Recent eLetters

Thank you for publishing the article by Draper et al. on intrauterine device (IUD) checks.(1) I would like to highlight an omission that is potentially confusing. The authors state "until recently, it has been usual for a patient [using intrauterine methods] to be advised to have an annual check". Reference is made to relevant clinical guidelines from the National Institute of Clinical Excellence (NICE) and from organisations outside the UK, but there is no mention of Faculty of Sexual and Reproductive Healthcare (FSRH) guidance.

FSRH guidance has not recommended annual IUD checks since 2004,(2) based on World Health Organization Selected Practice Recommendations published in 2002.(3) Follow-up is still recommended after the first menses or 3-6 weeks after insertion.(4)

The study supports FSRH recommendations on annual checks. As acknowledged by Dr Draper and colleagues, further research is required to assess the benefits of the initial post-insertion check.

Louise Melvin, MRCOG, MFSRH Director, FSRH Clinical Effectiveness Unit, Sandyford, Glasgow, UK; louise.melvin@nhs.net

Competing interests None.

References

(1)Draper IB, Haque MS, McManus RJ. Routine intrauterine device checks: are they advisable? J Fam Plann Reprod Health Care 2012;38:15-18.

(2)Clinical Effectiveness Unit. FFPRHC Guidance (January 2004). The copper intrauterine device as long-term contraception. J Fam Plann Reprod Health Care 2004;30:29-42.

(3)World Health Organization (WHO). Selected Practice Recommendations for Contraceptive Use. Geneva, Switzerland: WHO, 2002.

(4)Faculty of Sexual and Reproductive Healthcare. Intrauterine Contraception. 2007. http://www.fsrh.org/pdfs/CEUGuidanceIntrauterineContraceptionNov07.pdf [accessed 23 April 2012].

Conflict of Interest:

None declared

The article on HIV testing in abortion clinics provides a compelling argument for normalising HIV testing and making it part of our general medical care.(1) Similar discussions regarding approaches to HIV testing in low prevalence settings are ongoing in general practice.(2)(3) We recently reviewed the recorded HIV status of patients from countries of high HIV prevalence (>1%) in our practice in Portsmouth (an area with an HIV prevalence of less than 0.2%), identifying 124 patients born in sub-Saharan African countries.(4) Among these patients, there were a variety of ages and ethnic groups. In 90% of these patients, no HIV status was recorded. We were then faced with a dilemma. Based on 2008 UK National Guidelines for HIV testing, HIV testing should be routinely offered to people from countries of high HIV prevalence.(5) However, no further guidance is offered regarding what is meant by 'routine testing'; whether we should attempt to contact this at-risk group of patients systematically and, if so, how we should contact them? Opportunistic testing is an option, but given that some of these patients have not consulted for a number of years could mean that some time could pass before there is an opportunity to discuss HIV testing with the potential for delayed diagnosis. We have raised awareness regarding HIV testing to our staff and patients and plan to re-audit to see whether these changes have resulted in increased testing. In addition to people known to be from a country of high HIV prevalence (>1%), the guidelines outline seven other categories of patients in whom HIV testing should be routinely offered, in low prevalence settings. The recommendations for low prevalence settings appear sensible, but are difficult to implement in the real world. It requires significant input in terms of staff training to identify at-risk patients, and there are issues of raising the subject of an HIV test during a consultation for a different problem. In contrast, it is relatively easy to design services providing universal screening. Although the cost-effectiveness of universal testing in low prevalence settings is still to be established, such a strategy is likely to be the most successful in identifying those currently living with HIV and unaware of their infection. References 1. Bates S. HIV testing in abortion clinics. J Fam Plann Reprod Health Care. 2011;37(4):198-200. 2. Arkell P, Stewart E, Williams I. HIV: low prevalence is no excuse for not testing. The British Journal of General Practice. 2011 Apr;61(585):244 -5. 3. Smith C. HIV: low prevalence is no excuse for not testing. The British Journal of General Practice [Internet]. 2011 Jul [cited 2011 Nov 21];61(588):436. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3123475&tool=pmcentrez&rendertype=abstract 4. Health Protection Authority. Diagnosed HIV prevalence by Strategic Health Authority (SHA) and Primary Care Trust (PCT) in England, 2009 [Internet]. 2009. Available from: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1228207184991 5. British HIV Association. UK National Guidelines for HIV Testing 2008 [Internet]. 2008. Available from: http://www.bhiva.org/documents/Guidelines/Testing/GlinesHIVTest08.pdf

Conflict of Interest:

None declared

Yet again scientists and epidemiologists are publicly debating the controversies around the previously reported risks of HRT (hormone replacement therapy). Is this further publicity deserved? The impact of studies such as the Million Women Study (MWS)[1] and Women's Health Initiative (WHI)[2] has been profound leading to significant reductions in the use of HRT. This has understandably affected millions of menopausal women globally who deserve to be fully informed of any doubts that may exist concerning the studies and should be aware of the debate.[3-4]

Ever since these publications were published the headlines in the popular press have been biased towards the 'bad news' messages, resulting in our patients feeling confused and under pressure to stop HRT. Following a recent web-based survey 70% of women who came off their HRT were below the age of 50. More importantly had these women known what we know today, 45% would have stayed on treatment.[5]

Many patients have been advised by their doctors to stop HRT and in some cases have had their prescriptions unilaterally withdrawn. These women have sought additional, poorly researched products with unproven safety and efficacy - often sold as food supplements to circumvent regulatory authorities.

Which risk is greatest? Taking a treatment which has little evidence of effectiveness or safety, or taking a product with the enormous research base that applies to HRT? Do we really know the answer? Is there enough information to allow carers or patients to be fully informed? We believe that the risk, if any is small and it is the view of the British Menopause Society (BMS) that, when used appropriately, any risks are outweighed by the benefits for the majority of women.

We must not forget that at the centre of the current published arguments there are millions of women who want to be properly informed about whether they should be taking HRT. Further, there are likely to be thousands of doctors and nurses who want to be more knowledgeable and confident about prescribing HRT.

In recognition of the menopause having diverse consequences and in an attempt to improve the provision of essential information for women, the BMS has recently submitted recommendations to the Department of Health. The key recommendation is that women should, around the time of the menopause transition, have a formal assessment of their needs, including advice concerning lifestyle, diet and individualised discussion of the risks and benefits of any suitable hormonal therapies. The BMS also suggested that whilst this would require additional resources, the potential long-term health gains would make this consultation highly cost effective in disease prevention terms.[6]

The two main areas that require addressing urgently are:

1) A robust understanding of the benefits and risks of HRT for patients and carers.

Most women who have been taking HRT since the publication of WHI and MWS will have been doing so having weighed up the pros and cons of treatment. Many women, even if there were genuinely a small increased risk of breast cancer, would accept this, if they could have a good quality of life through relief of the debilitating symptoms that invariably affect personal, social and wider quality of life.

The clear benefits in osteoporosis treatment and prevention have recently been included in a recommendation from the National Osteoporosis Society that recommends HRT for the treatment and prevention of osteoporosis in women under 60.[7]

2) HRT is not a single drug as the press and our patients seem to have derived from the publicity.

HRT is a comprehensive suite of preparations and delivery routes produced by the pharmaceutical industry in response to women's needs over more than 20 years of development, refinement and research. This research continues, even though research funding is a fraction of what it once was.[8]

Recently completed trials not only suggest that natural progesterone may not affect the risk of breast cancer and have a neutral effect,[9] but also that soon to be released small studies of lower dose, endogenous-type hormone treatments given to recently menopausal women show great promise.[10]

The BMS feels that the research must continue. As the female population lives longer after the menopause we need to establish safe ways to prevent disease and maintain a high quality of life. This requires a trial to establish definitively the correct indications, patients and hormones for optimal postmenopausal health.[11] We should harness the wealth of knowledge from the debates around WHI and MWS to design this study rather than watch the arguments from the sidelines.

The BMS is dedicated to advancing education in all matters relating to the menopause and to the primary prevention of the burden of preventable chronic disease.

Nick Panay, Chairman, British Menopause Society; Consultant Gynaecologist, Queen Charlotte's and Chelsea & Westminster Hospitals, Honorary Lecturer, Imperial College London, London, UK

Heather Currie, Medical Advisory Council Member, British Menopause Society; Associate Specialist Gynaecologist, Dumfries and Galloway Royal Infirmary, Dumfries, UK; Medical Director "Menopause Matters Ltd"

Edward Morris, Medical Advisory Council Member, British Menopause Society; Consultant, Obstetrics & Gynaecology, Norfolk & Norwich University Hospital, Norwich, UK

References

[1] Million Women Study Collaborators. Breast cancer and HRT in the Million Women Study. Lancet 2003; 362: 419-427.

[2] Writing group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's health initiative randomised controlled trial JAMA 2002; 288(3): 321-333.

[3] Shapiro S, Farmer RD, Stevenson JC, Burger H, Mueck AO. Does hormone replacement therapy cause breast cancer? An application of causal principles to three studies Part 4: The Million Women Study J Fam Plann Reprod Health Care 2012. Jan 16 (ahead of print)

[4] Shapiro S, Farmer RD, Mueck AO, Seaman H, Stevenson JC. Does hormone replacement therapy cause breast cancer? An application of causal principles to three studies: part 2. The Women's Health Initiative: estrogen plus progestogen. J Fam Plann Reprod Health Care 2011 Jul;37(3):165-172.

[5] Cumming GP, Currie HD, Panay N, Moncur R, Lee AJ. Stopping hormone replacement therapy: were women ill advised? Menopause Int 2011; 17(3): 82-87.

[6] British Menopause Society Council. Modernizing the NHS: observations and recommendations from the British Menopause Society. Menopause Int 2011 Jun;17(2):41-43.

[7] Bowring CE, Francis RM. National Osteoporosis Society's Position Statement on hormone replacement therapy in the prevention and treatment of osteoporosis. Menopause Int 2011; 17: 63-65.

[8] Panay N, Ylikorkala O, Archer DF, Rakov V, Gut R, Lang E. Ultra low-dose estradiol and norethisterone acetate: Effective menopausal symptom relief. Climacteric 2007; 10(2): 120-131.

[9] Fournier A, Fabre A, Mesrine S, Boutron-Ruault MC, Berrino F, Clavel-Chapelon F. Use of different postmenopausal hormone therapies and risk of histology- and hormone receptor-defined invasive breast cancer. J Clin Oncol 2008; 26(8):1260-1268.

[10] Harman SM, Brinton EA, Cedars M, Lobo R, Manson JE, Merriam GR, Miller VM, Naftolin F, Santoro N. KEEPS: The Kronos Early Estrogen Prevention Study. Climacteric 2005 Mar;8(1):3-12.

[11] Panay N, Fenton A. Has the time for the definitive, randomized, placebo-controlled HRT trial arrived? Climacteric 2011 Apr;14(2):195-196.

Conflict of Interest:

Nick Panay (NP), Eddie Morris (EM) and Heather Currie (HC) have received sponsorship for lectures and advisory work performed for pharmaceutical companies. NP and HC have received educational grants for meetings and NP has received funding for pharmaceutical trials. NP is co-editor in chief of Climacteric (International Menopause Society Journal) and EM/HC are co-editors in chief of Menopause International (British Menopause Society Journal).