Gillian Robinson

HIV and contraception.

Clearer guidelines I propose a Campaign for Clearer Guidelines. I was pleased to see the title for the most recent Guideline from the Clinical Effectiveness Unit (CEU)1 for managing vaginal discharge. This will be really useful in general practices and contraception clinics, I thought. But I was so disappointed with how difficult it was to understand. I am afraid most people will look at the title, start to read it and then put it unread into a drawer to ‘tackle it when I have time’, rather than actively using it in their clinical practice. Have the writers of the Guideline decided who the target audience is? The information seems poorly focused on the actual clinical setting in which it should be useful and contains large amounts of information irrelevant to health professionals working in general practice and contraception clinics. The vocabulary used is a mixture of medical and non-medical terms. For example, in the list of symptoms that might be identified are ‘itch’, ‘dysuria’ and ‘superficial dyspareunia’. A professional term would be pruritus vulvae or vulval itching – otherwise this might mean itching anywhere (is it scabies?). Contrast this Guideline with the one from the British Association for Sexual Health and HIV (BASHH) on bacterial vaginosis.2 The BASHH Guideline gives the full explanation of the meaningless section in Table 31 where information has been compressed and says: Nugent or Hay/Ison criteria: Gardnerella and/or Mobiluncus morphotypes predominant Score >6. Table 3 does not give the full criteria, nor explain to what the score refers. By contrast, the example from the BASHH Guideline2 is perfectly full and clear. However, as this is a bacteriological diagnosis made in the laboratory, why is the information supplied at all? Similarly, on page 38, why do we need to know: “Culture in Sabouraud’s medium can be used to detect candida if microscopy is inconclusive ...”? Readers will find other examples of superfluous and unnecessary information. The whole point was, I thought, to give a guideline to clinicians working in non-GUM venues. Table 4 sets out clearly the options for treatment (although a definition of what constitutes recurrent infection would be helpful) but then recommends readers to consult an up-todate British National Formulary. Why give the dosages in the first place, if the authors think (correctly) that you should check them out anyway? There are just too many words! Throughout the document, the excessive use of words obscures the usefulness of the rest of the information. The clear message of whether investigation is necessary or not is well presented in Figure 1 – but the information repeated under Boxes 2, 3 and 4. Why not just refer to the figure and remove the unnecessary text? I fail to see why information presented in Box 5 is then repeated in the text below. Surely, readers are able to refer back with a sentence: “Investigation is indicated if any of the conditions listed in Box 5 are present”. The addition of the small amount of qualifying information about the information in Box 5 then clarifies the statement. The same repetition of information in the summary boxes and in the text appears for almost every point. This wordy style of writing fails one of the most important criteria for communication. The easier the text, the more understandable information can be transferred from writer to reader. A guideline is useless unless used. I would propose that guideline writers should: Study the techniques of the Plain English Campaign3 Attend a course on writing skills, or read a book on writing skills4 Consult guidance on writing guidelines5 Allow those guidelines published in the Journal of Family Planning and Reproductive Health Care to be edited in exactly the same way as all articles to maintain quality in the Journal.

Integrated sexual health: a better way of working?

©FSRH J Fam Plann Reprod Health Care 2009: 35(4) Background In 2001, the Department of Health (DH) published the National Strategy for Sexual Health and HIV, which included a 10-year programme to improve sexual ill-health and modernise sexual health services in England.1 Crucial to the implementation of the Strategy was the integration of the services treating sexually transmitted infections (STIs) and those providing contraceptive guidance. Services were to be planned around patient need, and were to include choice, open access, extended opening hours and seamless care. Since 2001, commissioners within primary care trusts have therefore concentrated on seeking services, preferably integrated, that treat STIs and reduce teenage pregnancy. How this integration has been achieved varies; in some areas the hospital genitourinary medicine (GUM) department has expanded to include contraceptive provision, in others the contraceptive clinics provide a limited service for the testing and treatment of some STIs, whilst other areas have achieved a full merger resulting in a service that provides STI screening and contraceptive provision on one site. Theoretically this latter approach has many advantages: the disciplines of management of STIs, contraceptive provision and ‘medical gynaecology’ are closely related and it would certainly be in the patient’s interest if they were located in one clinic. However, the DH and commissioners do not appear to have considered that the main providers of treatment of STIs are physicians trained in general medicine who are members of the Royal College of Physicians, whilst those providing contraception services are members of the Faculty of Sexual and Reproductive Healthcare (FSRH) [formerly the Faculty of Family Planning and Reproductive Health Care (FFPRHC)], which is part of the Royal College of Obstetricians and Gynaecologists (RCOG). Consultants in either GUM or sexual and reproductive health (SRH) do not generally have specialist training in both disciplines. Integration to date has tended to result in one of the specialities dominating the other; my own perception is that GUM services have often overtaken the reproductive health services. This is perhaps inevitable given the government targets but it has focused service delivery on screening and testing for STIs with a corresponding loss of emphasis on conditions such as menorrhagia and other gynaecological conditions, which were often managed in contraceptive clinics.

XX FIGO World Congress of Gynecology and Obstetrics, Rome, Italy, 7–12 October 2012

Very little seems to have changed since I last attended an International Federation of Gynecology and Obstetrics (FIGO) conference over 20 years ago. At FIGO 2012 there were still many competing sessions; several posters were poorly presented, making one feel sorry for those who had spent many hours producing a document that was easy to read, understand and gave a take-home message. I did notice that the youngsters (as I was last time!) were no longer …

Early implant removal: an ethical dilemma

A 29-year-old woman recently presented to our service, having attempted to remove her contraceptive implant (Implanon®). She had a knife wound on her arm near the distal end of the implant and the surrounding skin was inflamed. The patient told us that she had had the implant fitted at the time she underwent termination of pregnancy 6 months …

Combined pill and GTD

randomised non-inferiority trial and meta-analysis. Lancet 2010; 375: 555–562. 4 Creinin MD, Schlaff W, Archer DF, Wan L, Frezieres R, Thomas M, et al. Progesterone receptor modulator for emergency contraception: a randomized controlled trial. Obstet Gynecol 2006; 108: 1089–1097. 5 von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Bártfai G, et al; WHO Research Group on Postovulatory Methods of Fertility Regulation. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet 2002; 360: 1803–1810. 6 Cameron S, Glasier A, Fine P, Mathé H, Gainer E. Ulipristal acetate compared to levonorgestrel for emergency contraception within five days of unprotected intercourse: a randomized controlled trial. Abstract presented at the 8th Congress of the European Society of Gynecology, Rome, Italy, 10–13 September 2009. 7 Cheng L, Gülmezoglu AM, Piaggio G, Ezcurra E, Van Look PF. Interventions for emergency contraception. Cochrane Database Syst Rev 2008; 2: CD001324. 8 Cameron S, Glasier A . The need to take a ‘new look’ at emergency contraception. J Fam Plann Reprod Health Care 2010; 36: 3–4. 9 HRA Pharma UK Ltd. ellaOne 30 mg: Summary of Product Characteristics. 2009. http://emc.medicines. org.uk/medicine/22280/SPC/el laOne+30+mg/ [Accessed 4 February 2010]. 10 Croxatto HB, Brache V, Cochon L, Jesam C, Salvatierra AM, Levy D, et al. The effects of immediate pre-ovulatory administration of 30 mg ulipristal acetate on follicular rupture. Abstract presented at the 8th Congress of the European Society of Gynecology, Rome, Italy, 10–13 September 2009. 11 Rickert VI, Tiezzi L, Lipshutz J, León J, Vaughan RD, Westhoff C. Depo now: preventing unintended pregnancies among adolescents and young adults. J Adolesc Health 2007; 40: 22–28.

Pediatric and Adolescent Gynecology: Evidence-Based Clinical Practice (2nd revised and extended edition)

Charles Sultan (ed.). Basel, Switzerland; Karger. 2012. ISBN-13: 978-3-805-59336-6. Price: £140.73. Pages: 396 (hardback) This is a most interesting book. It is a collection of chapters each of which stands independently. The editor is to be congratulated for the fact that there is little overlap or contradiction between individual chapters. The book is divided into three sections: Background and Tools, The Prepubertal Girl and the Adolescent Girl. There are four chapters in the Background and Tools section that …

Pain of Death

Pain of Death Adam Creed. London, UK: Faber and Faber, 2011. ISBN-13: 978-0-57124-524-6. Price: £12.99. Pages: 416 (paperback) Lovers of crime fiction who mourn the death of Morse and the retirement of Rebus can breathe a sigh of relief as Adam Creed introduces DI Wagstaffe (Staffe). It seems almost obligatory for the heroes of crime fiction to be tortured souls and Staffe is no exception. Orphaned as a teenager, a sister addicted to drugs and difficulties with his personal life are but a few of …

Crocus sativus L. (saffron) in the treatment of pre-menstrual syndrome: a double blind, randomised and placebo controlled trial

©FSRH J Fam Plann Reprod Health Care 2008: 34(4) women tended to be more educated and 70% had a high school diploma). The women were recruited from four different geographical regions and included large Hispanic and black populations. Some selection bias is also likely because of the 3:1 ratio of medical to surgical treatment (women with a strong preference for surgical treatment would not have agreed to be randomised). Urban populations in the UK are far more diverse and the educational level varies significantly depending upon the area a particular hospital serves. This could have a greater impact on the women’s understanding of treatment choices and subsequent side effects likely to occur, thus affecting QOL.

Comment on Lancet website: Missed pill guidelines

References 1 Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. FFPRHC Guidance (April 2005). Drug interactions with hormonal contraception. J Fam Plann Reprod Health Care 2005; 31: 139–150. 2 Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. FFPRHC Guidance (April 2003). Emergency contraception. J Fam Plann Reprod Health Care 2003; 29(2): 9–16.