Ailsa E Gebbie

Hormonal contraceptive regimens in the perimenopause

Perimenopausal women have low fertility but still need contraception if they are sexually active. They often have co-existing menstrual problems and menopausal symptoms. No method of contraception is contraindicated by age alone. In addition to highly effective contraception, hormonal methods offer non-contraceptive benefits which can improve quality of life for perimenopausal women. Combined hormonal oral contraception has been available for many decades. The combined vaginal ring and transdermal patch are newer methods offering alternative delivery systems but similar risk profiles to oral preparations. New combinations containing naturally occurring estrogens in place of the synthetic hormone ethinylestradiol are now available and, in theory, could be safer. The progestogen-only methods have an excellent safety profile and have a range of delivery systems and dosages to suit all. Concerns regarding loss of bone mineral density with the injectable depot medroxyprogesterone acetate continue but to date there is no evidence that this translates into higher fracture risk. Effective use of any method of contraception is strongly dependent on good counselling and support from healthcare professionals. Risks should be explained in absolute terms for each individual woman, enabling her to make an informed choice on evidence-based medicine and not influenced by ill-informed media publicity.

The contraception needs of the perimenopausal woman.

Perimenopausal women have low fertility but must still be advised to use contraception until natural sterility is reached if they are sexually active. Patterns of contraceptive use vary in different countries worldwide. Long-acting reversible contraceptive methods offer reliable contraception that may be an alternative to sterilisation. Hormonal methods confer significant non-contraceptive benefits, and each individual woman should weigh up the benefits and risks of a particular method. No method of contraception is contraindicated by age alone, although combined hormonal contraception and injectable progestogens are not recommended for women over the age of 50 years. The intrauterine system has particular advantages as a low-dose method of effective hormonal contraception, which also offers control of menstrual dysfunction and endometrial protection in women requiring oestrogen replacement. Condoms are recommended for personal protection against sexually transmitted infections in new relationships. Standard hormone replacement therapy is not a method of contraception.

Managing unscheduled bleeding in non-pregnant premenopausal women

#### Summary points Unscheduled vaginal bleeding—bleeding that occurs outside the normal menstrual period or the regular withdrawal bleed associated with the combined oral contraceptive pill—is a common reason for women of reproductive age to attend primary care. It is also referred to as intermenstrual bleeding. As well as intermenstrual bleeding, unscheduled bleeding also includes postcoital bleeding; it can be difficult to distinguish between the two because they often occur together. Because postcoital bleeding may have different implications, the causes of both need to be considered in a woman with unscheduled bleeding. Irregular bleeding associated with hormonal contraception is generally called breakthrough bleeding. In a study of women presenting to primary care with menstrual problems, 36% of women reported intermenstrual bleeding or postcoital bleeding in addition to heavy menstrual loss.1 Unscheduled bleeding causes anxiety and concern because it can be a presenting symptom for gynaecological cancer, particularly cervical and endometrial cancer. This symptom can also be associated with other menstrual disorders, such as heavy menstrual bleeding, particularly when caused by benign lesions such as fibroids or endometrial polyps, but also heavy menstrual bleeding of no known cause (formally called dysfunctional bleeding). However, it …

Improving the clarity and consistency of advice on missed contraceptive pills in the UK

We write to report the findings of a questionnaire study within a large family planning centre in the UK that examined womens knowledge and understanding of the current missed pills rules. Three different sets of missed pill rules have been available to the 3.5 million combined oral contraception (COC) users in the UK. The guidance from the World Health Organization and the Faculty of Sexual and Reproductive Healthcare (FSRH) reflected the current scientific, evidence-based recommendations.1 This evidence-based guidance was not reflected in UK National Licences [in patient information leaflets (PIL)] or, in full, by the British National Formulary. …

Clinicians’ views on low-lying intrauterine devices or systems

Background There is a lack of consensus and very little published guidance on the management of a low-lying or malpositioned intrauterine contraceptive device (IUD) or system (IUS). Methods and results A short e-mail questionnaire sent to senior medical staff working in contraceptive services confirmed the variation in views and management of this clinical area. Almost all respondents would replace an IUD/IUS lying either totally or partially in the cervical canal. The nearer the device was to the fundus the more likely respondents were to leave it in situ and there was less concern if the device was an IUS, presumably in view of the hormonal action. In the presence of abnormal bleeding or pain, most respondents would look for other causes rather than assume that the low-lying device was to blame. Respondents expressed uncertainty as to whether low-lying devices were more likely to fail or not and around half the respondents felt that low-lying devices could migrate upwards within the cavity. Conclusion This survey highlighted the need for accurate evidence-based guidance to assist in this area of clinical contraceptive practice.

Contraception in the perimenopause – old and new

This review article discusses contraception for women in the perimenopause phase - the final period which is characterized by menstrual irregularity and the onset of menopausal symptoms such as hot flushes. It addresses the subject of choosing and using the appropriate contraception as well as discontinuing contraception. More specific information is provided on the different contraceptive options including: combined hormonal contraception progestogen-only contraception emergency contraception and barrier methods.

Family Planning/Contraception

Family planning is widely used throughout the world but uptake of the individual methods varies enormously in different countries. Hormonal contraception is available in many delivery systems and the combined contraceptive pill is a safe and popular method. Barrier methods of contraception offer significant protection against sexually transmitted infections and, in particular, condoms are recommended to reduce the transmission of HIV/AIDS. Fertility awareness methods are of value to individuals who lack access or have objections to artificial methods. Both men and women can have permanent sterilization, however vasectomy is a technically easier, safer, and more effective procedure than female sterilization.

‘All singing, all dancing’: staff views on the integration of family planning and genitourinary medicine in Lothian, UK

Background UK policy documents advocate integrated approaches to sexual health service provision to ensure that everyone can access high-quality treatment. However, there is relatively little evidence to demonstrate any resultant benefits. The family planning and genitourinary medicine services in Lothian have been fully integrated and most care is now delivered from a purpose-built sexual health centre. We wished to study the views of staff on integrated sexual and reproductive care. Methods Staff completed anonymous questionnaires before and after integration, looking at four main aspects: the patient pathway, specific patient groups, their own professional status, and their working environment. The surveys used a mixture of five-point Likert-type scales and open-ended questions. Results Over 50% of staff completed the surveys on each occasion. Six months after the new building opened, staff attitudes about the integrated service were mixed. Staff reported more stress and less opportunity for specialisation but there was no change in their sense of professional status or development. There were concerns about how well the integrated service met the needs of specific patient groups, notably women. These concerns co-existed with a verdict that overall service quality was no worse following integration. Conclusions Staff views should form an important part of service redesign and integration projects. Although the results from the Lothian surveys suggest a perceived worsening of some aspects of the service, further evaluation is needed to unpick the different problems that have appeared under the catch-all term of ‘integration’.

Management of menopausal symptoms after cancer and risk-reduction bilateral oophorectomy: a move towards consensus.

As more women survive reproductive cancers, menopausal symptoms following treatment can be a significant problem affecting quality of life and wellbeing. Hormone replacement therapy may or may not be contraindicated. Women often receive conflicting information about their management from different specialists. The aim of this study, based in a regional menopause clinic, was to examine referral patterns and symptom profiles of women with cancer or at high risk of cancer; to identify areas of need where a more integrated approach to management might be required; and to reach a local consensus across disciplines involved in the care of these women regarding prescribing of hormonal therapies. A retrospective case record review of all women attending Edinburgh Menopause Clinic for one 12-month period in 2011/2012 for management of cancer-related menopausal symptoms was undertaken. The results of the review were discussed at a multidisciplinary meeting and regional guidance on the management of these women was agreed. There has been an immediate improvement in communication between departments and the quality of information received in referral letters.

The new specialty training for future consultants in sexual and reproductive health.

©FSRH J Fam Plann Reprod Health Care 2010: 36(2) Background There is widespread acknowledgement that the UK has poor levels of sexual health compared to our immediate European neighbours. The reasons for this are deep seated, complex and not easily amenable to change. One important part of the solution is to raise and sustain a high quality of community-based clinical sexual and reproductive health (SRH) services within the National Health Service (NHS); services which until recently suffered from a low priority and major disinvestment. Sexual health strategies from all four devolved UK nations have supported the concept of strong clinical leadership for multidisciplinary and multiprofessional SRH teams within the NHS in order to achieve targets such as reducing teenage pregnancy, abortion and sexually transmitted infection rates. Leadership of effective specialist SRH services is only possible if clinicians have received an appropriate and ‘fit for purpose’ training. The first tranche of consultants appointed in the late 1980s were largely from an obstetrics and gynaecology (O&G) background. More recent consultant appointments have been to individuals, who again trained in O&G, but who had acquired specific knowledge and skills by undertaking the subspecialty training in sexual and reproductive health of the Royal College of Obstetricians and Gynaecologists (RCOG). All recent workforce census figures have shown a serious shortage of appropriately trained consultants to meet the current vacancies and those likely to arise in the near future. In addition, subspecialty posts in SRH are often unfilled because of a lack of suitable trainees with a genuine commitment to the specialty. As trainees have to complete 5 years of mainstream O&G with in-depth obstetrics before undertaking subspecialty training, they have often missed the opportunity to be exposed to the challenges and breadth of SRH. One other significant factor has strongly impacted on the situation. SRH now has a solid core of doctors working in the specialty who have consolidated their specialist knowledge by achieving the Membership examination of the Faculty of Sexual and Reproductive Healthcare (MFSRH). Some will also have undertaken structured Faculty training as career grade trainees. These doctors have great difficulty applying to the Postgraduate Medical Education Training Board (PMETB) for equivalence of training to lead to a Certificate of Completion of Training (CCT) because the current criteria are determined by the core specialty of O&G. A separate ‘fit for purpose’ training programme in SRH would pave the way for these clinicians to apply for assessment of equivalence in the new specialty, which would lead to eligibility for a Certificate of The new specialty training for future consultants in sexual and reproductive health