Rudiger Pittrof

Do women requesting only contraception find attendance at an integrated sexual health clinic more stigmatizing than attendance at a family planning-only clinic?

Purpose Both sexually transmitted infections and the genitourinary medicine clinics that patients attend for management of sexually transmitted infections are stigmatized by patients’ perceptions. The aim of this study was to assess whether women requesting contraception only find attendance at an integrated sexual health clinic (ISHC) more stigmatizing than attendance at a family planning (FP)–only clinic. Patients and methods Women requesting contraception only were asked to complete a stigma assessment questionnaire in the waiting room of the clinic they attended. Ease of understanding was assessed for each item of the questionnaire prior to commencement of the survey. The questionnaire was given to women attending either an ISHC or a FP-only clinic. Results One hundred questionnaires that fulfilled the inclusion criteria were returned. The users of FP-only services were generally older than the users of ISHCs and were more likely than the users of ISHCs to classify themselves as UK white. Stigma perception was significantly higher for the ISHC than the FP-only clinic. Conclusion The results of this research indicate that among women who request contraception only, perceived stigma is higher when they attend an ISHC than when they attend a FP-only clinic. As this survey only enrolled clinic users, the authors were unable to assess whether integration generates sufficient stigma to deter some women from accessing contraception from integrated services. Of all stigma-related issues, disclosure concerns are likely to be the most important to the service user. Stigma is not an issue of overriding concern for most service users.

Stimulating an immune response? Oral sex is associated with less endometritis.

Secondary analysis of the PID Evaluation and Clinical Health (PEACH) data suggests that among women presenting with signs and symptoms of pelvic inflammatory disease (PID), those who reported oral sex were less likely to have endometritis (adjusted odds ratio [OR] 0.5 [0.3–0.8]) than those who did not report oral sex. Adaptive immunity requires antigenic priming of the lymphatic system. As lymphatic tissue is abundant in the oropharynx, oral sex could lead to effective immune stimulation and prevent PID. To determine whether oral sex could be a protective factor for PID the relationship between self-reported oral sex and endometritis was analysed among 619 women with clinically suspected PID who participated in the PEACH study. Nearly one quarter of participants reported oral sex in the past four weeks. These women also reported a higher number of sexual partners, a new partner within the past four weeks and a higher frequency of sexual intercourse (all P < 0.03). They were more likely to smoke (P < 0.0001), drink alcohol (P < 0.004) and use recreational drugs (P < 0.02). Participants reporting oral sex were significantly less likely to be black or to have a positive test for Neisseria gonorrhoeae (7.8% versus 21.6%, P = 0.001). Women who disclosed oral sex were significantly less likely to have endometritis after adjusting for race, number of partners, recent new partner, smoking, alcohol use and drug use (adjusted OR 0.5 [0.3–0.8]). This is the first paper showing a negative association between oral sex and endometritis. This may be mediated by a protective immune response in the genital tract following priming in the oropharynx. This hypothesis needs to be tested in further studies.

Diagnosis and treatment of pelvic inflammatory disease: Pelvic inflammatory disease

Pelvic inflammatory disease (PID) can be difficult to diagnose, but delaying treatment increases the risk of both acute and longterm complications. This article provides a guide to the assessment and recommended management of PID.

Human rights and clinical ethics are the right framework to address the probable DMPA-HIV interaction.

We were delighted to read the very timely paper by Haddad et al .1 that has become even more topical with the recent publication of a systematic review showing that depot medroxyprogesterone acetate (DMPA) use is indeed associated with about a 40% increased risk of HIV acquisition (12 studies involving more than 39 500 women, pooled hazard ratio 1·40, 95% confidence interval 1.16–1.69).2 Other forms of hormonal contraception do not appear to increase this risk. In the accompanying press release the lead author, Lauren Ralph, stated: “Banning DMPA would leave many women without immediate access to alternative, effective contraceptive options. This is likely to lead to more unintended pregnancies, and because childbirth remains life-threatening in many developing countries, could …

Comment on ‘Midwives’ experiences and views of giving postpartum contraceptive advice and providing long-acting reversible contraception: a qualitative study’

We thank McCance and Cameron1 for their article on midwives’ experiences and views on postpartum contraception and for highlighting an often neglected aspect of maternity care. The midwives interviewed by McCance were generally not very positive about their ability to make a difference. We would like to describe a positive experience and the approach used in our work with vulnerable families. There is no current best practice for promoting and providing postpartum contraception. However, we feel that new mothers are in a health care environment and are open to receiving information about reproductive health. Estrogen-containing contraceptives and intrauterine methods are United Kingdom Medical Eligibility Criteria (UKMEC) Category 3 in the postpartum period. Diaphragms …

Is it ethical to use drospirenone-containing combined oral contraceptives?

This Journal recently published a review of the thrombogenic risk associated with drospirenone (DRSP)-containing combined oral contraceptives (COCs).1 The same issue has recently been addressed by the Food and Drug Administration (FDA). Like other studies the FDA study reported that the use of DRSP-containing COCs was associated with an increased risk of venous thromboembolism (VTE) as compared to levonorgestrel (LNG)-containing COCs [incidence rate ratio: all users 1.49 (95% CI 1.19–1.8), new users 1.48 (95% CI 1.07–2.05)].2 While epidemiological studies find it difficult to show causality they provide useful information on which to base clinical practice. Clinical decision-making has to be ethical. Beauchamp and Childress3 set out the most commonly applied framework in Western bioethics. …

First name, surname or number: how to call a patient in the waiting room?

In sexual health services the first interaction between providers and service users typically occurs when patients are called from the waiting area; getting the greeting right is thus important for the quality of the consultation.1 Confidentiality is one of the key functions sexual and reproductive health patients expect from our service2 and therefore some may choose to register under a pseudonym, rather than risk having their identity divulged. Calling patients by their first name could be perceived as unearned familiarity,3 calling patients by their surname may disclose their identity and calling patients by a number may be impersonal. It is not clear for general1 4 and sexual health services how best to address our service users and most services will have experienced complaints from patients about the way they have been called from the waiting room. This triggered us to undertake a needs assessment of …

LNG may still be the best oral EC option

for obesity could possibly have reduced confounding, but it would not have eliminated it, especially since its effect in combination with other risk factors is multiplicative. With regard to possible confounding from other sources, VTE was more frequently diagnosed in women who only completed primary school. Socioeconomic status was thus a determinant of VTE risk, and the possibility that this factor may have reflected detection bias was not evaluated. With regard to other potential confounders Lidegaard mentioned that allowance for treated diabetes, heart disease, hypertension and hyperlipidaemia did not affect the findings. Only heart disease and diabetes are risk factors for VTE; hypertension and hyperlipidaemia are not. As for other factors, the Danish study did not evaluate potential confounding due to a family history of VTE, recent surgery, trauma or immobilisation.

The magnitude and severity of abortion-related morbidity in settings with limited access to abortion services: a systematic review and meta-regression

Introduction Defining and accurately measuring abortion-related morbidity is important for understanding the spectrum of risk associated with unsafe abortion and for assessing the impact of changes in abortion-related policy and practices. This systematic review aims to estimate the magnitude and severity of complications associated with abortion in areas where access to abortion is limited, with a particular focus on potentially life-threatening complications. Methods A previous systematic review covering the literature up to 2010 was updated with studies identified through a systematic search of Medline, Embase, Popline and two WHO regional databases until July 2016. Studies from settings where access to abortion is limited were included if they quantified the percentage of abortion-related hospital admissions that had any of the following complications: mortality, a near-miss event, haemorrhage, sepsis, injury and anaemia. We calculated summary measures of the percentage of abortion-related hospital admissions with each complication by conducting meta-analysis and explored whether these have changed over time. Results Based on data collected between 1988 and 2014 from 70 studies from 28 countries, we estimate that at least 9% of abortion-related hospital admissions have a near-miss event and approximately 1.5% ends in a death. Haemorrhage was the most common complication reported; the pooled percentage of abortion-related hospital admissions with severe haemorrhage was 23%, with around 9% having near-miss haemorrhage reported. There was strong evidence for between-study heterogeneity across most outcomes. Conclusions In spite of the challenges on how near miss morbidity has been defined and measured in the included studies, our results suggest that a substantial percentage of abortion-related hospital admissions have potentially life-threatening complications. Estimates that are more reliable will only be obtained with increased use of standard definitions such as the WHO near-miss criteria and/or better reporting of clinical criteria applied in studies.

Months dispensed and oral contraceptive discontinuation.

“I just ran out” appears to be a common explanation for discontinuation of oral contraception in clinical experience but surprisingly this was not mentioned in the excellent article by Inoue et al .1 There is a simple option for reducing the risk of “just running out”: supply more months of contraception per prescription. A recent systematic review2 found two randomised controlled trials and two cohort studies (168 075 women) of good quality that compared continuation …