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

A 24 year old patient with stable epilepsy on sodium valproate and Keppra. Wanting a coil - is copper or IUS a better option? Because of the risk of seizure is this ok to be done in primary care or should it be done in secondary care with monitoring etc?

Response:

With reference to avoiding pregnancy in women taking valproate (a teratogen):-
The Medicines and Healthcare products regulatory Agency (MHRA) made new recommendations in 2018 regarding use of sodium valproate by women of childbearing age. MHRA stipulates that valproate should only be used where the conditions of a pregnancy prevention programme are met. Guidance on this including written information and a video for health professionals can be accessed to support implementation of these measures via the MHRA website. Further information can be found at www.uktis.org.

In line with this, the FSRH CEU issued a statement in February 2018 stating:

“FSRH guidance advises that women of reproductive age who are taking known teratogenic drugs or drugs with potential teratogenic effects should always be advised to use highly effective contraception both during treatment and for the recommended timeframe after discontinuation to avoid unintended pregnancy.” 

“Methods of contraception which are considered ‘highly effective’ in this context include the long-acting reversible contraceptives (LARC) copper intrauterine device (Cu-IUD), levonorgestrel intrauterine system (LNG-IUS) and progestogen-only implant (IMP) and male and female sterilisation, all of which have a failure rate of less than 1% with typical use.”

The statement also notes that women should be made aware that no method of contraception is 100% effective. FSRH notes that first year typical use failure rate of the LNG-IUS is estimated at 0.2%; for the copper IUD, this is estimated at 0.8% The effectiveness of intrauterine contraception is not affected by concomitant use of other medications.

With reference to safety of use of intrauterine contraception by women with epilepsy:-
UKMEC 2016 indicates that both IUD and IUS can safely be used by women with epilepsy (UKMEC1). The woman can be supported regarding choice based on discussion of risks and benefits of the two in relation to her needs and wishes.

FSRH Guidance on intrauterine contraception identifies that

“Any invasive procedure in a non-anaesthetised woman, including IUC fitting, can trigger a vasovagal response. It is recommended that all staff involved with IUC insertion should undergo training and regular updates in resuscitation.”

Women with epilepsy undergoing IUC insertion should be made aware of the possibility of vasovagal response, which could lead to seizure in someone with a lowered threshold. There is no evidence on which to base a recommendation as to whether this should be performed in primary or secondary care, but no current guidance suggests that secondary care is required. FSRH Service Standards for Resuscitation in Sexual and Reproductive Healthcare Services offer guidance relating to required resuscitation equipment.

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Example Question Two

Is there any evidence about effectiveness in the COC vs POP in young people for example under 18s with regard to remembering to take it. I know the effectiveness with general Typical  9% vs Perfect use  >99 %  for POP and COC- but has there been any separate data for young people that may guide choice of contraception as a new starter who doesn’t want a LARC.. The data looks at all women taking the POP and my concern is Young people may not be such good pill takers so have a higher failure rate.

Response:

There are no data from randomised trials comparing contraceptive effectiveness of COC and POP in young people; there is not useful evidence as to how compliance with COC compares with compliance with POP and what effect that has on contraceptive effectiveness. We do not even have clear data to inform relative contraceptive effectiveness of traditional POP with its 3 hour window with desogestrel POP (12 hour window) in the general population. The best that we have are the estimates for first year contraceptive failure rate for the population as a whole as cited in FSRH Guidance.

As with any group of oral contraceptive users, there will be organised, motivated young people and chaotic young people and every shade between. Young people may be comfortable using apps/ electronic reminders to help them remember to take oral contraception. All women requesting user-dependent contraception should be made fully aware that contraceptive effectiveness relies on perfect use and that more effective, reversible contraception is freely available.

 

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.