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EDITORIALS: Basil Donovan Never underestimate the force of reproduction BMJ 2000; 321: 461-462 [Full text]

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Never underestimate the force of sex

Ron Law   (18 August 2000)

Contraception for teenagers

Terri Foran   (24 August 2000)

Never underestimate the force of sex 18 August 2000
Ron Law, Avid Reader of Medical Literature Send response to journal: Re: Never underestimate the force of sex	Editors of medical journals need to tighten up on the titles used in printed articles. For editorials and letter, the only information Medline searchers get about an article is the heading. In this case the article provides evidence and discussion for the 'Never underestimate the force of sex' not 'reproduction.' Let's have evidence based titles - not titles designed to sell magazines.
Contraception for teenagers 24 August 2000
Terri Foran, Medical Director Send response to journal: Re: Contraception for teenagers	I was interested to read the editorial by Professor Basil Donovan, regarding effective contraception for teenagers requiring a change of medical culture. I am in agreement with his belief that we as medical practitioners must constantly re-examine our own biases and prejudices in order to deliver the best possible medical care to all our patients. I found myself disagreeing strongly however with Professor Donovan's contention that the Intrauterine Device (IUD) may well be the ideal method of contraception for teenagers at risk of pregnancy because of their difficulty in using the Combined Pill consistently. John Guillebaud states in his book "Contraception - your questions answered"2 with regard to Pelvic infection in IUD users that it is primarily a 'self or partner inflicted wound'. There is no doubt that the greatest risk of pelvic infection is in the first 20 days after the insertion of the IUD, and is caused by pre-existing sexually transmitted infection (STI) carriage. In most cases adequate pre-insertion screening and treatment can indeed ameliorate this risk. The risk thereafter however relates to the patient's background risk of STI's, and I would contend that teenagers engaging in "sporadic, unexpected, or coerced" intercourse could hardly be considered to be in a low risk category. Some US studies have found a carriage rate for chlamydia in asymptomatic female Seattle teenagers of 8.6%.3 The asymptomatic nature of the infection means the majority of these young women would be unlikely to present for screening or treatment. While the progestogen bearing IUD has a theoretical benefit in increasing cervical mucus viscosity and thereby possibly preventing ascending pelvic infection, this is as yet by no means proven and manufacturers continue to advise that the device be used only in those at low risk of STI's. I agree that we in the medical profession perhaps need to look "outside the square" when discussing contraception with young people, and that recommending the pill as "99.9% effective" is a significant over- statement in teenagers where non-compliance is a real issue. Thankfully in many countries now we have long acting progestogen-based contraception which may fact provide a possible solution to the compliance issue for many young contraceptors since it does not have to be taken daily. One option is Depot medroxyprogesterone acetate (DMPA) which many of us working in the field of contraception have found a very useful choice for our adolescent patients whose lives can undoubtedly be somewhat chaotic. The availability of progestogen implants such as Implanon also allows for long-term and convenient contraception for adolescents without the risks associated with IUDs. In many countries also monthly combined injections are available, overcoming to some extent at least the irregular bleeding associated with progestogen-only contraception. There is no doubt that unwanted, unplanned adolescent pregnancy has significant social and psychological and economic effects for the young mother, and for the family, community and society in which she lives. It would be a pity however, if in a zealous attempt to prevent such pregnancies we were to recommend contraceptive methods like the IUD which might well compromise her ability to achieve a desired pregnancy later in life and increase the ever-growing demand for assisted conception services. 1 Donovan B. Never underestimate the force of reproduction. Editorial BMJ 2000, 321: 461-462. 2 Guillebaud J. Contraception - your questions answered. Edinburgh: Churchill Livingstone, 1999. 3 Marrazzo JM, White CL, Krekeler B, Celum CL, Lafferty WE Stamm WE, Handsfield HH Community-based urine screening for Chlamydia trachomatis with a ligase chain reaction assay. Ann Intern Med 1997, 127(9): 796-803.