An algorithm for the provision of emergency contraception
J Fam Plann Reprod Health Care 2013; doi:10.1136/fprhc-2012.100495
Three types of postcoital contraception are available - levonorgestrel, the copper IUD and ulipristal acetate (UPA). The IUD is the most effective, so should be encouraged as the first-line choice.
In Cambridge clinics, an algorithm was introduced to assess risk of pregnancy according to a number of factors, including time since unprotected sex and time in cycle of unprotected sex, to guide choice of treatment.
Those at low risk were offered levonorgestrel or an IUD. Those at moderate risk were offered an IUD, or levonorgestrel if less than 72 hours had elapsed since they had unprotected sex, and an IUD or UPA if more than 72 hours had elapsed. Those at high risk were encouraged to have an IUD fitted unless there were contraindications.
The group most commonly requesting emergency contraception was 16-24-year-olds. Before the protocol was introduced, only 49% were offered an IUD, compared with 61.6% afterwards.
In women at high risk, an IUD was offered to 93.3% after the protocol was introduced, compared with 59% initially. This seems an improvement, but after UPA's introduction in 2011, the percentage of women accepting the IUD fell from 30% to 14.1%. So although more were offered the IUD, those accepting it halved.
Analgesia and IUD insertion
J Fam Plann Reprod Health Care 2013; doi:10.1136/fprsh-2012-100486
Pain associated with IUD insertion is a known barrier to use of the IUD in the UK. It is good practice to discuss use of analgesia with women before fitting an IUD.
This survey of 129 participants in the UK found that about a quarter were using local anaesthetic routinely for IUD insertion, but a further quarter hardly ever used local anaesthetic for IUD insertion. About a half used it sometimes.
Those who rarely or never used local anaesthetic were found to be more likely to work in general practice. The authors concluded that pain relief should be discussed and offered to patients before IUD insertion as part of the care pathway for those patients who choose to use an IUD.
Local anaesthetic may be in the form of topical gel or injectable anaesthetic, the former being more commonly used. Topical gel takes five to 10 minutes to become effective and this may be a reason why it is not used commonly by GPs.
Resumption of sexual intercourse after delivery
BJOG 2013; doi:10.1111/1471-0528. 12166
In this study from Australia, more than 1,500 women were recruited before 24 weeks of pregnancy and asked to fill in questionnaires at the time of recruitment and at three, six and 12 months following delivery.
Sexual activity was resumed earlier than vaginal sex, with 53% resuming sexual activity and 41% attempting vaginal sex at six weeks postpartum. Those having vaginal sex increased to 65% at eight weeks, 78% at 12 weeks and 94% at six months.
Having an episiotomy or sutured tear made it less likely for the woman to have resumed sex, while assisted vaginal birth or caesarean section delayed resumption of sex.
I shall certainly use these figures to reassure patients that they are not in the minority if they have not had sex by the time of their postnatal check.
Development in males on stimulant treatment for ADHD
Med J Aust 2013; 198(1): 29-32
The use of stimulant medication for the management of ADHD appears to be on the increase.
This longitudinal study from Australia, of males aged 12-15 years at recruitment with stimulant treatment for ADHD for at least three years, compared the growth of 65 subjects with 174 controls. Mean duration of treatment was 6.3 +/1.9 years.
At baseline, growth parameters were not significantly different between those on medication and the controls. At all ages, those on medication had lower weight than the controls and those aged 14-15 years also showed significant delay in pubertal development. Dose of drug correlated inversely with height velocity.
Prolonged treatment of more than three years with a stimulant drug was associated with a slower rate of physical development during puberty, so it is suggested that the duration of treatment should be kept as short as possible and the lowest possible dose should be used.
- Dr Lewis is a GP in Windsor, Berkshire, and a member of our team who regularly review the journals
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