Members Evidence Request - Supporting Clinical Practice

The Clinical Effectiveness Unit (CEU) provides an evidence-based enquiry service for FSRH members. The CEU will conduct a literature review and summarise the available evidence in relation to a particular medical condition and/or contraceptive method.


Recent Questions and Answers that have been submitted to the CEU can be seen below. Please note, the full answer includes references to more information and guidance.

The FSRH CEU has produced a quick guide on conducting systematic literature reviews to answer clinical questions (log in to access the guide). This brief and easy-to-use guide aims to support FSRH members to conduct a systematic literature search/review to answer clinical enquiries they may have. The process described in this guidance is adapted from the process used by the FSRH CEU when responding to enquiries made via the members evidence request service.

How to Submit a Members' Evidence Request

How do I get access to the Members' Evidence Request?

  • please log in to ‘My FSRH’ and
  • click on ‘Members' evidence request’ to search for questions or submit your own question.

This service is available to current FSRH members (Diplomates, Associates, Members, Fellows). 

I haven't set up a log in yet - what should I do?

If you are an FSRH member and have not yet created your ‘My FSRH’ account, please click the ‘Register’ button on the top right of this website and follow the steps to gain access to your account. Please use an email address that we will have contacted you on previously.

Once you have registered you will be able to access the full service and search the database as shown in the video. 

 

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Example Question One

Please can you explain why it is OK to use a Nexplanon for 4 years and Mirena for 6 years during Covid-19 but not under normal circumstances?

Response:

The risk of pregnancy during one additional year of use of Nexplanon and the 52mg LNG-IUS is likely to be small (as indicated by the available evidence), but we do not know for certain that it is as low as that during the licensed duration of use.

There is inadequate evidence to recommend this as standard practice in “normal” times as women expect extremely low failure rates from LARC. We note that effectiveness may still be greater than with user-dependent contraceptive methods (further studies are required to confirm this) and that extended use is standard in some parts of the world (where, for example individuals have limited access to contraception or pay a lot of money for it).

This comes down to a balance of risk and benefit at all times: At a time when there is a significant risk of coronavirus transmission associated with medical procedures, any small possible risk of pregnancy during a year of extended use is considered to be outweighed by the benefit of avoiding virus transmission.

However, FSRH guidance has been clear that contraceptive effectiveness cannot be guaranteed during this time and that women may wish to use additional contraceptive precautions.

In "normal" times in the UK, when LARC replacement is not associated with significant risk of virus transmission, the benefit of achieving extremely effective contraception by replacing the LARC at the end of the licence is likely to outweigh the risks associated with replacement (certainly until we have more study evidence).

Thus, at times other than during the current pandemic, FSRH advice will be that Nexplanon should generally be changed after 3 years and the 52mg LNG-IUS at 5 years (except in older women).”

In summary, because of different risk/benefit balance, slightly differing guidance may be applicable to different situations. 

Example Question Two

What Covid-19 PPE requirements are there when performing manual vacuum aspiration and other SRH procedures?

Response:

In the absence of specific evidence of Covid-19 transmission associated with SRH procedures, the FSRH CEU can make no formal recommendation regarding required PPE. However, the following published guidance is identified:-

1. RCOG guidance on abortion care during the Covid pandemic [1]
The Royal College of Obstetricians & Gynaecologists (RCOG) guidance Coronavirus (COVID-19) infection and abortion care: Information for healthcare professionals indicates that:

“Unless the anaesthetic used involves ventilation, neither abortion nor obstetric procedures are classed as aerosol generating procedures which carry the highest risk of transmission of respiratory viruses.”

The RCOG guidance also notes that:

“Current evidence, based on a small number of cases, suggests that COVID-19 is not present in genital fluid, although it is too early to know whether vertical transmission is a significant risk.”

2. PHE guidance on COVID-19 PPE [2]

Public Health England (PHE) Guidance COVID-19 personal protective equipment (PPE) states:

“Health and social care workers should consider the need for contact and droplet precautions based on the nature of care or task being undertaken.

Risk assessment on the use of eye protection, for example, should consider the likelihood of encountering a case(s) and the risk of droplet transmission (risk of droplet transmission to eye mucosa such as with a coughing patient) during the care episode.

Sessional use of FRSMs and eye protection is indicated if there is perceived to be close or prolonged interaction with patients in a context of sustained community COVID-19 transmission. 

Ultimately, where staff consider there is a risk to themselves or the individuals they are caring for they should wear a fluid repellent surgical mask with or without eye protection, as determined by the individual staff member for the episode of care or single session.”

With regard to aerosol-generating procedures (AGP) specifically, the guidance states:

“The highest risk of transmission of respiratory viruses is during AGPs of the respiratory tract, and use of enhanced respiratory protective equipment is indicated for health and social care workers performing or assisting in such procedures. The evidence review will continue to be updated in light of emerging evidence for this new pathogen.”

PHE guidance indicates:

“The following procedures are currently considered to be potentially infectious AGPs for COVID-19:

- intubation, extubation and related procedures, for example, manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)

- tracheotomy or tracheostomy procedures (insertion or open suctioning or removal) 

- bronchoscopy and upper ENT airway procedures that involve suctioning 

- upper gastro-intestinal endoscopy where there is open suctioning of the upper respiratory tract

- surgery and post mortem procedures involving high-speed devices 

- some dental procedures (for example, high-speed drilling) 

- non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)

- High Frequency Oscillatory Ventilation (HFOV) 

- induction of sputum

 - high flow nasal oxygen (HFNO)"

3. Intercollegiate general surgery guidance [3]

Updated Intercollegiate General Surgery Guidance on COVID-19. Guidance for surgeons working the pandemic states:

“Operating theatres where Aerosol Generating Procedures (AGPs) are regularly performed are considered a higher risk clinical area and full PPE is advised where COVID-19 is possible or confirmed. General anaesthesia is an AGP.”
“Laparoscopy is considered to carry some risks of aerosol-type formation and infection and considerable caution is advised. The level of risk has not been clearly defined and the level of PPE deployed may be important. Advocated safety mechanisms (filters, traps, careful deflating) can be difficult to implement.

The smoke plume at laparotomy from coagulating instruments may also not be without some risk. Given the current requirement to protect staff and other patients, a safety-first approach is needed.”

Ultimately, local policy, relevant to the current local infection risk, must be followed.

References

1. Royal College of Obstetricians & Gynaecologists. Coronavirus (COVID-19) infection and abortion care. Information for healthcare professionals. Version 2. 1 April 2020. (accessed on 15/05/2020)

2. Public Health England. Gov.uk. The Department of Health. Guidance: COVID-19 personal protective equipment (PPE). Updated 3 May 2020. (accessed on 15/05/2020)

3. Royal College of Surgeons of England. Updated Intercollegiate General Surgery Guidance on COVID-19. Guidance for surgeons working the pandemic. 7 April 2020. (accessed on 15/05/2020)

Please note: The advice given by the CEU should be considered as guidance only and is meant to be used alongside clinical judgement to guide clinical practice or policy. Questions that are a matter of clinical judgment and not evidence should be directed to local sexual and reproductive health leads.