Louise Melvin

Vaginal yeast colonization in non-pregnant women: a longitudinal study

The relationship between yeast colonisation, symptoms and antifungal self-medication remains poorly understood. Previous studies have involved pregnant women or women using hormonal contraception, and many have been underpowered. This American cohort study aimed to determine the prevalence of yeast colonisation over a 1-year period in 18–30-year-old, sexually active, non-pregnant women. A total of 1248 women were recruited and more than 80% of the scheduled visits at baseline, 4, 8 and 12 months were attended. At each visit a questionnaire was used to enquire about symptoms, antifungal use, sexual/personal behaviour and contraception in the preceding 4 months. A swab of vaginal fluid was transferred to candida-selective culture media. Some 70% of women were colonised by vaginal yeast at one or more visits, but only 4% were colonised at all four visits. Factors associated with yeast colonisation included marijuana use [odds ratio (OR) 1.3, 95% CI 1.1–1.5], depot medroxyprogesterone acetate (DMPA) use (OR 1.4, 95% CI 1.1–1.7), sexual activity in past 5 days (OR 1.5, 95% CI 1.2–1.8) and concurrent colonisation with lactobacillus and group B streptococcus. Symptoms of pruritis and vulvovaginal burning were associated with yeast colonisation but antifungal use was not. The results support the concept that Candida albicans exists as part of the normal vaginal flora in many healthy asymptomatic women, and that host factors influence the development of symptoms. The authors suggest that the lack of an association with antifungal use casts doubt on the reliability of self-diagnosis and self-treatment of thrush symptoms. However, the study was limited by possible recall bias and the fact that most women were not examined at the time they had symptoms or used antifungal treatment. Moreover, the study population was relatively young (80% under 25 years) and from similar socioeconomic backgrounds, so may not be representative of the wider female population. The finding of an association with DMPA conflicts with previous studies showing a protective effect against yeast colonisation. Further research is therefore required to confirm an association between yeast colonisation and injectable progestogen-only contraceptives.

Pitfalls of adapting emergency contraception CEU guidance

The introduction of a new oral emergency contraceptive (EC), ulipristal acetate (UPA) with a higher up-front cost, has led many clinicians to consider trying to identify women at higher risk of pregnancy so that they can be preferentially offered the drug that works closer to ovulation. These attempts, however well meaning, are flawed, are not based on the published evidence, go against best practice guidance as established by the Clinical Effectiveness Unit (CEU), and may deprive women at definite risk of pregnancy from making an informed choice. If it were possible to determine, consistently and reasonably accurately, where a woman is in relation to ovulation we could reassure the majority of women that they did not need any EC. We know levonorgestrel …

Intrauterine device checks

Thank you for publishing the article by Draper et al. on intrauterine device (IUD) checks.1 I would like to highlight an omission that is potentially confusing. The authors state “until …

Quick starting contraception after emergency contraception: have clinical guidelines made a difference?

Objective When initiating contraception after emergency contraception (EC), conventional practice had been to wait until the next menses. Since 2010, UK guidelines have endorsed quick starting (QS) contraception, namely offering immediate start when requested. We conducted an audit to assess clinical practice before and after QS guidance publication. Methods A full cycle audit was performed on the clinical notes of women requesting EC during two 2-month periods in 2010 and 2011 in an Integrated Sexual Health Service. All case notes were identified using the National Sexual Health database of sexual health records (Scotland). Information was collated and interpreted using Microsoft Excel and SPSS V.17. Results During January and February 2010 and 2011, 190 and 180 women, respectively, attended for EC, of whom 96 and 97 were identified as potential quick starters. Between 2010 and 2011, a statistically significant increase in QS practice was noted from 20.8% (n=20) to 37.1% (n=36) (p=0.011), with a corresponding decrease in the percentage of women traditionally started on hormonal contraception (HC): 24% (n=23) and 14.6% (n=14), respectively. There was also a decrease in those advised to return for commencement of HC [55.2% (n=53) vs 49% (n=47)]. Of those advised to return, 26.4% (n=14) and 31.9% (n=15) had no further contact with the service within at least 6 months. Conclusions QS practice increased after the introduction of clinical guidelines. However, overall provision of HC remained low, with only around half of women prescribed a hormonal method.

Unintended pregnancy with subdermal implant following miscarriage: response from the CEU

Thank you for the opportunity to comment on Dr Ranks letter.1 From her description of the case I calculate that the patient must have conceived 2 weeks after the first scan indicating possible miscarriage and attended for implant insertion before a urine pregnancy test would have been positive. This case illustrates two pitfalls that can lead to …

Health needs of immigrants: rights to treatment and confidentiality

J Fam Plann Reprod Health Care 2005: 31(4) Introduction Immigration has featured much in the media and political arena of late. Foreign patients can present particular challenges to health professionals due to language barriers, cultural differences, transient residency and sometimes complex medical and social problems. Uncertainty about immigration status and rights to National Health Service (NHS) treatment can further complicate patient care. In this issue we feature a scenario adapted from a real case. (The patient consented to disclosure. Her name has been changed.)

Reproductive issues and learning disability: different perspectives of professionals and parents

The reproductive rights of adults with learning disabilities raise complex social ethical moral and legal issues. In this article various professionals and two parents express their views on a real-life ethical dilemma. (NB. Names have been changed to preserve anonymity.) Melanie is a 25-year-old woman with Down syndrome. She requires help with the normal activities of daily living and lives with her parents who receive the highest level of attendance allowance. Her boyfriend Tom also has learning difficulties. They have been in a relationship for 3 years and Melanie has had an intrauterine device (IUD) inserted for contraception. Melanie comes to see you on her own to ask you to remove her IUD: she and Tom have decided that they want to have a baby. From the conversation you get the impression that perhaps Tom wants the baby more than she does but she does not confirm this. What would you do in this situation? (excerpt)

Oral Contraceptives: Benefits and Risks

Oral contraceptives remain one of the most commonly used hormonal contraceptives worldwide. Oral contraceptives contain either a combination of synthetic estrogen and progestogen or progestogen only. Combined oral contraceptives often receive negative press because of their impact on cardiovascular health. Yet, when prescribed appropriately offer an effective method which generally offer a favourable benefit to risk profile for most women. There are few medical conditions that would pose an unacceptable health risk to use of the progestogen-only pill.

Timing of emergency IUD fitting.

We wish to thank Dr Davies1 for raising an issue we were not able to address in our original letter2 due to space limitations. The issue with emergency contraception intrauterine devices (EC IUDs) is slightly different. An EC IUD has to be fitted prior to implantation. This is a process that starts no sooner than 6 days after fertilisation, and fertilisation cannot happen prior to …

Missed pill rules: response from the CEU

The Clinical Effectiveness Unit acknowledges the points raised by Drs Donegan1 and Mansour2 in their letter and commentary article, respectively, published in this Journal. In our initial draft of …