Dr Elliman[1] asked whether other clinicians had experience of
damaged implants. Rekers[2] replied that breakage is rare and would not
alter contraceptive efficacy.
I have removed damaged implants from seven patients since June 2011,
all of which were sited correctly. Two patients underwent subsequent
removal of a second damaged implant. All the patients were aware of
abnormality, but only one remembered trauma...
Dr Elliman[1] asked whether other clinicians had experience of
damaged implants. Rekers[2] replied that breakage is rare and would not
alter contraceptive efficacy.
I have removed damaged implants from seven patients since June 2011,
all of which were sited correctly. Two patients underwent subsequent
removal of a second damaged implant. All the patients were aware of
abnormality, but only one remembered trauma. One had positive home
pregnancy tests from 3 days after implant removal, suggesting method
failure.
The first patient requested exchange of a bent Nexplanon at 10
months. She described an injury 4 months previously. She felt unwell and
had experienced recent heavy bleeding in place of the initial amenorrhoea.
Pickard and Bacon[3] described bleeding in association with a damaged
implant. I chose incision over the bend but found that the two halves were
attached by the rate-limiting membrane.
The second patient attended for Nexplanon exchange at 5 months,
describing 'popping' in her arm and a broken implant. This implant was
completely fractured. Both halves popped out easily via an incision over
the break, which I also used for reinsertion. Five months later the
patient requested removal because of burning pain at the implant site. A
colleague removed the implant and recorded that it was bent in several
places. The patient reported three positive pregnancy tests during the
next 7 days followed by heavy bleeding with clots. A pregnancy test 8 days
after implant removal was negative.
The third patient requested Nexplanon exchange for bending at 8
months. The usual removal technique revealed two incomplete fractures of
the core. I used the same incision for reinsertion. Three days later the
patient experienced pain and again found abnormal bending. She demanded
immediate removal. I acquiesced and found minor cracking of the implant
core.
I performed early removal because of a bent Nexplanon for a fourth
patient 15 months after insertion.
Two further patients were aware of Nexplanon damage but attended for
removal because they wanted to get pregnant. One attended at 16 months and
underwent the usual removal technique, which revealed two central bends.
The other woman who attended at 24 months had a complete break in her
implant that required a second incision for the proximal half. I had
quickly checked that the implant was palpable and hadn't enquired about
possible damage. When the first half popped out the patient confirmed that
she had suspected the implant was broken for many months. These were the
only two implants with identical batch numbers.
A final patient only reported her bent Implanon when attending for
routine exchange after 3 years.
All the cases I have described except the final one involve
Nexplanon. In my previous years of experience with Implanon I had been
unaware of any cases involving implant damage. Structurally Nexplanon
differs from Implanon by the addition of 3% barium. Unlike Implanon,
Nexplanon cannot slip in its inserter, and errors during the insertion
process seem unlikely to explain the apparent increased frequency of
damage.
I would be interested to know whether other Journal readers have
noticed an increase in damaged implants since Nexplanon replaced Implanon.
I routinely use the same incision for reinsertion, but having two
patients attend with recurrent damage might suggest that this practice
should be avoided.
Only two of these damaged implants were completely broken. Doshi[4]
suggested that taking an X-ray of the bent Nexplanon might help clarify
the situation. In practice my patients were unhappy with the bent device
and wanted it removed even if it wasn't fractured. Removing partially
fractured implants using the usual pop-out technique is the simplest and
least traumatic method of removal but it does carry the risk of needing a
second small incision if the implant is truly broken. An incision over the
centre of an implant that is only bent needs to be a little larger in
order to remove the implant in its bent form. I would suggest careful
enquiry and examination, and unless the implant is clearly in two pieces I
would recommend that the usual pop-out removal technique be employed.
References
1. Elliman A. Removal of a fractured Nexplanon?. J Fam Plann Reprod
Health Care 2013;39:66-67.
2. Rekers K. Removal of a fractured Nexplanon?: MSD response. J Fam
Plann Reprod Health Care 2013;39:67.
3. Pickard S, Bacon L. Persistent vaginal bleeding in a patient with
a broken Implanon?. J Fam Plann Reprod Health Care 2002;28:207-208.
4. Doshi J. Bent Implanon?. J Fam Plann Reprod Health Care
2011;37:126.
I am pleased to note on reading Dr Duncan’s letter[1] in the January 2013 issue of the Journal that I am not the only person who waits a full 3 minutes after using local anaesthetic gel prior to fitting an intrauterine device/system. I totally agree that this makes a difference to the pain experienced by women. I have been fitting 'coils' for almost 30 years and when I started was totally reliant on a good 'vocal local' to get...
I am pleased to note on reading Dr Duncan’s letter[1] in the January 2013 issue of the Journal that I am not the only person who waits a full 3 minutes after using local anaesthetic gel prior to fitting an intrauterine device/system. I totally agree that this makes a difference to the pain experienced by women. I have been fitting 'coils' for almost 30 years and when I started was totally reliant on a good 'vocal local' to get the women relaxed, an experienced nurse was then my assistant. Over the years I have had to explain to many nurses and now health care assistants how vital this role is, but now adding local anaesthetic gel for 3 minutes I find that there is hardly ever an occasion when 'fail to fit' occurs. I totally agree with Margaret Duncan that this is of benefit to women but wait with interest to see if Entonox will help further.
Reference
1. Duncan M. Reducing the pain of IUD insertion. J Fam Plann Reprod Health Care 2013;39:63.
Despite the increased interest in evidence-based medicine, many
medical guidelines and statements of medical professionals are based
primarily on opinion rather than scientific facts. The 'Statement on
combined hormonal contraceptives containing third- or fourth-generation
progestogens or cyproterone acetate, and the associated risk of
thromboembolism' raises such concerns.[1]
Despite the increased interest in evidence-based medicine, many
medical guidelines and statements of medical professionals are based
primarily on opinion rather than scientific facts. The 'Statement on
combined hormonal contraceptives containing third- or fourth-generation
progestogens or cyproterone acetate, and the associated risk of
thromboembolism' raises such concerns.[1]
While we agree that the importance of effective and well-tolerated
contraceptives is indisputable, we must ask for evidence that questioning
the safety of newer generation progestogens compared to older formulations
has caused a "new pill scare", or a "crisis" resulting in a "highly
emotional political dimension".[1] The implication that ideology or
overreaction rather than scientific analysis underlies the numerous recent
calls for increased scrutiny and changes in prescribing practice, and that
patients are being harmed as a result deserves a serious response.
Contraceptives improve women's lives and their health, and there is
no question that all contraceptive methods have lower thromboembolic risks
than pregnancy. However, given that all combined oral contraceptives have
similar efficacy in terms of pregnancy prevention, the public health
question should be what differences in adverse reactions are acceptable,
to patients, doctors and regulatory government entities. Clearly the
nature of the adverse effect is the crucial issue; patients and their
physicians may be willing to tolerate numerous minor side effects such as
spotting and breast tenderness, but a statistically significant increased
risk of potentially fatal blood clots in most independent studies deserves
the attention of all physicians. For example, the largest study to date
found an increase in the hazard ratio (HR) for venous thromboembolism
among new users of drospirenone in relation to low-dose estrogen
comparators [HR 1.77 (95% confidence interval 1.33-2.35)].[2]
Even a small, significant additional risk is greatly magnified
because millions of women and girls use contraceptives. Are any additional
deaths and disabilities acceptable, to patients or their doctors, when so
many safer, equally effective oral contraceptives are available? The
authors posit that women "need a large spectrum of options ... in order to
tailor contraceptive choice to individual women's needs", but how large
does that spectrum need to be? Scores of different brand name and generic
oral contraceptives are sold in the USA, and the French Health Plan pays
for at least a dozen different products that do not contain
drospirenone.[3] Our review of all the published studies has failed to
find any evidence that it is necessary to offer more than a dozen of the
safer types of oral contraceptives to maximise patient satisfaction,
contraceptive use or compliance.
Physician behaviour has been shown to be influenced by financial
relationships with pharmaceutical companies, from the level of individual
prescribing practice to consensus guidelines.[4] In the menopausal hormone
therapy literature, for example, a connection has been observed between
receiving industry funding for speaking, consulting or research and the
publication of promotional opinion pieces.[5] Given that almost all of the
25 Statement authors reported conflicts of interest, their strongly
expressed hostility toward physicians who express concerns about
contraceptives with significantly riskier profiles in numerous well-designed studies seems inappropriate for a medical journal.
References
1. Blitzer J, Amy JJ, Beerhuizen R, et al. Statement on combined
hormonal contraceptives containing third- or fourth-generation
progestogens or cyproterone acetate, and the associated risk of
thromboembolism. J Fam Plann Reprod Health Care 2013;0:1-4.
doi:10.1136/jfprhc-2013-100624.
2. Sidney S, Cheetham TC, Connell FA, et al. Recent combined
hormonal contraceptives (CHCs) and the risk of thromboembolism and other
cardiovascular events in new users. Eur J Contracept Reprod Health Care
2013;1:93-100.
3. Watkins ES. How the pill became a lifestyle drug: the
pharmaceutical industry and birth control in the United States since 1960.
Am J Public Health 2012;8:1462-1472.
4. Newman J, Korenstein D, Ross JS, et al. Prevalence of financial
conflicts of interest among panel members producing clinical practice
guidelines in Canada and United States: cross sectional study. BMJ
2011;343:d5621.
5. Fugh-Berman A, McDonald CP, Bell AM, et al. Promotional tone in
reviews of menopausal hormone therapy after the Women's Health Initiative:
an analysis of published articles. PLoS Med 2011;3:e1000425.
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.
I would like to thank Drs Terplan and Zuckerman for their comments[1]
on the recently published position statement,[2] which myself and the
other cosignatory authors take very seriously.
If I may summarise Drs Terplan and Zuckerman's argument: It starts
with the assumption that there is now clear evidence proving that
levonorgestel (LNG)- and norethisterone acetate (NETA)-containing combined
oral contraceptives (...
I would like to thank Drs Terplan and Zuckerman for their comments[1]
on the recently published position statement,[2] which myself and the
other cosignatory authors take very seriously.
If I may summarise Drs Terplan and Zuckerman's argument: It starts
with the assumption that there is now clear evidence proving that
levonorgestel (LNG)- and norethisterone acetate (NETA)-containing combined
oral contraceptives (COCs) have half the risk of all other combined
hormonal contraceptives (oral, transdermal, transvaginal) containing four
'newer' progestogens, namely desogestrel, gestodene, drospirenone and
cyproterone acetate. Following this statement Drs Terplan and Zuckerman
argue that the public health conclusion has to be that the use of the
newer preparations has to be limited to special indications and that the
older preparations provide health care professionals and women with enough
possibilities to protect women against unwanted pregnancies. Drs Terplan
and Zuckerman argue that due to the fact that millions of women take COCs
it is a public health duty to establish this policy of prescription to
save many womens' lives, and that statements like ours are are based
primarily on opinion rather than scientific facts and that the authors of
the statement[2] are very likely driven by interests related to
pharmaceutical companies leading them to "hostile behavior towards
physicians who are driven by evidence and concern for women" (assuming
that the authors of the statement are not interested in evidence nor have
concerns for women).
My response to the points above is as follows.
(1) Drs Terplan and Zuckerman assume that there is now a high level
of evidence regarding the significant risk difference between older and
newer progestogens and that any doubts must come from physicians with
hidden agendas. There are, however, questions which currently remain
unanswered, including:
(a) Why do prospective studies find no difference?
(b) Are registry data appropriate to answer the question about
differences?
(c) Some questions about biological plausibility. The oral progestogen-
only contraceptive with a new progestogen seems not to increase venous
thromboembolism (VTE) risk. The increased risk compared to LNG when both
are administered in the combined form must be mediated through a
difference in the impact of ethinylestradiol (EE). This difference must be
pharmacologically such that it "doubles" the action of EE. This has not
been shown in laboratory investigations.
(d) How can it be explained that the vaginal ring, which provides the
lowest exposure to EE in pharmacokinetic studies, nevertheless apparently
has a higher risk compared to LNG-containing oral contraceptives, while
the patch, which contains the progestogen with the lowest risk
(norgestimate) has an even higher risk than the ring?
We have stated that these questions are scientifically legitimate and
that we would need more well-designed prospective studies with
participants stratified according to age, weight, family history and
behavioral risks. I think that this statement is not based on resistance
to evidence and that Drs Terplan and Zuckerman's assumption about the
hidden agenda is just what is called "ideological debate" in the
statement.[2]
(2) Drs Terplan and Zuckerman amplify the stated risks to millions of
users. This is in my view scientifically not correct because they amplify
also the doubts and do not take into account that in different populations
and races thromboembolic risks are different.
(3) Our review of all the published studies has failed to find any
evidence that it is necessary to offer more than a dozen of the safer
types of oral contraceptives to maximise patient satisfaction,
contraceptive use or compliance. What Drs Terplan and Zuckerman are saying
is that basically with two progestogens in COCs (NETA, LNG) we have enough
tools to tailor contraceptives to individual needs. This is an interesting
assumption that we have addressed in our statement.[2] We believe that
this has yet to be proven and therefore we suggest what is needed are
clinical studies that have as outcomes not only VTE but also unwanted
pregnancies, rates of discontinuation, compliance, and long-term
tolerability. Clinical experience and the statistics about unwanted
pregnancies show in our opinion that there are still unmet needs among
women regarding contraception, and that choices of different methods and
ways of application may be really important for women and not just an
invention or opinion of experts.
We fully agree that we should take any risks associated with
different contraceptive methods very seriously and reduce risk as much as
possible; therefore the studies that have been performed are important and
the results should be communicated to patients to help them to make
informed decisions and choices.
From a public health point of view, taking into account the presently
available evidence, all women should use the progestogen-only intrauterine
system (IUS) as this has the highest efficacy and lowest health risk. The
individual decision will, however, always have to take into account and
weigh efficacy, health risks, tolerability, health benefits, route of
application, preferences and values. This is why we have stressed the
importance of choice in our statement.[2]
One final remark concerning the fact that the main author and many of
the coauthors of the statement collaborate with pharmaceutical companies.
I believe that there are shared objectives (providing all women with
effective, safe and well-tolerated contraceptive methods) and clearly
different objectives (making money from the products versus having the
best methods available for our patients independent of the price). There
are possible dangers: for example, companies withholding information, or
physicians not being guided by the best interests of their patients. These
dangers have to be detected, named and avoided. The mere fact of
collaboration is however not a bias, nor a danger in itself, but is often
necessary in order to make scientific and practical progress.
References
1. Terplan M, Zuckerman D. Comment on 'Statement on combined hormonal
contraceptives containing third- or fourth-generation progestogens or
cyproterone acetate, and the associated risk of thromboembolism'. J Fam
Plann Reprod Health Care 2013; letter published online 4 June 2013.
2. Bitzer J, and cosignatories. Statement on combined hormonal
contraceptives containing third- or fourth-generation progestogens or
cyproterone acetate, and the associated risk of thromboembolism. J Fam
Plann Reprod Health Care 2013;39:156-159.
Conflict of Interest:
The author has received grants and honoraria for research projects, educational lectures and consultant service from Bayer Health Care, Merck (MSD), Gedeon Richter, Pfizer.
Reading Dr Lloyd's letter[1] in the July 2013 issue of the Journal
has prompted me to write in on this topic.
Removal of an intrauterine device (IUD) involves traction on the
threads causing the horizontal arms of the device to come together in the
narrower lower half of the uterus during its downward movement.
It is relatively easy for the collar of hormone in an intrauterine
system (IUS) to be dislod...
Reading Dr Lloyd's letter[1] in the July 2013 issue of the Journal
has prompted me to write in on this topic.
Removal of an intrauterine device (IUD) involves traction on the
threads causing the horizontal arms of the device to come together in the
narrower lower half of the uterus during its downward movement.
It is relatively easy for the collar of hormone in an intrauterine
system (IUS) to be dislodged. The combined diameter of the folded arms is
marginally greater than the vertical limb of the device. Shearing could
cause the hormonal collar to slip upwards on downward traction of the
device during removal.
This is different to a copper IUD where there is a difference in the
diameters of the vertical limb and the folded horizontal arms of the
device.
Neither collar, copper nor hormone, should be retained in the uterus
if conception is being considered by the woman. However, it is also
important to remove them to exclude the small possibility of actinomyces
infection.
Reference
1. Lloyd ARN. Unusual shaped IUS. J Fam Plann Reprod Health Care
2013;39:234.
The case referred to in Dr Chaudhry's letter to the editor[1] is
interesting in view of the time after insertion and the nature of the
breakdown in the overlying skin. While contamination is likely at the time
of insertion of an implant, one would expect this to cause infection early
and without an apparent symptom-free latent period. It is likely that the
patient would have had some discomfort from the time of insertion t...
The case referred to in Dr Chaudhry's letter to the editor[1] is
interesting in view of the time after insertion and the nature of the
breakdown in the overlying skin. While contamination is likely at the time
of insertion of an implant, one would expect this to cause infection early
and without an apparent symptom-free latent period. It is likely that the
patient would have had some discomfort from the time of insertion to its
final presentation.
Looking at the photographs it appears that the breakdown in Dr
Chaudhry's case has occurred in the skin overlying the middle of the
device. The upper end of the device is visible in Figure 2.
I wonder if the skin overlying the device was too thin and broke
down, leading to infection.
In an attempt to avoid a deep insertion with its inherent risks I
have encountered situations where the device is almost intradermal in
places. The overlying skin in such a situation is likely to break down.
While it remains important to deploy the device in a subdermal plane,
one also needs to exercise care in not inserting it too superficially.
Reference
1. Chaudhry F. Adverse reaction to Nexplanon. J Fam Plann Reprod
Health Care 2013;39:231-232.
Congratulations to Drs McKay and Gilbert on trying to increase access
to emergency contraception (EC) intrauterine device (IUD) and on achieving
high rates[1]. Even in Liverpool, UK where we pride ourselves on easy,
often immediate, IUD access and where we have long been promoting its
effectiveness we only achieve around 5%.
We have some concerns about the algorithm described in this
article.[1] The classificatio...
Congratulations to Drs McKay and Gilbert on trying to increase access
to emergency contraception (EC) intrauterine device (IUD) and on achieving
high rates[1]. Even in Liverpool, UK where we pride ourselves on easy,
often immediate, IUD access and where we have long been promoting its
effectiveness we only achieve around 5%.
We have some concerns about the algorithm described in this
article.[1] The classification of level of risks is not based on what is
known about variability of ovulation timing. The chance of pregnancy is
greater than 10% from Day 6 to Day 21 of the cycle, and by the fifth week
women still have a 4-6% chance of ovulating[2]. Contrary to previous
teaching, only 10% of women with a 28-day cycle will ovulate 14 days
before their next bleed[2]. Previous correspondence shows that when
hormonal assessments were carried out, women confident of the date of
their last menstrual period (LMP) and cycle length were not where they
thought they were in their cycle,[3] as Drs McKay and Gilbert hint in
their article. So, calculations based only on LMP and cycle length are not
accurate enough to inform an individual patient not wishing an unplanned
pregnancy. The pregnancies recorded during the pilot study,[1] in women
not assessed as high risk who had levonorgestrel (LNG) EC, support the
above.
Regarding IUD eligibility, it is only necessary to elucidate pre-insertion the possibility of an implanted pregnancy, should there have
been any unprotected sexual intercourse (UPSI) more than 5 days prior to
presentation. The method Drs McKay and Gilbert have used is useful when
there have been many episodes of UPSI but before a pregnancy test would be
positive. It is restrictive, but can reassure the IUD fitter that there
will not be an implanted pregnancy. It does not determine the date of
ovulation of the current cycle; it just estimates the earliest possible
date.
Evidence-based practice suggests that wherever women are in their
cycle, if all UPSI was within 72 hours, the IUD is the most effective, and
ulipristal acetate (UPA) has the edge on LNG, because of its action during
the luteinising (LH) surge (closer to ovulation: the highest risk time of
the cycle). For UPSI between 72 and 120 hours the IUD is the most
effective, UPA is licensed and LNG has neither been shown to have an
effect after 96 hours nor is it licensed. Only if there is UPSI more than
120 hours previously is it necessary to consider implantation with all the
caveats above.
However, the Faculty of Sexual & Reproductive Healthcare does not
rank the methods with regards to choice, it states: "Health professionals
should discuss individual need to ... [EC] and inform women about the
different methods with regard to efficacy, adverse effects, interactions,
medical eligibility and need for individual contraceptive precautions."[4]
It is for the woman then to make an informed choice and other factors may
come into play, as previous work has shown,[5] and there is no evidence of
a wholesale move towards UPA when free choice is introduced. The offer of
an IUD to women seeking EC has been UK standard practice for over 30
years; however, the introduction of an algorithm seems to have been
helpful within Drs McKay and Gilbert's service.
Restricting UPA to those aged over 18 years appears to imply that
women aged under 18 years are less deserving of protection against
unplanned pregnancy. The studies on UPA did include some 16- and 17-year-
olds, and subsequent studies have shown that adolescents are no different
to adults.[6] If the authors were being consistent then they would not
prescribe most contraceptives to teenagers as they are seldom included in
most studies. We would argue that it is precisely the young, fertile woman
presenting for EC who needs the most effective method, and though an IUD
is possible these individuals are often the ones most reluctant to accept
it. The FSRH guidance explicitly supports the use of UPA in under-18s.
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 ;39:201-206.
2. Wilcox A J, Dunson D, Baird DD. The timing of the "fertile window"
in the menstrual cycle: day specific estimates from a prospective study.
BMJ 2000;321:1259-1262.
3. Webb A, McGough P, Melvin L. Pitfalls of adapting emergency
contraception CEU guidance. J Fam Plann Reprod Health Care 2012;38:270.
4. Faculty of Sexual and Reproductive Healthcare. Emergency
Contraception. 2011.
http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf [accessed
11 July 2013].
5. Baird AS. Use of ulipristal acetate, levonorgestrel and the copper
-intrauterine device for emergency contraception following the
introduction of new FSRH guidelines. J Fam Plann Reprod Health Care 2013;
25 April 2013. doi: 10.1136/jfprhc-2012-100467.
6. Glasier A. EllaOne, a clinical update. Presentation at the First
Global Conference on Contraception, Reproductive and Sexual Health, 24 May
2013, Copenhagen, Denmark.
I would like to thank Dr Menon for his comments[1] regarding my
recently published letter to the editor[2] entitled 'Adverse reaction to
Nexplanon'.
The breakdown of the skin overlying the middle of the subdermal
implant (SDI) extended to the whole distal third almost all the way to the
tip. It is possible that the skin overlying this portion of the device was
too thin and broke down due to intradermal or superfi...
I would like to thank Dr Menon for his comments[1] regarding my
recently published letter to the editor[2] entitled 'Adverse reaction to
Nexplanon'.
The breakdown of the skin overlying the middle of the subdermal
implant (SDI) extended to the whole distal third almost all the way to the
tip. It is possible that the skin overlying this portion of the device was
too thin and broke down due to intradermal or superficial insertion.
Unfortunately I am unable to personally confirm if this was the case as I
did not examine the patient until they presented to me after the skin had
started to break down.
The patient herself had not felt that the device was more
superficially inserted than her previous SDI, and no reference to this was
made by the doctors whom she presented to prior to her appointment with
me. They did comment on there being swelling at the site, and this could
have perhaps made the implant feel less apparently superficial to
palpation at the time.
I agree that it remains important to deploy the device correctly and
avoid inserting it too superficially, and in my experience I have observed
an increase in superficially inserted SDIs being referred since the
changeover from Implanon to Nexplanon. This may be an area for potential
future research.
References
1. Menon K. Comment on 'Adverse reaction to Nexplanon'. J Fam Plann
Reprod Health Care 2013; eLetter published 10 July 2013;
doi:10.1136/jfprhc-2013-100722.
2. Chaudhry F. Adverse reaction to Nexplanon. J Fam Plann Reprod
Health Care 2013;39:231-232.
I write in response to Dr Phillips' letter to the editor[1] that
comments on my article[2] in the April 2013 issue of this Journal.
Despite any criticism of the system regulating abortion from a health
care and patient safety point of view, of course clinicians must conduct
themselves in accordance with case law, primary legislation, secondary
legislation, Department of Health directives and guidance from their...
I write in response to Dr Phillips' letter to the editor[1] that
comments on my article[2] in the April 2013 issue of this Journal.
Despite any criticism of the system regulating abortion from a health
care and patient safety point of view, of course clinicians must conduct
themselves in accordance with case law, primary legislation, secondary
legislation, Department of Health directives and guidance from their
professional bodies.
References
1. Phillips M. Comment on 'The policing of abortion services in
England'. J Fam Plann Reprod Health Care 2013; eLetter published 4 June
2013; doi:10.1136/jfprhc-2013-100695.
2. Rowlands S. The policing of abortion services in England. J Fam
Plann Reprod Health Care 2013;39:121-126.
Dr Elliman[1] asked whether other clinicians had experience of damaged implants. Rekers[2] replied that breakage is rare and would not alter contraceptive efficacy.
I have removed damaged implants from seven patients since June 2011, all of which were sited correctly. Two patients underwent subsequent removal of a second damaged implant. All the patients were aware of abnormality, but only one remembered trauma...
I am pleased to note on reading Dr Duncan’s letter[1] in the January 2013 issue of the Journal that I am not the only person who waits a full 3 minutes after using local anaesthetic gel prior to fitting an intrauterine device/system. I totally agree that this makes a difference to the pain experienced by women. I have been fitting 'coils' for almost 30 years and when I started was totally reliant on a good 'vocal local' to get...
Despite the increased interest in evidence-based medicine, many medical guidelines and statements of medical professionals are based primarily on opinion rather than scientific facts. The 'Statement on combined hormonal contraceptives containing third- or fourth-generation progestogens or cyproterone acetate, and the associated risk of thromboembolism' raises such concerns.[1]
While we agree that the importance...
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...
I would like to thank Drs Terplan and Zuckerman for their comments[1] on the recently published position statement,[2] which myself and the other cosignatory authors take very seriously.
If I may summarise Drs Terplan and Zuckerman's argument: It starts with the assumption that there is now clear evidence proving that levonorgestel (LNG)- and norethisterone acetate (NETA)-containing combined oral contraceptives (...
Reading Dr Lloyd's letter[1] in the July 2013 issue of the Journal has prompted me to write in on this topic.
Removal of an intrauterine device (IUD) involves traction on the threads causing the horizontal arms of the device to come together in the narrower lower half of the uterus during its downward movement.
It is relatively easy for the collar of hormone in an intrauterine system (IUS) to be dislod...
The case referred to in Dr Chaudhry's letter to the editor[1] is interesting in view of the time after insertion and the nature of the breakdown in the overlying skin. While contamination is likely at the time of insertion of an implant, one would expect this to cause infection early and without an apparent symptom-free latent period. It is likely that the patient would have had some discomfort from the time of insertion t...
Congratulations to Drs McKay and Gilbert on trying to increase access to emergency contraception (EC) intrauterine device (IUD) and on achieving high rates[1]. Even in Liverpool, UK where we pride ourselves on easy, often immediate, IUD access and where we have long been promoting its effectiveness we only achieve around 5%.
We have some concerns about the algorithm described in this article.[1] The classificatio...
I would like to thank Dr Menon for his comments[1] regarding my recently published letter to the editor[2] entitled 'Adverse reaction to Nexplanon'.
The breakdown of the skin overlying the middle of the subdermal implant (SDI) extended to the whole distal third almost all the way to the tip. It is possible that the skin overlying this portion of the device was too thin and broke down due to intradermal or superfi...
I write in response to Dr Phillips' letter to the editor[1] that comments on my article[2] in the April 2013 issue of this Journal.
Despite any criticism of the system regulating abortion from a health care and patient safety point of view, of course clinicians must conduct themselves in accordance with case law, primary legislation, secondary legislation, Department of Health directives and guidance from their...
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