Last year the Royal College of Obstetricians and Gynaecologists published ‘High Quality Women’s Health Care: a Proposal for Change' that proposed a radical change to the structure of UK women's health services. Andrew Horne and Johannes Bitzer discuss this exciting document from both a UK and a European perspective, commenting on its implications for sexual health provision.
Gonorrhoea infection is increasing in the UK with a 3% increase in cases between 2009 and 2010. Last year there was a report of a ceftriaxone-resistant isolate; there is a growing concern that gonorrhoea may become incurable. The commentary by Taylor and Bignell is timely. It reviews the current position and provides clear guidelines on screening and treatment, which may prove challenging for some community services that rely exclusively on the use of nucleic acid amplification tests.
...]]>A recent report from the Royal College of Obstetricians and Gynaecologists (RCOG), High Quality Women's Health Care: A Proposal for Change, published in July 2011, is proposing a radical change to the way UK women's health services are structured.
As health service providers, we are all working against a backdrop of increasing financial and workforce pressures, rising health care demand and, in some countries, government-driven health service reforms. Clearly, there is an urgent need to think laterally about how services can be provided, and by whom, to ensure that the required efficiency savings can...]]>
Reports of a gonorrhoea ‘superbug’ made the headlines last year following the description of a ceftriaxone-resistant isolate of Neisseria gonorrhoeae.
Anogenital infection with N. gonorrhoeae has been highly responsive to single-dose antimicrobial treatment since the introduction of penicillin. However, the progressive development of resistance by N. gonorrhoeae to many classes of antimicrobial has necessitated periodic changes in treatment recommendations to maintain treatment efficacy and led to ever diminishing treatment options. Third-generation cephalosporins, notably ceftriaxone and cefixime, have been the mainstay of treatment recommendations since 2004. Surveillance data in the UK show a progressive drift in the minimum inhibitory concentrations (MICs) of ceftriaxone and cefixime to N. gonorrhoeae,
Cross-protective efficacy of HPV-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by non-vaccine oncogenic HPV types: 4-year end-of-study analysis of the randomised, double-blind PATRICIA trial.
Persistent infection with high-risk (HR) human papillomavirus (HPV) is the underlying cause of cervical cancer.
There are two licensed prophylactic HPV vaccines: Cervarix™ targeting 16/18 and Gardasil® targeting 16/18 and HPV types 6/11 that cause genital warts. Clinical trials of both vaccines demonstrate high vaccine efficacy for prevention of cervical intraepithelial neoplasia grade 2 or greater (CIN2+).
The contraceptive efficacy and tolerability of a new flexible extended regimen of ethinylestradiol (EE) 20 μg/drospirenone (DRSP) 3 mg to extend the menstrual cycle and enable management of intracyclic (breakthrough) bleeding (flexibleMIB) was investigated and the bleeding pattern compared with a conventional 28-day regimen and a fixed extended 124-day regimen.
This Phase III, 2-year, multicentre, open-label study randomly (4:1:1) allocated women (aged 18–35 years) to the following regimens: flexibleMIB (24–120 days' active hormonal intake with 4-day tablet-free intervals); conventional (24 days' active hormonal intake followed by a 4-day hormone-free interval); or fixed extended (120 days' uninterrupted active hormonal intake followed by a 4-day tablet-free interval). Primary outcomes included the number of bleeding/spotting days during Year 1 (all regimens) and the number of observed unintended pregnancies over 2 years (flexibleMIB only).
Results were analysed in 1067 women (full analysis set). The mean number of bleeding/spotting days was lower with the flexibleMIB vs the conventional regimen [41.0±29.1 (95% CI 38.8–43.3) vs 65.8±27.0 (95% CI 62.2–69.4) days, p<0.0001; treatment difference –24.8 (95% CI –29.2 to –20.3) days]. The corresponding value for the fixed extended regimen was 60.9±51.1 (95% CI 53.9–67.9) days. The Pearl Index for the flexibleMIB regimen was 0.64 (95% CI 0.28–1.26). All regimens had comparable tolerability profiles.
EE 20 μg/DRSP 3 mg administered as a flexible extended regimen with MIB is effective, well tolerated and is associated with statistically significantly fewer bleeding/spotting days and fewer withdrawal bleeding episodes vs EE/DRSP in a conventional 28-day regimen. The flexibleMIB also provided statistically significantly fewer spotting days vs EE/DRSP in a fixed extended 124-day regimen (post hoc evaluation). The flexibleMIB regimen allows women to extend their menstrual cycle and manage their intracyclic (breakthrough) bleeding.
This study was designed to assess the long-term safety and tolerability of a new flexible extended regimen of ethinylestradiol (EE) 20 μg/drospirenone (DRSP) 3 mg, which allows management of intracyclic (breakthrough) bleeding [flexible management of intracyclic (breakthrough) bleeding (MIB)], in comparison to conventional 28-day and fixed extended regimens.
In this Phase III, multicentre, open-label study, women (aged 18–35 years) were randomised to EE/DRSP in the following regimens: flexibleMIB (24–120 days' active hormonal intake followed by a 4-day tablet-free interval), conventional 28-day (24 days' active hormonal intake followed by a 4-day hormone-free interval) or fixed extended (120 days' uninterrupted active hormonal intake followed by a 4-day tablet-free interval) during a 1-year comparative phase. Thereafter, women entered a 1-year safety extension phase in which the majority received the flexibleMIB regimen. Safety/tolerability outcomes were measured over 2 years. A separate analysis of certain safety parameters (endometrial, hormonal, lipid, haemostatic and metabolic variables) was conducted at two of the study centres.
Results were analysed in 1067 and 783 women in the comparative and safety extension phases. Overall, 56.3% of women experienced ≥1 adverse event (AE) in the safety extension phase. Serious AEs occurred in 3.0%, 1.4% and 3.3% of women receiving the flexibleMIB, conventional and fixed extended regimens, respectively. No unexpected endometrial, hormonal, lipid, haemostatic or metabolic findings occurred with any of the three regimens.
EE/DRSP in a flexible extended regimen with management of intracyclic (breakthrough) bleeding is well-tolerated and, when administered for up to 2 years, has a good safety profile comparable to other estrogen/progestogen oral contraceptives.
In Part One, protagonist Tony Webster recalls his admiring friendship with a school friend Adrian, his doomed relationship with sexually-withholding Veronica, his ambivalent reaction when Veronica and Adrian later become partners, and his shock when the latter kills himself. The descriptions of fumbled, teenage sexuality in those post-pill years are beautifully drawn, not only convincing but also humorous: "Wasn't this the Sixties? Yes, but only for some people and only in some parts of the country...".
Part Two brings us to the present day, when Tony – a pensioner now and divorced father – is forced to reassess everything he remembers of those days, when Veronica's mother leaves a message for him in her will. Trying to both grasp...]]>
The aim of this Phase III, multicentre, open-label, randomised study was to compare the efficacy and safety of ethinylestradiol (EE)/drospirenone (DRSP) in a new flexible extended regimen that allowed the management of intracyclic (breakthrough) bleeding (MIB) with that of EE/DRSP in a conventional 28-day regimen in women with moderate-to-severe primary dysmenorrhoea.
Women (aged 18–40 years) with moderate-to-severe primary dysmenorrhoea-related pain received a flexible extended regimen with MIB (flexibleMIB; minimum 24, maximum 120 days of continuous tablet intake for a flexible number of cycles to reach a treatment duration of at least 140 days with 4-day breaks between cycles) or a conventional 28-day regimen (24 active and four placebo tablets for five cycles) of EE/DRSP. The primary outcome was the number of days with dysmenorrhoeic pain over 140 days. Secondary outcomes included other dysmenorrhoea-related pain outcomes, bleeding profile, satisfaction and safety.
Overall, 223 patients received study medication. There were significantly fewer days with dysmenorrhoeic pain with the flexibleMIB regimen than the conventional regimen (difference –4.2 days, 95% CI –6.5 to –2.0; p=0.0003), as well as considerably fewer days with at least moderate dysmenorrhoeic pain (difference –2.5 days, 95% CI –3.7 to –1.3), dysmenorrhoeic pain that interfered with daily activities (difference –2.2 days, 95% CI –4.2 to –0.1) and pelvic pain (difference –3.4 days, 95% CI –5.9 to –0.9). Adverse events were similar with both regimens.
Compared with the conventional regimen, the flexible extended regimen of EE/DRSP with MIB was associated with a significantly greater reduction in days with dysmenorrhoeic pain in women with moderate-to-severe primary dysmenorrhoea. The flexibleMIB regimen was also associated with greater improvements in dysmenorrhea according to the Clinical Global Impression rating scale and was generally well tolerated.
This edition has two new editors, both experts and subspecialists in their field: Professor David Luesley has edited the Gynaecology Oncology section and Mr Ash Monga the one on Urogynaecology. The editors hope that this new edition will look forward to the challenges of the 21st century, updating readers on all major advances since the previous edition was published in 2003. The editors claim that the book will serve as a comprehensive text for the established specialist and a resource for trainees preparing for examinations as well as general practitioners.
The book comprises five sections: Basic Principles and Investigations, Reproductive Medicine, Benign and Malignant Tumours, Urogynaecology and...]]>
Based principally on findings in three studies, the collaborative reanalysis (CR), the Women's Health Initiative (WHI) and the Million Women Study (MWS), it is claimed that hormone replacement therapy (HRT) with estrogen plus progestogen (E+P) is now an established cause of breast cancer; the CR and MWS investigators claim that unopposed estrogen therapy (ET) also increases the risk, but to a lesser degree than does E+P. The authors have previously reviewed the findings in the CR and WHI (Parts 1–3).
To evaluate the evidence for causality in the MWS.
Using generally accepted causal criteria, in this article (Part 4) the authors evaluate the findings in the MWS for E+P and for ET.
Despite the massive size of the MWS the findings for E+P and for ET did not adequately satisfy the criteria of time order, information bias, detection bias, confounding, statistical stability and strength of association, duration-response, internal consistency, external consistency or biological plausibility. Had detection bias resulted in the identification in women aged 50–55 years of 0.3 additional cases of breast cancer in ET users per 1000 per year, or 1.2 in E+P users, it would have nullified the apparent risks reported.
HRT may or may not increase the risk of breast cancer, but the MWS did not establish that it does.
A significant number of women are referred with bleeding problems related to the use of hormonal contraception, for advice on management of heavy periods or following difficulty with intrauterine device insertion. The authors describe their experience with Instillagel® as the contrast medium for hysterosonography in a one-stop clinic for complex contraception referrals. They also comment on its analgesic properties for cervical and uterine instrumentation.
The authors reviewed 275 referrals seen over a 6-month period in consultant-delivered clinics provided by a contraception service that serves a single county (population 500 000). They describe the simple technique they use for hysterosonography with Instillagel.
The authors found Instillagel useful as a contrast medium for sonographic assessment of the endometrial cavity. Additionally, presence of gel in the endometrial cavity, with a time interval between insertion of gel and uterine instrumentation, appears to result in analgesia and relaxation of the uterus. There was a very low incidence of difficulties in a group of patients who had previously experienced significant problems with uterine instrumentation.
Hysterosonography is an efficacious, simple and inexpensive technique for assessment of the endometrial cavity. It has many potential applications in contraceptive care. An additional benefit appeared to be that once gel was instilled in the cavity for 10–15 minutes it facilitated instrumentation of the uterus.
This comment,
It reflects on Fraumeni's work, who reviewed cancer mortality data of nuns in the USA for the period 1900–1954, which showed an increase in mortality in nuns from breast cancer at all ages, and an increase in later life of uterine and ovarian cancer.
We owe a lot to scientists such as Baulieu
Early medical abortion has a key role to play in reducing unsafe abortion around the world, particularly in resource-poor settings where inadequate surgical services for abortion entail a high risk of infection and reproductive tract injury.
You might think that with the shadow of cancer underpinning the day, the mood would be solemn. Nothing could be further from the truth. Yes, there were tears. Yes, there was anger – often, it has to be admitted, against clinicians who while providing superb medical care, sometimes failed to relate to patients on a more human level. But these expressions of emotion only served to fuel the determination of...]]>
The involvement of a lay support person, known as a doula, in the labour process is a long-standing practice across different cultures and traditions. A great body of literature exists evaluating the effect of a support layperson within the labour process on maternal and neonatal outcomes. This literature demonstrates a positive association between doula support and decreased labour time, oxytocin utilisation, Caesarean section rates and need for epidural/anaesthesia.
One such setting in which doula support would be highly beneficial is in abortion care. Abortion is a stressful event regardless of a woman's circumstances. Unlike pregnancy...]]>
Even someone with only the most basic understanding of medical history knows that Hippocrates is viewed as the father of medicine and that the Hippocratic Oath forbids a physician from giving a woman an abortive remedy or giving the woman the means of procuring an abortion.
The translation of the Hippocratic Oath has been the subject of much debate as some academics claim that translations over the years through the medieval period and beyond have been general rather than specific. It is important to appreciate that these broad translations fitted nicely into ecclesiastical teachings in the medieval period giving dogma the extra foundation of classical teachings. Some may argue this is a cynical view but what is undeniable according to historians such as Professor John Riddle is that the line on abortion in the original Hippocratic Oath literally translates that the physician must not "......]]>
It is not so long ago – and certainly within the living memory of many Journal readers – that health professionals were gods. To be slightly more precise when it comes to definitions of the spheres of Heaven, nurses were ministering angels, the general practitioner (GP) was a benign and infallible minor deity, while the consultant – particularly in life-or-death specialties such as childbirth or oncology – was Jupiter Himself. One may note the gender of the reflexive pronoun.
Times have changed in medicine as well as in religion. Nowadays if we have not quite reached the Age of Reason, we are certainly living in an age of reasonable doubt. Society now rarely affords health professionals the same quasi-divine status; where there was faith now there are benchmarks and targets, where there was utter trust now there are tabloid headlines, public enquiries and questions in the House.
...]]>The topics covered include STIs and an explanation of test results, vaginal discharge, gonorrhoea, genital herpes, warts, syphilis, hepatitis, tropical infections, non-specific genital infections and, finally, HIV. There is a very useful chapter on understanding...]]>
In 1987, the threat of litigation led to the withdrawal of intrauterine devices (IUDs) from the American market where depot medroxyprogesterone acetate (DMPA) had already been banned. There were fears of repercussions that would have led to the limiting of contraceptive choice in Britain. HIV was also an emerging issue and a revival of interest in barrier contraception led to an emphasis on male condoms, with strengthening of manufacturing standards, promotion in the media, improved accessibility and emphasis of their value for dual protection. Twenty-five years later, links still need to be sought within reproductive health services, especially at the interface between the management of contraception and opportunities for HIV prevention.
An editorial in this Journal in 1987
Every day in the UK three women die from cervical cancer with another eight diagnosed and facing an uncertain future. In addition around 300 000 women a year are told they have an abnormality that might require treatment. Jo's Cervical Cancer Trust (http://www.jostrust.org.uk) is the UK's only charity dedicated to those affected by cervical cancer and cervical abnormalities. We are a national charity and our head office is in London, UK; we have four full-time members of staff.
The charity was set up by James Maxwell in memory of his wife Jo, who died from cervical cancer at the age of 40 years. Following Jo's diagnosis she (and James) had difficulty finding good information about every aspect of cervical cancer. It was their hope that one day everyone would have easy...]]>
Putting emotions aside, there are some problems with the original analysis of the Million Women Study (MWS). This type of study cannot make allowances for every possible bias, and as we are all aware ‘big is not necessarily better’ when biases are present. The statistically significant differences seen in the MWS are still very small,...]]>
Ever since these papers 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 years. More importantly, had these...]]>
Following the publication of papers regarding the risk of venous thromboembolism (VTE) with combined oral contraceptives (COCs) we would like to share some information regarding comparison between drospirenone-containing COCs and other COCs in Croatia. This short study was conducted during the 3-year period 2008–2010 using data on drug utilisation and data on side effects from the Agency for Medicinal Products and Medical Devices of Croatia (HALMED). The total female population aged 15–49 years was about 1 050 000. Like other COCs in Croatia, drospirenone/ethinylestradiol (DRSP/EE) is issued on private prescription in pharmacies. They are usually prescribed by gynaecologists, but may also be prescribed by other specialists. The DRSP-containing COC, Yasmin®, existed in the Croatian market from 2005, but the new DRSP-containing COC, Yaz®, was introduced in 2010.
...]]>We recently reviewed the recorded HIV status of patients from countries of high HIV prevalence (>1%) in our practice in Portsmouth, UK (an area with an HIV prevalence of less than 0.2%), identifying 124 patients born in sub-Saharan African countries.
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.
A total of 150 case notes of patients attending for pregnancy counselling prior to potential referral for a termination of pregnancy were analysed. Analysis was related to the offer of an HIV test, acceptance of the test and the reasons for declining the test. Overall 102/150 (68%) were offered the test and 21/102 (21%) accepted testing. Of the 81/102 who declined testing, 33 had recorded reasons in their notes for declining the test. Eight of these 33 patients stated that they had had the test...]]>
The Homerton Hospital, East London, UK has been performing opt-out HIV testing in the TOP unit since April 2008 and has an uptake of 60%.
All women attending the colposcopy unit of Homerton Hospital between 1 September 2010 and 28 February 2011 were offered opt-out HIV testing at the time of their colposcopy appointment. HIV testing was performed by point of care testing (Insti™ HIV Antibody Test, Pasante Healthcare, Hove, UK) and results were given immediately. Any woman with a reactive...]]>
In 2006 the Faculty of Family Planning and Reproductive Health Care (now the Faculty of Sexual and Reproductive Healthcare) Clinical Effectiveness Unit published UK guidance on the prescribing of EC.
None.
Semi-structured interviews were conducted with Muslim and non-Muslim women. The respondents for this qualitative study were recruited through the maternity departments of three university hospitals and one general hospital. The study was approved by the ethics committees of the hospitals where this study took place.
A total of 15 Muslim and 15 non-Muslim women...]]>
Women who presented requesting an IUD for contraception were recruited for the study. After consent was obtained women were randomised (using block randomisation) to either the copper IUD or Mirena. Each woman completed a questionnaire at 1, 3 and 6 months post-insertion to assess side effects.
There was a higher incidence of dysmenorrhea and backache at 3 months with the copper device. Those women with a Mirena had higher rates of spotting and bleeding at 1, 3 and 6 months and higher rates of headache and breast tenderness at 3 and 6 months.
Menstruation and...]]>
Despite a controversial and chequered history of sterilisation generally, the sterilisation of women in India today represents the overwhelming choice of Indian couples. About 37% of married women of reproductive age have chosen sterilisation,
During the 1960s, several Indian states began providing compensation to cover the out-of-pocket costs for couples who accepted sterilisation. At that time, vasectomy was by...]]>
The family moved to St Athan in South Wales when Yvonne was a toddler and then to Stroud, Gloucestershire. After a posting in Singapore for 3 years the family returned to Gloucestershire in 1963 and Yvonne completed her schooling at Stroud Girls High School. There she was Head Girl even though she was the youngest in her class. She qualified from Newcastle University in 1975 where she did her first house job, moving to Hope Hospital in Salford for her second job and to marry Michael.
Yvonne thought she might want to specialise in psychiatry but after a 6-month...]]>