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.
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.
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.
I was deeply saddened to read the opinions of Dr Rowlands in his
article entitled 'The policing of abortion services in England' in the
April 2013 issue of the Journal.[1] Although the argument is clear that
the requirement for two signatures on the HSA1 form is burdensome, and is
not seen as necessary by everyone, the article seems to miss a key point.
An overriding ethical duty for any clinician is truth telling, with...
I was deeply saddened to read the opinions of Dr Rowlands in his
article entitled 'The policing of abortion services in England' in the
April 2013 issue of the Journal.[1] Although the argument is clear that
the requirement for two signatures on the HSA1 form is burdensome, and is
not seen as necessary by everyone, the article seems to miss a key point.
An overriding ethical duty for any clinician is truth telling, with the
quality of probity reflecting this. By pre-signing blank forms for
abortion, the clinician is failing on both of these accounts. To sign
that one is satisfied that a procedure can take place in the absence of
knowledge of the patient is a clear departure from truth telling, and
raises important questions about probity. The pre-signature demonstrates
a willingness of the clinician to claim falsely that they have assessed a
patient, either in person or via professional consultation. Perhaps the
seriousness of a false claim has been underestimated in Dr Rowlands'
considerations in terms of its reflection on us as practitioners. The
need for simplification of the abortion process is stated eloquently, but
still must not be used as a justification for departure from professional
standards of behaviour.
Reference
1. Rowlands S. The policing of abortion services in England. J Fam
Plann Reprod Health Care 2013;39:121-126.
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.
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.
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.
We thank Drs Cogswell and Lipetz[1] for their comments on our
article[2] and for sharing the interesting results of their audits. They
have clearly demonstrated the importance of staff training in increasing
uptake of the emergency intrauterine device (IUD). Further work within our
service supports their conclusion.
In response to the apparent fall in IUD uptake when ulipristil
acetate (UPA) was introduced, the...
We thank Drs Cogswell and Lipetz[1] for their comments on our
article[2] and for sharing the interesting results of their audits. They
have clearly demonstrated the importance of staff training in increasing
uptake of the emergency intrauterine device (IUD). Further work within our
service supports their conclusion.
In response to the apparent fall in IUD uptake when ulipristil
acetate (UPA) was introduced, the results of our study were disseminated
and all staff reminded of the importance of offering an IUD as first line
to all eligible women.
In the 15 months following the data period for our article, 733
patients attended for emergency contraception; 76% received
levonorgestrel, 13% received UPA and IUD uptake was 11% (up from 8.7%
during the study). Although this improvement is modest, within this
interval is a 3-month period during which IUD uptake was significantly
higher at 17.9%. This followed the introduction in October 2012 of a
patient group directive for UPA that was accompanied by a face-to-face
teaching session.
Our initial study, subsequent audit and the findings of Drs Cogswell
and Lipetz all emphasise the importance and impact of continuous staff
education and training. Although staff training is a key element for
inclusion in all service specifications, when there are competing
interests and demands it is often inadequately resourced. This under-investment potentially threatens the projected financial and psychological
savings from increasing use of the emergency IUD and other long-acting
reversible contraceptive methods in general.
References
1. Cogswell C, Lipetz C. Comment on 'An emergency contraception
algorithm based on risk assessment: changes in clinicians' practice and
patients' choices'. J Fam Plann Reprod Health Care 2013;39:1. doi.
10.1136/jfprhc-2013-100663.
2. McKay RJ, Gilbert L. An emergency contraception algorithm based on
risk assessment: changes in clinicians' practice and patients choices. J
Fam Plann Reprod Health Care 2013;39:1-7. doi. 10.1136/jfprhc-2012-100495.
I read with interest the article Garrett and Kirkman et al.[1] wrote
on the limited success of the pilot telemedicine sexual health service and
their reflections on needing more advice from what young people thought to
have got it right.
A 2008 UNICEF statement entitled 'Young People: Partners for
Health'[2] written by an international group of young people states:
"Young people need to be at the forefront in the...
I read with interest the article Garrett and Kirkman et al.[1] wrote
on the limited success of the pilot telemedicine sexual health service and
their reflections on needing more advice from what young people thought to
have got it right.
A 2008 UNICEF statement entitled 'Young People: Partners for
Health'[2] written by an international group of young people states:
"Young people need to be at the forefront in the development of primary
health efforts" and urges all to act upon their recommendations so that
young people get involved as partners in primary health care.
We have recently started trying to work more closely with young
people at our practice. They have explained to us why some of our
"excellent" ideas would not work for young people and have given us
interesting and innovative solutions to problems.
The 2012 Report of the Children and Young People's Health Outcomes
Forum[3] highlights the benefits of involving young people in service
design. It comments on the fact that "public services that involve and
listen to children and young people find the result to be better services,
better informed consumers and overall, better value for the investment".
In this new era of Clinical Commissioning Groups and a cash-strapped
health service, the findings of Garrett and Kirkman[1] are an important
lesson for us all to take note of and learn from.
References
1. Garrett CC, Kirkman M. Despite the best intentions: a reflection
on low client numbers for a pilot telemedicine sexual health service. J
Fam Plann Reprod Health Care 2013;39:144-146.
2. UNICEF. Young People: Partners for Health. International
Conference Celebrating the 30th Anniversary of Alma Ata Declaration on
Primary Health Care, Final Statement, 16th October 2008.
3. Report of the Children and Young People's Health Outcomes Forum.
2012.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156062/CYP
-report.pdf.pdf [accessed 29 April 2013].
As with McKay and Gilbert[1] in Cambridge, UK, we also developed an
emergency contraception (EC) algorithm following the introduction of
ulipristal acetate (UPA), likewise recognising that fitting an
intrauterine device (IUD) was the 'gold standard'. Our ongoing experience
is rather different, however, in that our rates of emergency IUD fitting
have increased since the introduction of our algorithm from 6% to at least
9%...
As with McKay and Gilbert[1] in Cambridge, UK, we also developed an
emergency contraception (EC) algorithm following the introduction of
ulipristal acetate (UPA), likewise recognising that fitting an
intrauterine device (IUD) was the 'gold standard'. Our ongoing experience
is rather different, however, in that our rates of emergency IUD fitting
have increased since the introduction of our algorithm from 6% to at least
9%.
Within the Department of Sexual and Reproductive Healthcare in
Aneurin Bevan Health Board (South Wales), 6% (17/270) of clients leaving
the clinic with a method of EC in 2011 had an IUD fitted. Our service is
different to the one in Cambridge in that our clients can usually have an
IUD fitted on the day of presentation providing there is an IUD fitter in
clinic. Thus a second appointment is not needed.
Although there is no recognised standard for the percentage of
emergency IUDs fitted, Schwarz et al.[2] found that 12% of women attending
a walk-in clinic for either pregnancy testing or EC would consider same-day fitting of an IUD, and a further 22% expressed interest in having
further information about the IUD, suggesting that our emergency IUD
insertion rates could be improved. We therefore ran a teaching session in
January 2012 to emphasise the efficacy and benefits of emergency IUDs to
nursing staff, and between March and May 2012 introduced our algorithm for
EC, including the use of UPA. Our algorithm is similar to that used in
Cambridge but we consider the high risk time for conception to be Days 10-15 of the cycle, and our algorithm is designed so that staff must record
that they have discussed the emergency IUD. In the 3 months following the
intensive teaching programme our rate of emergency IUD use increased to
11.8%. Disappointingly, however, for the 9 months to the end of 2012 the
rate dropped to an average of 9%.
We audited the notes of all clients given EC between May and July
2012 and found that 31% of clients had been inaccurately recorded as
unsuitable for the IUD. In a further 11% of cases we could not assess
suitability for an IUD from the information provided. Consequently,
further teaching was undertaken to explain to staff when clients may have
an emergency IUD fitted, and the clinical proforma was amended so that
staff had to give reasons why the client was unsuitable for an IUD.
An audit for the first 3 months of 2013 demonstrates a small increase
in emergency IUD use to 10.5%. As well as being encouraging, this suggests
that clinician advice to clients is influential in their choice of EC. As
many of our clients have little or no knowledge of the emergency IUD[3,4]
and a possibly inflated estimate of the effectiveness of oral EC,[5] it is
also incumbent upon the clinician to give appropriate risk management
advice.[6]
In summary, our experience of introducing a new EC pathway that
includes UPA has been an increase in the rate of clients using emergency
IUD contraception from 6% to at least 9%. It is noteworthy that our
initial rate of emergency IUD use was initially far lower than in
Cambridge but our current endpoint is similar. We will continue auditing
emergency IUD use to see if we can sustain, or improve on, our current
usage. If this small effect were to be replicated nationally, this would
constitute a clinically important increase in long-acting reversible
contraception use and more cost-effective contraception[7] - a definite
bonus in these financially stretched times.
References
1. McKay RJ, Gilbert L. An emergency contraception algorithm based on
risk assessment: changes in clinicians' practice and patients' choices. J
Fam Plann Reprod Health Care 2013:39:1-7. doi.10.1136/jfprhc-2012-100495.
2. Schwarz EB, Kavanaugh M, Douglas E, et al. Interest in
intrauterine contraception among seekers of emergency contraception and
pregnancy testing. Obstet Gynecol 2009;113:833-839.
3. Wright RL, Frost CJ, Turok DK. A qualitative exploration of
emergency contraception users' willingness to select the copper IUD.
Contraception 2012;85:32-35.
4. Lader D. Opinions Survey Report No. 41, Contraception and Sexual
Health 2008/9. http://www.ons.gov.uk/ons/rel/lifestyles/contraception-and-
sexual-health/2008-09/2008-09.pdf [accessed 24 April 2013].
5. Bharadwaj P, Saxton J, Mann SC, et al. What influences young women
to choose between the emergency contraceptive pill and an intrauterine
device? A qualitative study. Eur J Contracept Reprod Health Care
2011;16:201-209. doi:10.3109/13625187.2001.565891.
6. Braybrook S, Ahmed H, Cogswell C, et al. Communicating risk about
emergency contraception. Gynaecology Forum 2013;(in press).
7. National Institute for Health and Clinical Excellence. Long-acting
Reversible Contraception. 1995.
http://guidance.nice.org.uk/CG30/Guidance/pdf/English [accessed 24 April
2013].
Conflict of Interest:
The Department of Sexual and Reproductive Healthcare in Aneurin Bevan Health Board has received sponsorship for clinical meetings from Durbin, Bayer Healthcare, HRA Pharma and MSD Women's Health. Dr Cogswell has received honoraria from MSD Women's Health and Bayer Healthcare. Dr Lipetz has received honoraria from Bayer Healthcare and MSD Women's Health.
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...
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...
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 was deeply saddened to read the opinions of Dr Rowlands in his article entitled 'The policing of abortion services in England' in the April 2013 issue of the Journal.[1] Although the argument is clear that the requirement for two signatures on the HSA1 form is burdensome, and is not seen as necessary by everyone, the article seems to miss a key point. An overriding ethical duty for any clinician is truth telling, with...
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...
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...
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...
We thank Drs Cogswell and Lipetz[1] for their comments on our article[2] and for sharing the interesting results of their audits. They have clearly demonstrated the importance of staff training in increasing uptake of the emergency intrauterine device (IUD). Further work within our service supports their conclusion.
In response to the apparent fall in IUD uptake when ulipristil acetate (UPA) was introduced, the...
I read with interest the article Garrett and Kirkman et al.[1] wrote on the limited success of the pilot telemedicine sexual health service and their reflections on needing more advice from what young people thought to have got it right.
A 2008 UNICEF statement entitled 'Young People: Partners for Health'[2] written by an international group of young people states: "Young people need to be at the forefront in the...
As with McKay and Gilbert[1] in Cambridge, UK, we also developed an emergency contraception (EC) algorithm following the introduction of ulipristal acetate (UPA), likewise recognising that fitting an intrauterine device (IUD) was the 'gold standard'. Our ongoing experience is rather different, however, in that our rates of emergency IUD fitting have increased since the introduction of our algorithm from 6% to at least 9%...
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