Christian Fiala

Rh‐prophylaxis in early abortion

In most countries anti-D immunoglobulin G (anti-D IgG) is given to rhesus (Rh)-negative women, although evidence is lacking for the need of this intervention after abortion in early pregnancy. This is especially true for medical abortion, which has been used increasingly in recent years. Mifepristone was approved for medical abortion in France in 1988 under the brand name of Mifegyne. The UK and Sweden followed in 1991 and 1992, respectively, and most other European countries in 2000. So far more than one million women have used this method in Europe alone, and the use is still increasing. The need for the application of immunoglobulin in medical abortion has never been evaluated. The necessity seems questionable when the intervention is performed in early pregnancy and in many cases even before a fetal heart rate can be demonstrated by ultrasound. The Swedish Board of Health and Welfare gave a recommendation against the use of anti-D IgG in early spontaneous or medical abortions in 1997. However, there is still no evidence-based analysis for or against prophylaxis. This leads to regional variations in the treatment of early abortion. This paper reviews publications on this subject with the particular aim of providing a background for recommendations or further research initiatives. A review of this kind could not be found in the literature, and has probably not been done recently.

Women’s preferences for menstrual bleeding frequency: results of the Inconvenience Due to Women’s Monthly Bleeding (ISY) survey

Abstract Objectives: Our aim was to assess the level of inconvenience associated with monthly bleeding, determine how many women would prefer a bleeding frequency of less than once a month, and what would motivate their choice. Methods: A 15-min quantitative online survey was carried out among 2883 women aged between 18 and 45 years in six European countries (Austria, Belgium, France, Italy, Poland and Spain). Results: Of those surveyed, 1319 women used a combined hormonal contraceptive (CHC group) and 1564 used a non-hormonal contraceptive or no contraceptive (non-HC group). The menstrual period was significantly longer (5 vs. 4.5 days), heavier (16% vs. 8% heavy menstrual flow) and associated with more symptoms (6.1 vs. 5.6) in non-HC users than in CHC users (pu2009<u20090.0001). More than half of the women in each group reported pelvic pain, bloating/swelling, mood swings and irritability, but the rate was significantly higher in the non-HC group. Given the choice, 57% of women in both groups said they would opt for longer intervals between periods. Sexuality, social life, work and sporting activities were key factors affecting their decision. Conclusions: The majority of women would prefer to have menstrual periods less than once a month, with a frequency ranging from once every 3 months to no periods at all. This can be explained by the desire to avoid the unpleasant aspects of menstruation and its negative impact on private and professional life.

Women’s preferences for menstrual bleeding frequency in 12 European countries: the Inconvenience Due to Women’s Monthly Bleeding (ISY) survey

Abstract Objectives: Our aim was to assess the level of inconvenience associated with menstrual bleeding and determine how many women across 12 European countries would prefer a bleeding frequency of less than once a month and what would motivate their choice. Methods: A 15-min quantitative online survey was conducted in two waves among 5728 women aged between 18 and 45 years, with an equal distribution of women using a combined hormonal contraceptive (CHC group, nu2009=u20092739) and women using a non-hormonal contraceptive or no contraceptive (non-HC group, nu2009=u20092989). The first wave was carried out in Austria, Belgium, France, Italy, Poland and Spain, in February 2015, and the results have been published. The second wave was conducted in the Czech Republic, Germany, Hungary, Portugal, Latvia and the Netherlands, between August and September 2015. Results: The menstrual period was significantly longer (5.0 versus 4.6 days) and heavier (15 versus 7%) in non-HC users than in CHC users (pu2009<u2009.0001). Given the choice, ∼60% of women would like less frequent menstrual bleeding. There was heterogeneity in the preference across countries. Sexuality, social life, work and sporting activities were key factors affecting women’s preference. Conclusion: The majority of women in the 12 European countries would prefer to reduce the frequency of menstrual periods. Quality of life was the main factor affecting their preference.

Male perception about the inconveniences associated with monthly bleeding for their partner–an international survey

Abstract Objective: To assess men’s perceptions about monthly bleeding and associated inconveniences for their partner, as well as men’s attitudes regarding the desired menstruation frequency for their partner and knowledge about hormonal contraceptives. Methods: A 15u2009min quantitative online survey was conducted among 5044 men aged 18–45 years, who had been in a relationship for more than 6 months, across 13 European countries (Austria, Belgium, Czech Republic, France, Germany, Hungary, Italy, Latvia, The Netherlands, Poland, Portugal, Spain and Switzerland). Responses were compared to those obtained in a similar study among European women. Results: Most men perceived that their partner considered her menstrual flow as moderate, lasting an average of 5.2 d, slightly longer than previously reported by women. Almost all men reported that their partners experience menstruation-related symptoms. However, prevalence of mood-related symptoms was perceived to be more frequent and physical symptoms less frequent, relative to women’s self-reported symptoms. Given the option, 71% of men would choose longer intervals between their partner’s periods. Maintaining the couple’s sex life, social life and relationship quality were key factors cited in their preference. Overall, 42% of respondents stated that women taking hormonal contraceptives needed to have monthly periods. Conclusions: Men’s perception regarding their partner’s periods was generally consistent with that previously reported by women. Most men would prefer less frequent bleeding episodes for their partners. Although, the present data suggest that couples are discussing periods, knowledge about contraception could be improved. Health care professionals should intensify counselling to better inform both partners about their contraceptive options.

The FSRH guideline on conscientious objection disrespects patient rights and endangers their health

We write to offer feedback on the new Faculty of Sexual & Reproductive Healthcare (FSRH) guideline1 on conscientious objection (CO) that was the subject of an editorial2 in the January 2018 issue of this journal. Our position, for which we have a clear evidence base, is set out below.nnEssential parts of the new FSRH guideline,1 as well as the reasoning behind it, contradict the available evidence around the practice of CO, so we predict that the guideline will largely fail in practice.nnWe have written extensively on the problem of so-called CO in reproductive healthcare.3 The available evidence clearly shows that CO is a violation of medical ethics and patients’ rights, has no place in reproductive healthcare, and has misleadingly been co-opted from military CO. CO in healthcare is about imposing one’s religious or personal beliefs, including any negative …

The dishonourable disobedience of not providing abortion

We thank Lesley Bacon for her response (‘Conscientious objection to abortion’, EJCRHC, 2016;21:5;414–415) to the papers in the June 2016 Journal on conscientious objection. As authors of one of these papers (‘Yes We Can! Successful examples of disallowing “conscientious objection” in reproductive health care’, EJCRHC, 2016;21:5:201–206), we would like to address the points she raises. We agree with Dr. Bacon that if we ever see the return of human rights violations like coercive contraception or eugenics, we will need HCPs with a conscience to be disobedient to such practices, and that would not be dishonourable. However, the type of conscientious objection that qualifies as ‘dishonourable disobedience’, is where an HCP refuses to provide a legal medical procedure that the patient requests and needs, not something imposed upon her. Also, providing a stigmatized or even illegal treatment that the patient requests and needs – such as safe abortion – is an act of ‘conscientious commitment’, a term coined by Canadian ethicist and legal scholar Dickens.[1] Refusing to provide a treatment that is harmful, coercive or done without patient consent, would be true conscientious objection (examples are torture or infant/child genital mutilation). Dr. Bacon also questions whether conscientious objection is really the main barrier to abortion care, when legal and organisational barriers are also major contributors. She points to examples of laws that reduce access, and also suggests that if abortion was done by a much wider range of HCPs, not just obstetricians/gynaecologists, this would greatly improve access. It is certainly true that abortion access is hampered by many legal and organisational barriers, and we agree that conscientious objection is not the only barrier, although it is a major problem in some regions and the hugely negative consequences for women cannot be ignored. Further, we would point out that most if not all barriers to abortion care are either the result of stigma (such as criminal laws), or are worsened by stigma, including how abortion practice tends to be limited to mostly obstetricians/gynaecologists. Expanding the field of abortion care to other HCPs such as nurses and midwives is a necessary and welcome reform, and has been shown to be safe, well accepted and cost effective, as implemented in Sweden.[2,3] However, making that happen is challenging in many countries because of abortion stigma and politics. While stigma negatively impacts almost every aspect of abortion care to some degree, ‘dishonourable disobedience’ is a form of full-blown, officially-approved stigma, which makes it particularly unsupportable, especially when abortion access is already curtailed by stigma in so many other ways.

The inconvenience due to women’s monthly bleeding (ISY) survey: a study of premenstrual symptoms among 5728 women in Europe

Abstract Objectives: The aim of the ISY study was to investigate the prevalence of menstrual-related symptoms prior to and/or during menstrual or withdrawal bleeding among women from 12 European countries. Methods: A 15-min quantitative online survey was conducted in two waves from February to September 2015 among 5728 women aged between 18 and 45 years, with an equal distribution of women using a combined hormonal contraceptive, including regular combined oral contraceptives (COCs) (CHC group, nu2009=u20092739) and women using a non-hormonal contraceptive or no contraceptive (non-HC group, nu2009=u20092989). Results: The prevalence of at least one menstrual-related symptom was high in CHC users (93%) and in non-HC users (95%) (pu2009<u2009.0001) and the average number of symptoms reported was 5.3 vs. 5.9, respectively, (pu2009<u2009.0001). Pelvic pain, bloating/swelling, irritability and mood swing were reported in more than half of the women in both groups. Although generally modest, symptom severity was higher in non-HC users, except for headache. Overall, during the last four cycles, 60–75% of women did not require a treatment for most symptoms but headaches and pelvic pain. Mood swings/irritability, water retention/weight gain, lack of energy/mood swings and lack of energy/irritability were common symptoms that frequently co-occurred. No associations were reported between symptoms and age, educational qualifications or women’s desire to reduce the frequency of menstruation. Conclusions: Premenstrual and menstrual symptomatology was less frequent, less numerous and less severe (except for headache) in women using CHCs; however, it remains a common concern. Reducing the frequency of menstrual periods could reduce withdrawal-related symptoms.

Missed pills: frequency, reasons, consequences and solutions

Abstract Objectives: Oral hormonal contraception is an effective contraceptive method as long as regular daily intake is maintained. However, a daily routine is a constraint for many women and can lead to missed pills, pill discontinuation and/or unintended pregnancy. This article describes the frequency of inconsistent use, the consequences, the risk factors and the possible solutions. Methods: The article comprises a narrative review of the literature. Results: Forgetting one to three pills per cycle is a frequent problem among 15–51% of users, generally adolescents. The reasons for this are age, inability to establish a routine, pill unavailability, side effects, loss of motivation and lack of involvement in the initial decision to use oral contraceptives. The consequences are ‘escape ovulations’ and, possibly, unintended pregnancy. Solutions are either to use a long-acting method or, for women who prefer to take oral contraceptives, use a continuous or long-cycle regimen to reduce the risks of follicular development and thus the likelihood of ovulation and unintended pregnancy. A progestogen with a long half-life can increase ovarian suppression. Conclusions: For women deciding to use oral contraceptives, a shortened or eliminated hormone-free interval and a progestogen with a long half-life may be an option to reduce the negative consequences of missed oral contraceptive pills.

Assessment of pain during medical abortion with home use of misoprostol

Abstract Objectives: Although medical abortion with home use of misoprostol has been shown to be safe and acceptable, there are few data about the experience of pain during the procedure. The aims of this study were to assess the intensity of pain associated with home use of misoprostol for medical abortion and to identify variables associated with severe pain. Methods: This was an observational study using an anonymous web-based questionnaire in patients having a medical abortion at home in France between 1 December 2013 and 30 April 2014. Results: The questionnaire was completed by 232 women and the results of 193 were retained for analysis. The average pain score was 5.6 on a 10 point scale. A pain score ≥6 was rated as severe and was reported by 105 patients (54%). Nulliparity (odds ratio [OR] 4.10; 95% confidence interval [CI] 2.04, 8.22; pu2009<u2009.0001), lack of choice regarding the method of abortion (OR 2.32; 95% CI 1.13, 4.78; pu2009=u2009.0218) and lack of information about the level of pain associated with the procedure (OR 3.27; 95% CI 1.09, 9.74; pu2009=u2009.0334) were significantly correlated with severe pain. Analgesic prescriptions were very heterogeneous. Conclusions: Pain remains the main side effect of medical abortion. More studies are needed on pain assessment and the effectiveness of analgesic treatments in women using misoprostol at home for medical abortion, in order to improve their care and improve evidence-based guidelines.

Development and conceptual validation of a questionnaire to help contraceptive choice: CHLOE (Contraception: HeLping for wOmen’s choicE)

Abstract Objective: The aim of this research was to develop a questionnaire to facilitate choice of the most appropriate contraceptive method for individual women. Methods: A literature review was conducted to identify key aspects influencing contraceptive choice and inform development of a questionnaire for online completion. Questionnaire development was overseen by a steering committee consisting of eight gynaecologists from across Europe. The initial draft underwent conceptual validation through cognitive debriefing interviews with six native English-speaking women. A qualitative content analysis was conducted to accurately identify potential issues and areas for questionnaire improvement. A revised version of the questionnaire then underwent face-to-face and online evaluation by 115 international gynaecologists/obstetricians with expertise in contraception, prior to development of a final version. Results: The final conceptually validated Contraception: HeLping for wOmen’s choicE (CHLOE) questionnaire takes ≤10u2009min to complete and includes three sections to elicit general information about the individual, the health conditions that might influence contraceptive choice, and the woman’s needs and preferences that might influence contraceptive choice. The questionnaire captures the core aspects of personalisation, efficacy and safety, identified as key attributes influencing contraceptive choice, and consists of 24 closed-ended questions for online completion prior to a health care provider (HCP) consultation. The HCP receives a summary of the responses. Conclusion: The CHLOE questionnaire has been developed to help women choose the contraception that best suits their needs and situation while optimising the HCP’s time.