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Sexual health

Clinical Articles

There is no perfect contraception…

Let us imagine that there has been a significant side-effect from a contraceptive choice occurs and a patient suffers harm. It is a known but very rare side-effect. How much legal and ethical responsibility lies with the doctor who prescribes the contraceptive, how much lies with the medical experts advocating this form of contraception as reasonable and safe, and how much lies with the pharmaceutical company who researched this product? Should this contraceptive be withdrawn from use, and if so, why would it be still available and advised for use in other countries around the world? A reasonable response to this question would include an assessment of the incidence of this particular complication among all users of this contraceptive, the incidence of any other significant complications, and the outcome for the patients of these complications. However, let us imagine the media finds this story and runs with it, giving widespread coverage of this single case and highlighting the contraceptive as the cause. This is the situation at present with the progestogen IUD, Mirena^® in the United States. It is also the case with oral contraceptive pills that contain cyproterone acetate (such as Diane-35^®) in Australia. Contraceptive pills like Diane-35^® are more oestrogenic in their balance and this could potentially increase their risk of venous-thromboembolism (VTE), although this still remains somewhat controversial. It was temporarily banned in France because of this in 2013. However, the risks need to be put in perspective. Even if the worst case-scenario is accepted, the actual increased risk of VTE for these newer pills over older types is an extra four to six VTEs per 10,000 Pill users per year.¹ “The risk of death from a VTE induced by a combined oral contraceptive is approximately one in 100,000, significantly less than the risk during pregnancy,” said Dr Foran. It is known that oral contraceptive pills containing 35ug ethinyl oestradiol and cyproterone acetate are being prescribed in Australia for indications beyond contraception, namely androgenising signs in women. It is also known, that for some women these pills provide the best control of their symptoms. In Europe, the regulatory authorities decided that the benefits outweighed the rare risks for properly selected patients and this OCP was quickly reintroduced to the market after only six months. However, in Australia there have recently been calls for the banning or restriction of this product in Australia following the diagnosis of a VTE in a young woman. How reasonable is it in our society to allow the traumatic stories of individuals to override medical opinion and determine regulation? The public needs to be made to realise that not only are these products very safe for the overwhelming majority of women, when prescribed appropriately, but they are also so much safer for women than an unplanned pregnancy would be. It might be valid to argue that there are other combined oral contraceptives that are ‘safer’ than those containing 35ug ethinyl oestradiol and cyproterone acetate, or that cyproterone acetate is available separately for use. However, what happens when one of these other oral contraceptive choices causes a major medical event in a different woman? In the UK, doctors have been advised to warn patients that there is an increased risk of VTE with Femodene^®, Marvelon^® and Yasmin^® named as some examples. The Daily Mail UK¹ had a massive heading to this effect: “Deadly risk of pill used by one million women: Every GP in Britain told to warn about threat from popular contraceptive” If media and legal pressure is allowed to result in the withdrawal of these medications, at some stage, there will be no oral contraceptive choices left. The seriousness of the situation is highlighted in the case of the Mirena^® IUD, since there is no similar alternative to this product in Australia. In the United States, this contraceptive device has been under a cloud of bad publicity since 2009, due to US Food and Drug Administration warnings relating to migration and perforation. Since then, the Mirena^® IUD has been scrutinised by patients with side-effects and, of course, lawyers. “The real question here is whether hysterectomy or endometrial ablation is a safer option than the Mirena^® IUD for women with heavy menstrual bleeding.” Dr Foran. The maintenance of a range of choices is important and women should have the right to make these decisions for themselves in consultation with their doctors. The Mirena IUD is also a safe form of contraception, especially for women who have thrombophilias and for older premenopausal women, most of whose other choices are less safe. Is it still enough for doctors to fully inform women of the side-effects and complications of their contraceptive options and to let them decide, or is modern contraception becoming a very personal, public and legal battlefield, the main casualties of this being expert medical advice and a woman’s choice? …and in the end, who is left holding the baby?

Bitzer J et al. Statement on combined hormonal contraceptives containing third- or fourth-generation progestogens or cyproterone acetate and the associated risk of thromboembolism. J Fam Plann Reprod Health Care. doi: 10. 1136/ jfprhc-2013-100624 http://srh.bmj.com/content/familyplanning/early/2013/04/10/jfprhc-2013-100624.full.pdf

Daily Mail, UK, 22^nd Feb 2018 http://www.dailymail.co.uk/news/article-2550216/Deadly-risk-pill-used-1m-women-Every-GP-Britain-told-warn-threat-popular-contraceptive.html

This article is based on an interview with Dr Terri Foran, Sexual Health Physician, Lecturer with the UNSW’s School of Women’s and Children’s Health and Director of Master Women’s Health Medicine on Saturday 17th February 2018 at the Annual Women’s and Children’s Health Update, Sydney

Expert/s: Dr Vivienne Miller

Sexual health

Pathologists from Sullivan Nicolaides Pathology

Clinical Articles

Syphilis – it’s back

Syphilis

Syphilis, caused by the spirochaete Treponema pallidum is an old disease. Many notable figures throughout history are thought to have suffered from this scourge. It remains exquisitely sensitive to penicillin so, in theory, should be easily treatable. Over the past two years, the number of notified cases of infectious syphilis – syphilis of less than two years' duration — has continued to grow. In the Northern Territory and Queensland, the emerging risk groups are young Aboriginal and Torres Strait Islanders (ATSI), particularly people from the north of the State. In this group, in which young females are infected, there is now a real risk of new cases of congenital syphilis. In other geographical areas, gay and bisexual males form the major risk group. Co-infections with other sexually transmitted infections (STIs) are common and should always be tested for simultaneously. Similarly, all STI screens should include a test for syphilis. At-risk patients require screening for co-existing chlamydia, gonorrhoea and/or and trichomonas if the patient belongs to the ATSI group. Screening for HIV, hepatitis A, B and C should also occur, with hepatitis A and B vaccination in those who are non-immune. The recommended regular screening for asymptomatic gay and bisexual males is outlined in the now renamed STIGMA guidelines (http://stipu.nsw.gov.au/wp-content/uploads/STIGMA_Testing_Guidelines_Final_v5.pdf).

Presentation

Early or infectious syphilis (less than two years' duration) includes primary, secondary and early latent syphilis (Algorithms 1 and 2). • Primary syphilis usually manifests as a chancre (an anogenital or, less commonly, extragenital painless, but also sometimes painful, ulcer with indurated edges). • Progression to secondary syphilis occurs over the following months and presents as an acute systemic illness with rash, which is usually truncal, but also involving palms and soles, condylomata lata (clusters of soft, moist lumps in skin folds of the anogenital area), mucosal lesions, alopecia, lymphadenopathy, hepatitis, or meningitis. • Early latent syphilis is infection of less than two years' duration where the patient is asymptomatic. Late latent syphilis is defined as latent (asymptomatic) syphilis of longer than two years' duration, or of unknown duration. Tertiary syphilis refers to syphilis of longer than two years' duration, or of unknown duration, with cardiovascular, central nervous system or skin and bone (gummatous syphilis) involvement. Risk of transmission of syphilis from a pregnant mother to her fetus depends on the stage of syphilis during pregnancy. Management is clearly outlined in the ASID Management of Perinatal Infections Guidelines (https://www.asid. net.au/documents/item/368)

General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial, free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.

Expert/s: Pathologists from Sullivan Nicolaides Pathology

Sexual health

Monographs

Update on Herpes Zoster

This article discusses herpes zoster, the condition and its complications as well as the benefits, risks and challenges associated with the herpes zoster vaccine.

Expert/s: A/Prof John Litt AM, Prof Tony Cunningham AO, Prof Paul Van Buynder

Sexual health

Clinical Articles

The Handmaid’s Tale and counting sperm: are fertility rates actually declining?

With the release of a new TV series based on Margaret Atwood’s The Handmaid’s Tale, and a recent study claiming male sperm count is decreasing globally, fertility is in the spotlight. Many want to know if the dystopian future Atwood created in which the world has largely become infertile, is in fact possible. And are we on our way there already?

What this latest study found

The recent paper that hit headlines all over the world highlighted the issue of declining sperm numbers in Western men. The study is a meta-analysis, which gathers together similar studies and combines the results. Each of the studies in the analysis has different men assessed at different times by different researchers. This means, as a whole, it is not as powerful as a study examining the same men over time. And many of the individual studies assessed have their own problems.

Read more - Health Check: when does fertility decline?

So is fertility actually declining?

The current estimate is that Western men produce 50 million sperm per millilitre in an ejaculate, which is lower than previously. However, only one sperm is needed to fertilise an egg, so 50 million sperm per ml suggests human males don’t have a problem just yet. There are data indicating that from below 40 million sperm per ml there is a linear relationship between sperm numbers and probability of pregnancy. The World Health Organisation (WHO) suggests 15 million per ml sperm is a minimum to be considered fertile. The minimum is based on men who have successfully fathered a child in the last 12 months. By definition, 5% of the men with numbers below 15 million per ml will still be able to reproduce. For females the issue that needs to be understood is that there is already a small window of time women are fertile, and this is decreasing as women are more educated and career-focused. Women have their highest number of eggs when they are still a fetus in their mother’s womb. About one sixth of the eggs are left at birth and by puberty the number is 500,000 eggs or less. From puberty until 37 years of age there is a steady decline from 500,000 to 25,000 eggs. After 37 years, the rate of decline increases and by menopause (average age of 51 in the US) only 1,000 eggs remain. It’s important to realise these are average numbers and there is no guarantee a woman will have 25,000 eggs at 37. The other issue is quality. Chromosomal issues (such as Down’s syndrome - where a person has three copies of chromosome 21 instead of two) increase with maternal age. IVF is seen as a way of rescuing fertility, but the success rate of 41.5% is for women younger than 35, and measures pregnancies, not live births. By 40 years old, that success rate is 22% and by 43 years it’s 5%.

Read more - Explainer: what causes women’s fertility to decline with age?

In short, the situation for women is not great, but the numbers are not changing with time (estimates of fertility from 1600 to 1950 don’t differ).

What is affecting fertility today?

The key determinant in women’s fertility is education - not individuals’ education but that of the community as a whole. If your community becomes educated, your fertility declines, as women become educated and less likely to have children in their youth. Choosing to delay having a child is not the only issue. Lifestyle choices matter. We know smoking, alcohol and obesity all affect the number and quality of eggs a woman has. As a female has all the eggs she will ever have when she is in her mother’s womb, the mother smoking will affect those eggs. Smoking in pregnancy is declining slowly (from 15% in 2009 to 11% in 2014) but is still very high in the Indigenous population (45%).

Read more: Why women’s eggs run out and what can be done about it

Smoking and alcohol are said to be major factors contributing to male sperm numbers but the evidence is limited by the nature of the studies. The effects of obesity and stress have the clearest evidence. For example, increased levels of anxiety and stress have been associated with lower sperm count. Life stress (defined as two or more stressful events in the last 12 months) has been found to have an effect, but not job stress. For men, the numbers themselves represent a blunt measure of fertility. It’s the quality of the sperm produced that’s of concern. The WHO minimum is that only 4% of male sperm need to be of good appearance to be considered fertile. It’s not really possible for us to be able to tell which of many factors may be influencing sperm appearance.

Problems with studying fertility

While we can talk about what research says on fertility, there are a few inherent problems with researching in this field. Most of the data we have on sperm count come from two sources: men attending an infertility clinic, and those undergoing a medical prior to military service. The first is restricted to those who likely already have a problem. The second is limited to one age group. Meta-analyses, which combine the results from lots of studies, are limited to those all using the same tools and approaches so they can be compared. As a result, a large meta-analysis that suggested smoking is detrimental was limited to men attending an infertility clinic, which would indicate many of them are likely to be infertile anyway. Another big study used conscripts in the US and Europe but failed to find an association between fertility and alcohol consumption. This is because it only assessed the alcohol consumed the week prior to the medical - and most recruits probably wouldn’t be out drinking in the days leading up to their medical.

So could we become extinct?

The reproduction rate is below that required for total population replacement in the US, Australia, and many other countries. But the human population in total is still growing as it ages.

Read more: Most men don’t realise age is a factor in their fertility too

The start of this millennium also represented the time when births for women aged 30-34 overtook those in the 25-29 age group, and the 35-39 age group overtook the 20-24 age group. Teenage pregnancy (15-19 years) is now level with older mums (40-44) in Australia. The quality of the sperm and egg is more important than the numbers. While we are still investigating what quality means to future generations, we do know that infertility represents a predictor of increased death rates. Men diagnosed with infertility had a higher risk of developing diabetes, ischaemic heart disease, alcohol abuse and drug abuse. Ultimately it’s not a numbers game but a quality game. This is true not just for the chances of having a child but having a healthy child. More immediately, fertility is a predictor of general health. While it does not appear that we are going to be extinct soon (at least not through reproductive failure), sperm quality could be a signal of wider health problems and should be investigated further. Shaun Roman, Senior Lecturer, University of Newcastle This article was originally published on The Conversation. Read the original article.

Expert/s: Prof Shaun Roman