamondes et al.'s
recommended practice.
1. I am fortunate to have an electric lithotomy couch but rarely use
the leg supports, usually only where access to the cervix is particularly
difficult. My preferred position is sitting on a stool with wheels at the
side of the couch rather than with the woman at the end of the couch.
Importantly the bed is elevated enough that my legs fit in under the couch
so the cervix is comfortably at eye level.
2. The consensus view was that a tenaculum should always be applied.
I avoid this painful stimulus if fitting is possible using gel alone. A
tenaculum is essential for GyneFix. However, with framed devices it is
often unnecessary and will only increase pain. Admittedly I have the
benefit of a scanner at the bedside and routinely check the position of
any IUD. Accurate fundal placement and minimising the risk of perforation
depends on good technique but this need not include use of a tenaculum in
many cases.
3. I disagree with the authors' recommended toothed tenaculum
pictured in their Figure 1. Although rarely reported,[2] I have seen
several cases with an IUD thread exiting the cervix through a fistula, and
one case where an intrauterine system reservoir was visibly protruding
from a fistula with the thread running back into the fistula and out of
the os. It is possible a fistulous tract may be created where tenaculum
teeth penetrated the cervix with the threads then finding their way into
the tract before it heals. I would recommend use of less traumatic forceps
such as Judd-Allis or Littlewood.
4. I endorse the superiority of tapered (e.g. Bonney Barker type)
dilators over shouldered (Hegar type) dilators, but more than this there
is a technique for finding the path of least resistance. Careful bimanual
examination establishing the position of the fundus relative to the cervix
does not allow the inserter to judge the exact direction to angle the
dilator when they meet resistance. Straightening the cervico-isthmic
junction with traction on the cervix can sometimes be helpful. However
gently manipulating a dilator through 360 degrees and sometimes changing the
angle quite acutely may find a path with almost no resistance. This is
much easier with a scanner at the bedside and a uterus that is
sufficiently anteverted for simultaneous ultrasound guidance. Through use
of simultaneous ultrasound guidance I have noted that suprapubic pressure
can sometimes relax the internal os. On occasions when I have left the
sound at the point of resistance while helping the assistant focus the
image on the endocervical-endometrial canal we have noted the sound
suddenly 'fall into' the cavity. I have not tried a suprapubic warming
pack but presume that this is likely to have the same or better effect.
5. The os finder is good for stenosis of the external os. I would not
recommend its use to overcome stenosis (or spasm) of the internal os. A
tapered metal dilator would be my instrument of choice as it enables one
to find a path of least resistance when the dilator is gently rotated and
angulated at the point of resistance. One cannot do this with the os
finder as it is too flexible and too sharp.
6. The authors recommend an intracervical block for difficult
sounding. Cochrane Reviews conclude there is inadequate evidence of
benefit with local anaesthetic. However, data available on abortion under
local anaesthetic supports that deep paracervical injection combined with
a relatively high concentration of intrauterine lidocaine infusion
improves pain scores.[3] So my own practice where injection is needed is
to insert a paracervical block. My understanding of the difference between
intracervical and paracervical block is that with the former the needle is
introduced through the cervical os and with the latter the needle is
introduced a distance of 1-2 cm lateral to the os, which enables placement
of the block at a higher level. I would strongly discourage use of a
syringe with a 21 gauge needle, not only because it does not fit down the
speculum leaving room for visualisation but because the needle size is too
large for comfort. Use of a dental syringe with long 27 gauge needle is
superior. Although one cannot exclude vascular injection by checking for
backflow, in practice a slight resistance with injection should confirm
placement within tissue.
A recurring proportion of referrals are women who have had an IUD
removed followed by failed reinsertion. This supports the impression that
reflex closure of the internal os may be triggered by the stimulus of
removing a device. Personally I have found the technique of slow filling
the cavity with local anaesthetic gel, avoiding overfilling by asking the
woman to say as soon as any sensation of cramping starts, and waiting
several minutes together with care to avoid any sudden or sharp stimulus
on removal of the old device avoids this problem. A criticism of this
technique is that there is a lack of evidence. However, studies on topical
gel have generally not considered the difference between endometrial and
endocervical absorption nor the importance that 3 minutes or less may be
unrealistically short for topical absorption. Evidence to support this
practice lies in the success of managing 99% of referrals with one or more
previous failed procedures in a 30-minute one-stop outpatient appointment,
and a VVS rate of less than 0.2% (two cases in over 4 years, neither
requiring medication) despite high-risk referrals, a number of whom had
experienced severe VVS at a previous procedure. It is my personal view
that a painful stimulus is likely to be the most important cause of VVS.
References
1. Bahamondes L, Mansour D, Fiala C, et al. Practical advice for
avoidance of pain associated with insertion of intrauterine
contraceptives. J Fam Plann Reprod Health Care 2013; 40: 54-60.
2. Gonec I, Zeynep E, Vural T, et al. Cervical perforation by the
strings of a levonorgestrel releasing-intrauterine system: a case report.
Eur J Contracept Reprod Health Care, 2013; 18: 415-418.
3. Renner RM, Jensen JT, Nichols MD, et al. Pain control in first
trimester surgical abortion. Cochrane Database of Systematic Reviews 2009;
2: CD006712.
Following a 7-month trial on the use of Entonox for the relief of
pain or anxiety during intrauterine device (IUD) or intrauterine system
(IUS) fitting, we now offer this method of pain relief to all women
attending for an intrauterine procedure. It is available to any patient
who wishes to use it but its use is entirely optional. Entonox can be used
alongside other analgesics and there is no need for the woman to decide...
Following a 7-month trial on the use of Entonox for the relief of
pain or anxiety during intrauterine device (IUD) or intrauterine system
(IUS) fitting, we now offer this method of pain relief to all women
attending for an intrauterine procedure. It is available to any patient
who wishes to use it but its use is entirely optional. Entonox can be used
alongside other analgesics and there is no need for the woman to decide
beforehand.
Our services currently insert a minimum of 20 IUDs/IUSs per week at
two clinic sites in Central Buckinghamshire, UK. The clinics serve all
ages and client groups who mainly self-refer, as well as accepting general
practitioner (GP) referrals for emergency IUDs.
Reducing pain and anxiety for these procedures has been much debated
over the last few years. Hutt[1] and more recently Akintomide et al.[2]
have advocated an increased use of intracervical local anaesthesia.
Hutt[3] suggests that lignocaine gel is ineffective and that "...it is simply a salve to our guilty consciences".
Entonox provides pain relief and conscious sedation for a variety of
short-term procedures[4] and is licensed for such indications.[5] The
manufacturer of Entonox, BOC, expects that within a minute of
discontinuing breathing Entonox the effect has worn off so clients could
drive within 30 minutes of the procedure. This is confirmed in the Summary
of Product Characteristics (SPC).[5] Our National Health Service Trust states that clients
should not drive for 12 hours after using Entonox. We counsel women prior
to procedures and are hoping that the Trust will take a more pragmatic
stance in the future in the light of BOC's guidance and the information
within the SPC. Our current information states: "[Entonox] wears off
within a minute or two of stopping breathing it, however, please note
that: (a) it is currently a Trust policy that she should not drive herself
home if she has used Entonox so needs to arrange a lift, and (b) she
should not use Entonox if she has recently had a 'burst eardrum' or within
48 hours of SCUBA diving."
Since introducing Entonox in our clinics, we have had a steady rise
in the number of clients opting for IUD/IUS. Some state that they choose
our service "... because you have the 'gas and air'". However, some women
also state that at a previous procedure carried by their GP they had not
been advised to take any analgesics beforehand nor were they offered any
at the procedure. The clinics run a large teaching practice for both GPs
and nurses, and the many GPs we talk to who state that they never give
intracervical local anaesthesia as "women don't need it" are perhaps
unaware of the number of women who choose to go to a Level 3 service for
their next IUD/IUS in the hope of a better experience when analgesia is
available. I suggest that these women are reluctant to tell their GPs,
whom they like and trust, that the procedure was less than perfect.
Striking the balance between letting women know that Entonox is
available and worrying some who say "...if it is so painful you need 'gas
and air' I am not having one", has been something we have addressed in our
literature and by having a poster containing information and comments in
the waiting room.
The final word needs to go to one of our satisfied clients: "10 years
of contraception and gas to breathe when it's fitted, what's not to
like?".
Journal readers who would like further information on using Entonox
for procedures or who are interested in the questionnaire from which the
quotations above were taken and its audit may e-mail me direct.
References
1. Hutt S. Injectable local anaesthesia for IUD/IUS fittings J Fam
Plann Reprod Health Care 2011;37:59.
2. Akintomide H, Sewell R, Stephenson J. The use of local
anaesthesia for intrauterine device insertion by health professionals in
the UK. J Fam Plann Reprod Health Care 2013;39:276-280.
3. Hutt S. Option of local anaesthetic for IUD fittings: author's
response. J Fam Plann Reprod Health Care 2011;37:190.
4. BOC. How ENTONOX works. 2012.
http://www.entonox.co.uk/en/discover_entonox/how_entonox_works/index.shtml?style
[accessed 13 June 2012].
5. Entonox: Summary of Product Characteristics. 2013.
http://www.mhra.gov.uk/home/groups/spcpil/documents/spcpil/con1384326173333.pdf
[accessed 17 December 2013].
In their article about Natural Cycles, Hough et al quote a Cochrane Review that dismisses fertility awareness based contraception (natural family planning).
Show MoreA 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...
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...
Show MoreRegarding 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...
Show MoreThe 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...
Counseling is voluntary by definition. A person being 'counseled' can leave at any time and without any consequences. If 'counseling' is mandatory it becomes in fact a state ordered instruction. Like for example in the case of obligatory military service. We as society should at least have the courage to name things with their correct terminology. And not pretend to 'counsel' women if in fact we force them to listen to an...
It was interesting to read Sharon Moses' thoughtful commentary questioning the role of an 'express' contraceptive service in a community sexual health clinic and advocating improving contraceptive provision in primary care, the primary provider of contraception in the UK.[1] My colleagues in Newcastle, however, support this service innovation as they feel that women in their late teens and early twenties have been overl...
We thank Dr Kell and Ms McMahon for their comments[1] on our article[2] and for sharing their experience of running an abortion service from a community setting. It is reassuring to learn that both staff and patients welcomed this service and that contraceptive provision and sexually transmitted infection diagnosis have improved as a result. We hope other clinicians providing abortion care services may be encouraged to c...
We thank to Dr Pillai for her letter[1] about our review article entitled "Practical advice of pain associated with insertion of intrauterine contraceptives".[2] We would like to make the following comments regarding the specific points Dr Pillai raised in her letter.
1. Dr Pillai suggests that clinicians may wish to sit on a stool with wheels at the side of the couch rather than with the woman at the end of the...
Congratulations are due to the authors for producing much needed guidelines.[1] These are necessarily a consensus owing to the lack of quality studies on pharmacological interventions. Since 2009 I have provided a referral service for intrauterine device (IUD) problems, and currently manage 400-500 referrals per year for failed insertion or removal, or a history of severe pain and/or vasovagal syncope (VVS). Women referr...
Following a 7-month trial on the use of Entonox for the relief of pain or anxiety during intrauterine device (IUD) or intrauterine system (IUS) fitting, we now offer this method of pain relief to all women attending for an intrauterine procedure. It is available to any patient who wishes to use it but its use is entirely optional. Entonox can be used alongside other analgesics and there is no need for the woman to decide...
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