The contraception needs of the perimenopausal woman.

Perimenopausal women have low fertility but must still be advised to use contraception until natural sterility is reached if they are sexually active. Patterns of contraceptive use vary in different countries worldwide. Long-acting reversible contraceptive methods offer reliable contraception that may be an alternative to sterilisation. Hormonal methods confer significant non-contraceptive benefits, and each individual woman should weigh up the benefits and risks of a particular method. No method of contraception is contraindicated by age alone, although combined hormonal contraception and injectable progestogens are not recommended for women over the age of 50 years. The intrauterine system has particular advantages as a low-dose method of effective hormonal contraception, which also offers control of menstrual dysfunction and endometrial protection in women requiring oestrogen replacement. Condoms are recommended for personal protection against sexually transmitted infections in new relationships. Standard hormone replacement therapy is not a method of contraception.

'All singing, all dancing': staff views on the integration of family planning and genitourinary medicine in Lothian, UK.

BACKGROUND: UK policy documents advocate integrated approaches to sexual health service provision to ensure that everyone can access high-quality treatment. However, there is relatively little evidence to demonstrate any resultant benefits. The family planning and genitourinary medicine services in Lothian have been fully integrated and most care is now delivered from a purpose-built sexual health centre. We wished to study the views of staff on integrated sexual and reproductive care. METHODS: Staff completed anonymous questionnaires before and after integration, looking at four main aspects: the patient pathway, specific patient groups, their own professional status, and their working environment. The surveys used a mixture of five-point Likert-type scales and open-ended questions. RESULTS: Over 50% of staff completed the surveys on each occasion. Six months after the new building opened, staff attitudes about the integrated service were mixed. Staff reported more stress and less opportunity for specialisation but there was no change in their sense of professional status or development. There were concerns about how well the integrated service met the needs of specific patient groups, notably women. These concerns co-existed with a verdict that overall service quality was no worse following integration. CONCLUSIONS: Staff views should form an important part of service redesign and integration projects. Although the results from the Lothian surveys suggest a perceived worsening of some aspects of the service, further evaluation is needed to unpick the different problems that have appeared under the catch-all term of 'integration'.

Clinicians' views on low-lying intrauterine devices or systems.

BACKGROUND: There is a lack of consensus and very little published guidance on the management of a low-lying or malpositioned intrauterine contraceptive device (IUD) or system (IUS). METHODS AND RESULTS: A short e-mail questionnaire sent to senior medical staff working in contraceptive services confirmed the variation in views and management of this clinical area. Almost all respondents would replace an IUD/IUS lying either totally or partially in the cervical canal. The nearer the device was to the fundus the more likely respondents were to leave it in situ and there was less concern if the device was an IUS, presumably in view of the hormonal action. In the presence of abnormal bleeding or pain, most respondents would look for other causes rather than assume that the low-lying device was to blame. Respondents expressed uncertainty as to whether low-lying devices were more likely to fail or not and around half the respondents felt that low-lying devices could migrate upwards within the cavity. CONCLUSION: This survey highlighted the need for accurate evidence-based guidance to assist in this area of clinical contraceptive practice.

Low-lying or malpositioned intrauterine devices and systems.

INTRODUCTION: The intrauterine device (IUD) and intrauterine system (IUS) are widely used forms of long-acting reversible contraception. Occasionally, IUD/IUS users have an ultrasound scan that shows a low-lying IUD/IUS or an IUD/IUS is found incidentally on scan to be low-lying within the uterus. No formal guidelines exist on the clinical implications of this scenario or the most appropriate management. We report here on a systematic review of the literature. METHODS: A search of the online database PubMed was performed to identify articles relating to low-lying or malpositioned IUD/IUS. RESULTS: A total of 1101 articles was identified, and 15 were determined to be relevant to the research question. DISCUSSION: There is little published evidence to determine the nature and extent of the clinical relevance of a low-lying IUD. We recommend individualised management of these women, with particular caution in younger women and those with a history of previous IUD/IUS expulsion. Consideration may be given to attempting to readjust the IUD/IUS position, but if removal is performed, immediate replacement is essential if provision of alternative effective contraception has not been established.

Management of menopausal symptoms after cancer and risk-reduction bilateral oophorectomy: a move towards consensus.

As more women survive reproductive cancers, menopausal symptoms following treatment can be a significant problem affecting quality of life and wellbeing. Hormone replacement therapy may or may not be contraindicated. Women often receive conflicting information about their management from different specialists. The aim of this study, based in a regional menopause clinic, was to examine referral patterns and symptom profiles of women with cancer or at high risk of cancer; to identify areas of need where a more integrated approach to management might be required; and to reach a local consensus across disciplines involved in the care of these women regarding prescribing of hormonal therapies. A retrospective case record review of all women attending Edinburgh Menopause Clinic for one 12-month period in 2011/2012 for management of cancer-related menopausal symptoms was undertaken. The results of the review were discussed at a multidisciplinary meeting and regional guidance on the management of these women was agreed. There has been an immediate improvement in communication between departments and the quality of information received in referral letters.

Assessing and addressing cardiovascular risk in adults with Turner syndrome.

UNLABELLED: Turner syndrome (TS), the result of a structurally abnormal or absent X chromosome, occurs in one in 2 000 live born females. The phenotype is highly variable, but short stature and gonadal dysgenesis are usually present. The main objective in adults with TS is health surveillance, but TS still causes a reduction in life expectancy of up to 13 years, with cardiovascular disease, congenital or acquired, as the major cause of an early death. While it has been established that all women with TS should undergo in-depth cardiovascular examination at diagnosis, advice on the cardiovascular management of women with TS is limited. Here, we provide a summary of our current practice within a multidisciplinary team, supported by our expertise in various aspects of cardiovascular risk management, and the evidence from research where it is available, with the aim of providing optimal support to our patients with TS. BACKGROUND: A dedicated Adult Turner Clinic was established in South East Scotland in 2002. This gynaecology-led clinic serves a population of roughly 1·2 million and, currently, reviews around 50 women with TS annually. Referrals for adult care come from paediatrics or general practice. Following a series of individual case discussions regarding the management of more complex cardiovascular problems, we have assembled a dedicated multidisciplinary group to determine a timely cardiovascular screening strategy, a basis for specialist referral, and appropriate hypertension management. This team now includes a paediatric endocrinologist, gynaecologist, cardiologist (with an interest in inherited disorders), vascular radiologist and hypertension specialist. Here, we review the literature on cardiovascular disease in women with TS and, make recommendations, based on relatively limited high-quality evidence, together with our experience, on the optimal timing of cardiovascular screening.

Contraception in obese older women.

Obesity is increasing in most western countries and rises significantly with age. Obese women are as sexually active as women of normal weight, and new sexual relationships in the older reproductive years are becoming more commonplace and still require effective contraception. Continuation of pregnancy in a woman over 40 carries health risks which are exacerbated by the presence of obesity. A high proportion of pregnancies in women over 40 are unplanned and end in therapeutic abortion. The prevalence of obesity and the high rates of contraceptive use amongst older women mean that any increase in associated risk is likely to be of public health concern. There are very few data on the specific risks of contraceptive use in obese older women. As fertility declines with age, all methods become increasingly effective. No single method is contraindicated by age alone but particular caution is required where the use of estrogen containing preparations is considered as the risks associated with estrogen are all also independently associated with increasing age and body mass index. Non-estrogen containing methods are available, whether hormonal, barrier or surgical, which are effective, acceptable and safer in the obese older woman. Some methods of contraception may indeed have particular non-contraceptive benefits for this population.

Patients, clients, users or customers: what should we call people attending sexual health services?

BACKGROUND AND METHODOLOGY: In sexual health clinics there is debate on whether to call service users 'patients' or 'clients' and this mirrors an ongoing dialogue in the medical literature. The authors undertook a questionnaire survey in five UK centres of clinic attendees and staff to assess their preference. RESULTS: A total of 1428 clinic attendees and 250 staff members completed questionnaires. 61% of attendees who responded preferred 'patient', with 23% expressing no preference. Only 9% of respondents preferred the term 'client'. 148 (59%) of all staff groups preferred the term 'patient' followed by 82 (33%) selecting 'client'. No staff member opted for 'customer' or 'user' as the preferred term. The difference between preference for 'patient' between doctors and nurses was statistically significant, with most doctors preferring the term 'patient'. Out of a total of 84 nurses, there was equal preference for 'patient' and 'client' (38 nurses in each group). Comments from attendees and staff who responded generally emphasised the concept of the 'caring' role of the health professional towards people attending the services. DISCUSSION AND CONCLUSIONS: The majority of people attending sexual health clinics and medical and clerical staff working in these services expressed a preference to retain the title of 'patient'. The main justification for this appeared to relate to the concept of caring for people. The authors therefore conclude that the terminology in sexual health services should revert to predominantly using the term 'patient'.

The use of sex hormones in women with rheumatological diseases.

A number of rheumatological diseases predominantly affect women of reproductive age. There has always been concern that the use of oestrogen-containing agents such as combined hormonal contraception and hormone therapy might aggravate these conditions. This article reviews the up-to-date evidence regarding the safety of using these agents in women with various rheumatological diseases, with emphasis on systemic lupus erythematosus and rheumatoid arthritis. In the absence of antiphospholipid antibody or other prothrombotic risk factors, combined hormonal contraception is not contra-indicated in most rheumatological conditions including inactive systemic lupus erythematosus. Moreover, hormone therapy is generally not contra-indicated except for women with active systemic lupus erythematosus disease where its effect on disease flare is less clear and individual judgement is required.

Women's perceptions of the effects of menopause and hormone replacement therapy on skin.

Although women frequently associate skin issues with menopause and hormone replacement therapy (HRT), little work has been done to investigate a possible relationship. A questionnaire was given to women attending a specialist menopause clinic; 87 women responded. Skin problems generally were common, with over 64% of respondents reporting past problems. Around half felt that the menopause had resulted in skin changes; dry skin was the predominant complaint at this stage. However, use of HRT in the short term did not result in any conclusive trends in skin condition in the majority of users.

Hormonal contraceptive regimens in the perimenopause.

Perimenopausal women have low fertility but still need contraception if they are sexually active. They often have co-existing menstrual problems and menopausal symptoms. No method of contraception is contraindicated by age alone. In addition to highly effective contraception, hormonal methods offer non-contraceptive benefits which can improve quality of life for perimenopausal women. Combined hormonal oral contraception has been available for many decades. The combined vaginal ring and transdermal patch are newer methods offering alternative delivery systems but similar risk profiles to oral preparations. New combinations containing naturally occurring estrogens in place of the synthetic hormone ethinylestradiol are now available and, in theory, could be safer. The progestogen-only methods have an excellent safety profile and have a range of delivery systems and dosages to suit all. Concerns regarding loss of bone mineral density with the injectable depot medroxyprogesterone acetate continue but to date there is no evidence that this translates into higher fracture risk. Effective use of any method of contraception is strongly dependent on good counselling and support from healthcare professionals. Risks should be explained in absolute terms for each individual woman, enabling her to make an informed choice on evidence-based medicine and not influenced by ill-informed media publicity.

Comparison of a transdermal continuous combined and an interrupted progestogen HRT.

OBJECTIVES: Pilot study to compare the effects of a continuous combined hormone replacement therapy (HRT) regimen with an interrupted progestogen regimen administered transdermally, upon the endometrium of postmenopausal women, the incidence of amenorrhoea and relief of menopausal symptoms. METHODS: Fifty-nine postmenopausal women aged 50-63 years were randomised to either (i) continuous combined regimen: combined oestrogen/progestogen skin patches (releasing continuous 50 microg estradiol and 20 microg levonorgestrel/day) or (ii) interrupted regimen: oestrogen-only patches (releasing 80 microg estradiol/day) for 4 days followed by combined oestrogen/progestogen patches (releasing continuous 50 microg estradiol and 20 microg levonorgestrel/day) for 3 days, for 6 months. An endometrial biopsy was performed at end of treatment for histological analysis. RESULTS: Thirty-three women (56%) completed the study. Significantly higher rates of amenorrhoea were observed with the interrupted than continuous combined regimen (P<0.0001; 25% versus 7% at 6 months). The interrupted regimen was also associated with fewer days of bleeding overall (total 20 versus 44 days during months 4-6; P=0.001). Both regimens improved vasomotor symptoms. No endometrial hyperplasia or atypical changes were observed in endometrial biopsies. CONCLUSIONS: Although significantly less bleeding was observed with the interrupted regimen, it did not have a sufficiently high incidence of amenorrhoea to render it clinically useful.