64 e-Letters

  • 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...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • "Mandatory counseling" is a misnomer
    Christian Fiala

    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...

    Show More
  • Response to Mini-Commentary on 'Would an exclusive contraceptive clinic help meet the needs of patients attending an integrated sexual health clinic?'
    Diana Mansour

    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...

    Show More
  • Comment on 'Abortion care services delivered from a community sexual and reproductive health setting: views of health care professionals': authors' response
    Lucy Michie

    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...

    Show More
  • Comment on "Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives": authors' response
    Luis Bahamondes

    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...

    Show More
  • Comment on 'Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives'
    Mary Pillai

    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...

    Show More
  • Entonox for the relief of pain or anxiety during IUS/IUD fitting
    Eppy Sewell

    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...

    Show More