Hannat Akintomide

Determinants of long-acting reversible contraceptive (LARC) use by adolescent girls and young women.

Abstract Objectives To identify factors relevant for adolescents and young women in their selection of a contraceptive method and reasons for acceptance or rejection of long-acting reversible contraceptives (LARCs). Method Questionnaire survey among 194 women attending an integrated young people service. Results Compared to the number of those who had heard about all LARCs (71%), the number of respondents who had used a LARC was low (28%). Awareness of intrauterine methods was the lowest, compared to other LARCs. High efficacy, protection against sexually transmitted infections and non interference with sex were the three most important factors when choosing a contraceptive method, whereas the possibility of altering the menstrual pattern and reversibility were not considered important. Qualities of LARCs such as reliability and long duration of action would encourage young women to accept LARCs. Knowledge of peers’ good experience with a LARC fosters, but fear of pain and needle (most obvious for intrauterine methods) restrains use of these methods. Conclusions Despite reliability and long-term use being important advantages, fear of pain and needles make LARCs less appealing to young people. Current LARCs meet some, but not all expectations of adolescents and young women.

Randomized trial of the effect of tailored versus standard use of the combined oral contraceptive pill on continuation rates at 1 year

BACKGROUND There is growing interest from women and clinicians in extended or tailored use of the combined oral contraceptive (COC) pill. Potential advantages include less bleeding, greater contraceptive efficacy and user satisfaction. We examined the effect of a tailored pill regimen, compared with the standard regimen, on continuation and satisfaction rates at 1 year and associated bleeding patterns. STUDY DESIGN This was a randomized controlled trial with 503 women aged 18-45 years. Women were randomized to either the standard regimen (21 daily pills followed by a 7-day pill-free interval) or tailored regimen (daily pills until three consecutive days bleeding triggers a 3-day pill-free interval) of Microgynon 30® (ethinyl oestradiol 30 mcg, levonorgestrel 150 mcg). Primary outcome was COC continuation at 12 months; secondary outcomes included satisfaction with pill regimen regarding contraception and bleeding pattern. Daily electronic diaries were used to record womens pill use, switching to other contraceptive methods, menstrual bleeding patterns and satisfaction levels. RESULTS Eighty-three percent of women were already taking the COC at recruitment, 13% were restarting the COC and 4% were first time COC users. Seventy-one percent of all women were followed up at 12 months. Continuation rates at 1 year were 82% in the tailored arm versus 80% in the standard arm [odds ratio (OR)=1.13; 95% confidence interval (CI)=0.67-1.91]. Satisfaction with contraceptive regimen was 86% (tailored) versus 94% (standard) (OR=0.37; 95% CI=0.17-0.79), and satisfaction with bleeding pattern was 79% versus 87%, respectively (OR=0.53; 95% CI=0.30-0.93). Median number of bleeding days per month was 2.4 (tailored) and 4.9 (standard). Incidence, duration and intensity of bleeding episodes were significantly lower in the tailored arm. CONCLUSIONS In women familiar with standard use of the COC, switching to tailored COC use or continuing with standard use were both associated with high COC continuation rates and high satisfaction with contraceptive regimen and bleeding pattern. While significant differences tended to favor the standard group, tailored COC use was associated with significantly less bleeding, suited some women very well and can provide a suitable alternative to standard use.

Patients' experiences and providers' observations on pain during intrauterine device insertion

Abstract Objective To determine womens (patients’) experiences of intrauterine device (IUD) insertion under our current practice and the extent to which these agreed with the observations of the health professionals (providers) who had performed the IUD insertion procedures. Method Questionnaires were used to collect information on womens experiences of the IUD insertion procedure from both patients and providers in a sexual and reproductive health service. Results Overall response rates were high (77%, 284 responses in total). Seventy-three percent of patients were nulliparous and over half nulligravid. The providers predominantly used local anaesthesia for IUD insertions (93%). Most patients reported being anxious before their procedure (86%). Patients mainly described the overall experience of their IUD insertion procedure as being associated with ‘minimal discomfort/nothing’ (42%) or ‘uncomfortable’ (41%). ‘Minimal discomfort/nothing’ (56%) and ‘uncomfortable’ (33%) were the main observations of providers. When responses of patients and their providers were compared, agreement was slight for reported pain levels (k = 0.167 CI [0.13–0.24]). Patients’ reported pain levels were significantly higher than those reported to have been observed by their providers (p < 0.001). Conclusion Patients’ and providers’ responses suggested that the IUD insertion procedure under our current practice appeared acceptable to most patients. However, providers were not usually accurate in their observations and tended to underestimate the degree of pain experienced by their patients during IUD insertion procedures. Chinese Abstract 摘要： 目的 了解妇女（患者）在宫内节育器放置术中的感受与术者观察评估的一致性。 方法 在一个性健康和生殖健康服务机构，对患者和术者进行问卷调查，收集妇女在宫内节育器放置过程中的感受的信息。 结果 总共284人回答，问卷回收率较高，为77%。其中73%的妇女未生育过，超过一半未妊娠过。术者放置宫内节育器时主要采用局麻方式，占（93%）。大部分患者（86%）报告说在术前感到紧张。患者描述在宫内节育器放置过程中总的反应主要为极少的不适/没有不适（42%）或感觉不舒服（41%）。极少的不适/没有不适（56%）和感觉不舒服（33%）是术者的主要的观察意见。关于疼痛水平，患者的感受和术者的观察评估比较一致性较差( k= 0.167 CI [0.13 -0.24])。患者报告的疼痛程度明显高于她们的术者报告的观察到的疼痛程度。 结论 患者和术者的反应提示：按照我们目前的操作，宫内节育器放置过程可被大多数患者接受。然而，术者的观察评估往往不准确，并且往往会低估患者在宫内节育器放置术中感受到的疼痛的程度。

The use of local anaesthesia for intrauterine device insertion by health professionals in the UK.

Background Pain associated with the insertion of an intrauterine device (IUD) is a known barrier to intrauterine contraception use in the UK. It is good practice for health professionals to discuss pain relief and use with women prior to the insertion of an IUD. Objectives This study aimed to determine the prevalence of and reasons for and against the use of local anaesthesia (LA) for IUD insertion. Methods A survey was undertaken using paper questionnaires to determine LA use for IUD insertion by UK health professionals. Results Overall, approximately one quarter (n=129) of all respondents use LA routinely, one quarter hardly ever or never use LA, while the remaining half use it sometimes. Use of LA was more prevalent among health professionals who worked in integrated sexual and reproductive health and contraception-only services, compared to general practice. UK health professionals who hardly ever or never used LA for the insertion of IUDs were more likely to be working in general practice. Conclusions The results of this survey suggest that more UK health professionals need to routinely discuss pain relief and offer this to their patients prior to IUD insertion as part of the care pathway for patients who choose to use intrauterine contraception.

Counselling to include tailored use of combined oral contraception in clinical practice: an evaluation.

Background Combined oral contraception (COC, ‘the pill’) remains the most prescribed method of contraception in the UK. Although a variety of regimens for taking monophasic COC are held to be clinically safe, women are not routinely counselled about these choices and there is a lack of evidence on how to provide this information to women. Aim To assess the usefulness and feasibility of including tailored use of monophasic COC within routine COC counselling in a sexual and reproductive health (SRH) service using a structured format. Method Using a structured format, healthcare professionals (HCPs) counselled new and established COC users attending an SRH service about standard and tailored ways of taking the pill. Questionnaires were used to survey both the HCPs and patients immediately after the initial consultation, and then the patients again 8 weeks later. Results Nearly all patients (98%, n=95) felt it was helpful to be informed of the different ways of using monophasic COC by the HCP, without giving too much information at one time (96%, n=108). The HCPs were confident of their COC counselling (99%, n=110) and did not think the consultations took significantly longer (88%, n=98). Conclusion This study demonstrates that information on different pill taking regimens is useful and acceptable to patients, and can improve contraceptive pill user choice. It is also feasible for HCPs to perform COC counselling to include tailored pill use during routine consultations in a clinical setting.

Presenting risk information in sexual and reproductive health care

Objectives Presenting risk information to patients is an important part of clinical encounters. Good risk communication improves patient satisfaction with their care and the decisions they make. In sexual and reproductive healthcare (SRH), women frequently need to make decisions based on their perceived risk. Risk perception can be altered by how actual risk is presented to patients. Methods Databases were searched using MeSH terms combined with a keyword search for articles relevant to SRH; the search was limited to English language. Results Personalised risk communication where a risk score is provided, increases knowledge and slightly increases uptake of screening tests. Decision aids improve a patients knowledge of the options, create realistic expectations of their benefits and harms, reduce difficulty with decision-making, and increase participation in the process. The most effective way to present risks uses a range of structured, tailored presentation styles; interactive formats are best. Framing the information improves patient understanding. Most people understand natural frequencies or event rates better than probability formats with varying denominators. Expressing changes in risk as an absolute risk reduction or relative risk reduction with baseline risk formats improves understanding. Descriptive terms such as ‘low risk’ or ‘high risk’ should be quantified as a frequency rather than a percentage. Using a consistent denominator to portray risk is recommended. Using the ‘number needed to treat’ and visual aids puts benefits or risks into perspective. The duration of risk should be presented. Conclusion Presenting risk information to patients can be optimised using a number of strategies.

Emergency intrauterine device insertion in teenagers: an informal retrospective study

Background Widespread and increased availability of oral emergency contraception (EC) over the past 10 years has made little difference to rates of unintended pregnancy, abortion and repeat abortion amongst teenagers. The insertion of an intrauterine device for EC (EC-IUD) is 98–99% effective compared with 85% for oral methods and can be used for ongoing, long-term reversible contraception. However this method is seldom used for teenagers, a group with a high risk of unintended pregnancy, and there is little published data on the use of EC-IUD in this group. Methods An anonymous case note review of EC-IUD use in teenagers in three centres in the UK was conducted to quantify provision, to identify insertion difficulties and short-term complications and to ascertain compliance with national guidance concerning sexually transmitted infection (STI) risk assessment and prophylaxis. Results A total of 103 cases was identified over 4 years (2007–2010) from the three centres (London, Liverpool and Aberdeen). The results show that the majority of fittings were straightforward (94%) with few complications. Antibiotic prophylaxis was deemed necessary in 64% of attenders. Conclusions The authors recommend that with STI screening and appropriate antibiotic prophylaxis, use of IUDs in women under the age of 20 years should be unrestricted both for long-term contraception and for EC.

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abdominal wall is also known.5 These migration events have been reported from 10 months to 13 years following application. There is a small but significant literature describing unusual migration of the tubal clip. It is unclear if the tubal clip within the uterine cavity contributed to the symptoms or formation of the polyp. Although uncommon, women should be informed of the possibility of tubal clip migration. Tubal patency assessment may be required in women during their reproductive years.

Nomegestrol acetate/17-beta estradiol: a review of efficacy, safety, and patient acceptability

Nomegestrol acetate (NOMAC) 2.5 mg with 17-beta estradiol (E2) 1.5 mg is a new combined oral contraceptive (COC) formulation and is the first monophasic E2 pill to be marketed, having been licensed for use in Europe in 2011. It is available to be taken daily in a regimen of 24 active pills followed by four placebo pills. NOMAC is a highly selective 19-nor progestogen derivative with specific binding to progesterone receptors, anti-estrogenic activity and no androgenic, mineralocorticoid nor glucocorticoid effects. E2 is an estrogen that is identical to endogenous estrogen. While it has been in use for only a short period of time, current evidence suggests that NOMAC/E2 is just as effective, safe, and acceptable as existing COC preparations. Two large Phase III trials conducted in the Americas and across Europe, Australia, and Asia showed lower cumulative pregnancy rates in the NOMAC/E2 groups compared to the drospirenone (DRSP) 3 mg in combination with ethinyl estradiol (EE) 30 µg (DRSP/EE) groups but this difference was not statistically significant. NOMAC/E2 exhibits a good safety profile and has less effects on cardiovascular risk, hemostatic, metabolic, and endocrine factors in comparison to COCs containing EE in combination with levonorgestrel (LNG) or DRSP. NOMAC/E2 has also been found to cause less breast cell proliferation when compared to E2 alone and has some anti-proliferative effect on human breast cancer cells. NOMAC/E2 is considered acceptable as its compliance, continuation rates, and bleeding patterns were similar to COCs containing DRSP/EE and LNG 150 µg combined with EE 30 µg or LNG 100 µg combined with EE 20 µg (LNG/EE). However, discontinuation was found to be slightly higher in the NOMAC/E2 groups in the two large Phase III trials comparing NOMAC/E2 use with DRSP/EE. As the scientific literature has limited information on NOMAC/E2, further experience with NOMAC/E2 is required.

Lost IUD penetrating bladder wall

Thanks to Vural and colleagues who reported their interesting case of a misplaced intrauterine device (IUD).1 I would like to mention some points in relation to their letter. With the increased uptake of intrauterine methods2 and the majority of uterine perforations said to occur at the time of device insertion (but go undetected),3 uterine perforation is more frequent than Vural et al.1 suggest. Uterine perforation is now undiagnosed at the time of IUD insertion procedure, also because patients are asymptomatic despite this complication having occurred. There is currently greater use of analgesia prior to as well as local anaesthetic (including injectable) during IUD insertion procedures than before. To facilitate early diagnosis of uterine perforation, especially in the absence of symptoms, clinicians should have a low threshold for performing, or referring for, pelvic ultrasonography. Instances of difficult insertion, insertion after difficult removal, where uterine sounding measurements are much different from the previous of a patient’s (especially after a difficult removal of an old device), and no visible threads at routine follow up post-IUD insertion are examples. Unfortunately most services where IUD fitting procedures take place are not equipped with ultrasound scanners. Where there is local access to ultrasound or a referral has to be made, appointment waiting times tend to cause a delay in diagnosis of uterine perforation. Similarly, an appointment for laparascopic removal of a misplaced device could be a few months. However, initial counselling on intrauterine methods4 to include information about the small risk of uterine perforation and its management will be helpful to patients interested in this highly effective method of contraception.