BMJ Sexual & Reproductive Health最新文献

Objective: To describe patterns of oral emergency contraception (EC) orders among users of a free service, commissioned by the UK National Health Service, ordered online and delivered by post.

Study design: Routinely collected anonymised data from an online sexual health service in the UK from 1 January to 31 December 2023 were analysed. The number of times EC was ordered and prescribed was calculated and the age and level of deprivation assigned to the postcode where the user resided were extracted. Individual time lines were developed for those prescribed more than 10 times in 12 months.

Results: During 2023 there were 32 659 oral EC requests from 19 501 users, resulting in 29 073 prescriptions from 17 576 users. Ulipristal acetate (UPA) was prescribed in 90% of the orders. The majority of users (n=12 238; 69.63%) received EC once a year, 5237 (29.80%) received it more than once and 101 (0.57%) received it more than 10 times. The mean (SD) number of prescribed orders per user was 1.65 (1.49) and the highest was 29. Oral EC had been used in the previous week by 794 of the 17 576 users (4.5%) and nine (0.05%) were prescribed more than 150 mg of UPA in 30 days.

Conclusions: A small group of people order EC repeatedly, sometimes within the same cycle, putting them at increased risk of pregnancy. A minority of people order doses of UPA of >150 mg in 30 days.

Background: Most guidelines recommend post-vasectomy semen analysis (PVSA) on fresh samples to confirm success. Postal submission increases compliance although reliability remains controversial. We assessed agreement between first PVSA sperm concentrations on the same sample, freshly and following postage, and determined if any sperm concentration levels other than 'no sperm seen' on a postal sample could be used to advise cessation of other contraceptive methods.

Methods: 12 weeks after vasectomy, men submitted fresh semen samples to laboratory A. Samples were analysed within 2 hours. The remainder of each sample was posted to laboratory B for analysis 72 hours later. Both laboratories examined one aliquot of 25 µL using 100 µm CellVision counting chambers. Sperm counts for the entire slide were reported. No exact count was performed at concentrations estimated >100 000/mL.

Results: We analysed the results of 197 paired PVSA. The Bland-Altman plot showed high agreement between fresh and postal sperm concentrations, with only seven samples outlying 95% CIs. Fresh PVSA sperm concentrations were classified higher than postal in 47 (22.1%) pairs and lower in 42 (19.8%). Most discrepancies were observed at sperm concentrations <1000 sperm/mL. 'No sperm seen' was reported in 86 (43.7%) pairs with false negatives encountered in both laboratories (McNemar's test p=0.045). Negative predictive values of postal compared with fresh results were >99% at all cut-off values from 1000 to 100 000 sperm/mL CONCLUSION: Our study showed high agreement in sperm concentrations of first PVSA performed on the same samples submitted fresh or by postal submission. The current postal testing strategy could be modified to encompass clearance on postal PVSA showing very low sperm concentrations.

Introduction: Since 2020, legislation in Britain has allowed both mifepristone and misoprostol to be taken at home for early medical abortion (EMA). In England and Wales, legislation restricts this to 9+6 weeks, but in Scotland this is permitted up to 11+6 weeks. Data on the outcomes of EMA at home >10 weeks' gestation is limited and so we aimed to establish the safety and efficacy of this in comparison with EMA in a hospital setting.

Methods: We conducted a retrospective review from our abortion service in Edinburgh, Scotland of outcomes of EMA at home versus hospital between 10+0 and 11+6 weeks' gestation over the 5-year period April 2020-March 2025. The primary outcome was complete abortion rate. Secondary outcomes were rates of incomplete abortion, ongoing pregnancy and serious complications.

Results: A total of 371 EMAs occurred at this gestation (n=258 home, n=113 hospital). Complete abortion rates were not statistically significantly different between groups: 251/258 (97%) (95% CI: 94% to 99%) at home and 110/113 (97%) (95% CI: 92% to 99%) in hospital. Neither incomplete abortion rates (home: 4/258, 1.6%; hospital: 3/113, 2.6%) nor ongoing pregnancy rates (home: 3/258, 1.2%; hospital: 0/113, 0%) were significantly different between groups. There was one case of haemorrhage requiring transfusion and three cases of infection receiving intravenous antibiotics, all in the at home group.

Conclusions: EMA at home between 10+0 and 11+6 weeks has the same high efficacy and safety as when conducted in hospital. Action is needed to extend EMA at home after 10 weeks' gestation to women across the rest of the UK and beyond.

Background: Social stigma and the marginalisation of abortion care within medical settings can negatively affect abortion providers. While some research has evaluated stigma interventions in legally restrictive settings, little work has explored the experiences of healthcare professionals (HCPs) providing abortion and post-abortion care (PAC) outside the USA. This study, part of the Royal College of Obstetricians and Gynaecologists' 'Making Abortion Safe' programme, aimed to understand providers' experiences of abortion stigma in four African countries with restrictive legislation.

Methods: In-depth interviews with 44 abortion and PAC providers were conducted in Nigeria, Rwanda, Sierra Leone and Zimbabwe.

Results: Four themes emerged: personal and professional effects of stigma, multiple manifestations of stigma, driving forces of stigma, and positivity and resilience. Stigma affects providers' professional identity, community belonging and relationships. Restrictive legal frameworks are the main driver of abortion stigma, operating at multiple levels that reinforce each other. The legal status of abortion labels it as 'dirty work', conflicting with healthcare principles. Judgmental attitudes from other HCPs negatively impact providers' well-being and care quality. However, providers showed resilience through professional and personal commitment, and the belief in 'doing the right thing' helped them resist stigma.

Conclusions: Legal changes are crucial for increasing access and reducing stigma among the workforce. In these countries, providers face challenges in offering legal healthcare. Organisational interventions are needed to address stigmatising values and create positive workplaces. Ongoing support is essential for HCPs to remain resilient against abortion stigma, helping to normalise abortion care and those who provide it.

Background: Progesterone is critical for cyclic breast changes and breast cancer carcinogenesis. The commercially available progesterone receptor modulators (PRMs), ulipristal acetate (UPA) and mifepristone, have been utilised for their antiprogestogen effect in gynaecology. Administration of these medicines appears to induce favourable cellular and radiographic changes in the breast.

Methods: This is a narrative review of the basic science, translational and clinical trials utilising UPA and mifepristone for breast health. It integrates historical and recent trials from around the world.

Results: PRMs have shown promise in decreasing molecular markers of carcinogenesis in BRCA1 carriers. Outside of genetic cancer risk, PRMs decrease background parenchymal enhancement on breast magnetic resonance imaging and could be developed as a personalised protocol for breast cancer screening. Although there was limited efficacy of antiprogestogens in progression-free survival for people with breast cancer, there may be a role as neoadjuvant therapy prior to surgical resection.

Conclusions: UPA and mifepristone have the potential to revolutionise breast cancer prevention, screening and treatment. As protocols emerge, gynaecologists will be on the front lines as regards both identifying patients who may benefit from these medications and serving as interdisciplinary support in accessing these medicines.

Background: Recent research has shown that women often report that their concerns are not listened to in exchanges with clinicians when accessing reproductive healthcare, including contraceptive consultations. When people do not feel listened to, or have their concerns taken seriously, this can lead to disengagement with contraceptive services and distrust of healthcare professionals.

Methods: A participatory approach, with 18 volunteer researchers interviewing 52 friends and family members about information-seeking and contraceptive methods.

Results: Most participants were not satisfied with contraceptive consultations and felt that healthcare professionals did not give them all the information they wanted. Because of this, they found personal stories about contraception to be very important in their information-seeking and decision-making processes. Sharing these stories, both what they heard from others and their own experiences, helped them consider the potential side effects of different contraceptive methods. Participants thereby drew on vernacular knowledge (unofficial, informal and everyday culture of a group), some of which was accessed through social media. Vernacular knowledge also included experiential knowledge, as provided by friends and family members. This kind of knowledge was not covered in their contraceptive consultations.

Conclusions: Patients' understanding of side effects does not always align with medical evidence. Dismissing reported side effects can undermine patient experience, leading to disengagement or the seeking of counter-expertise. Practitioner knowledge and patient vernacular knowledge should be considered together when counselling about contraceptives. Our research suggests that a more prominent culture of active listening is required in clinician-patient exchanges that acknowledges and works with patient concerns and lived experiences.