Healthline: 1300 658 886 www.fpnsw.org.au

October Medical Director In August I attended the RANZCOG Indigenous Women’s 2008 Health Conference in Darwin which impressed me enormously – it was a ‘real’ conference; the sense of really wanting to make a difference to Indigenous women’s health was palpable in listening to the presentations and in networking with the other delegates. There were Aboriginal and Torres Strait Islander women telling it like it is in their communities and inspiring stories from Aboriginal Health Workers on the impact their work has made in improving services such as the provision of Pap testing in the Northern Territory. Sister Alison Bush, Aboriginal Midwife told us how she taught AHWs from remote communities in the Maternal Health Skills program at King George V Hospital – 262 workers were trained before the program was sadly discontinued in 2002. There were flying obstetricians / gynaecologists like Margaret O’Brien in Far North Queensland who take their expertise to tiny, remote communities, there were stories of professionals passionately committed to finding a way to allowing more Indigenous women to be able to have their babies born ‘on country’. Sue Kildea presented on the Inuit women of Canada who now do deliver in their country and she presented a potent argument for it to be able to happen here. Some statistics presented to the forum; there are 130,000 Indigenous women of reproductive age, their fertility rate is 2.12 compared to the non Indigenous fertility rate of 1.81; 80% give birth under 30 years of age and 22% are adolescent mothers compared to 4% of non Indigenous women. For Indigenous women, the most commonly diagnosed cancers are; breast 24.5%; lung 11.6%, large bowel 8.9% and cervix 6.9% (the cervical cancer rate in Indigenous women is 2.4 times that of non Indigenous women). On the topic of improving reproductive and sexual health in both indigenous and rural communities, I am very pleased to congratulate the successful applicants for the FPNSW Scholarships; for a doctor working in Aboriginal Medical Services Dr Frick of Illawarra AMS was successful and there are two awardees for the rural scholarship which has been divided between Dr Murcott of Lemon Tree Passage and Dr Gabriel Caswell of Moree - Well done! Christine Read

Lets Talk: Sex & Reproduction Our other keynote speaker was Hermine Scheeres, standing in at the last minute for Report on FPNSW Conference Diana Slade. Hermine is a linguist and shared and Open Day 16 August, 2008 with us some ground breaking research that her Following on from the success of our 2007 Open team at UTS has been doing in collaboration Day, we decided to do it again! The theme of this with FPNSW. Having analysed many medical year’s Open Day was communication in all its consultations they are trying to define the forms. Once again we devised a program of essence of what makes a well communicated expert speakers for the morning plenary and consultation. The good news is that doctors at practical interactive workshops in the afternoon. FPNSW are pretty close to the perfect example! We had four Clinical Letter expert speakers each giving an update on the latest and greatest in their particular field. Ellie Freedman & Lesley Andrews Lesley Andrews spoke about screening for Ann Brassil, Hermine Scheeres, Christine Read, Caroline de Costa & Deborah Bateson cancer genes implicated in breast and ovarian cancer, Devora Lieberman about the new technologies, enabling IVF to work so many We were honoured to have Professor Caroline wonders. Christine Read spoke about the latest de Costa as one of our key note speakers. She advances in contraception – a new pill, some gave an insightful and inspiring talk on Ethics new guidelines and a new handbook. I was able and Politics of Reproductive Health taking the to share some research insights into the sticky law around abortion as her paradigm. problem of urethral discharge.

Volume 8, Issue 4 Page 1 Healthline: 1300 658 886 www.fpnsw.org.au

The workshops included vulval biopsy skills (happily on pig’s trotters only!), thanks to Gayle Fischer, Men Opportunistic Chlamydia testing and the City in which Patrick Duley and Mark Morris Chlamydia infection is sometimes called the “silent proved to us that’s its not all martinis. epidemic”. We have been keeping a surveillance database of the number of tests we carry out as well Rachel Skinner ran a workshop on talking to teens, as the positive test rate across all of our clinics since using her own research material which gave a 2006. The number of tests performed in our centres fascinating insight (especially for the many mums in has increased from 2628 in the 2006/2007 financial the room!) and Organon provided an Implanon training year to 3212 in 2007/2008. Dubbo consistently has the session. highest positive test rate followed by the Hunter clinic The organisation leading up to the day was and there has been a small decline in the proportion of outstanding, everything from the food and the parking tested young people with a positive result. to the IT equipment worked perfectly. Many Thanks It can sometimes be difficult to introduce the topic of go to all the staff that helped with the planning and testing for STIs. A recent study suggests that women ensured smooth running on the day. may prefer the offer of chlamydia screening to be We were so happy with the day that we have already based on age rather than the assessment of sexual set next year’s date Saturday 15th August 2009. risk in order to normalize and destigmatise the testing. 1 Put in your diary now ! A sentence along the lines of “we are offering Chlamydia testing to all sexually active people under Contributed by Dr Ellie Freedman the age of 30, would you like to have a test while you are here and find out more about Chlamydia?” is likely What’s new in contraception? to be the most effective way of introducing the topic. Postinor®-1 was released through pharmacies on 1 st 1.Take the sex out of STI screening! Views of young women on implementing Chlamydia screening in General Practice. Pavlin N, September 2008. It is a single tablet emergency Parker R, Fairley C, Gunn J & Hocking J. BMC Infectious Diseases contraception regimen (containing 1.5mg 2008, 8: 62doi: 10.1186/1471-2334-8-62. levonorgestrel) and it replaces the two tablet Percentage of young people under 25 years tested Postinor®-2. It is indicated for use within 72 hours of for Chlamydia who have a positive result unprotected intercourse with an estimated efficacy of 93% i.e. it can prevent 93% of unplanned Chlamydia positive (< 25 yrs old): FPNSW clinics pregnancies if taken within this timeframe. It will be 30 Ashfield Dubbo Fairfield Hunter Warehouse FPNSW much more convenient for women as they won’t have to get up in the middle of the night for the second 25 dose! 20 We now also have a new combined oral contraceptive pill choice for women. Yaz® is a low dose 20 mcg pill 15 which contains 3mg of drosperinone (Yasmin® contains 30 mcg of ethinyl estradiol and 3 mg rates Positive 10 drosperinone). The major difference with Yaz® and 5 other pills is that it has a 24/4 regimen i.e. there are 5.4 15.3 0.0 9.8 8.1 8.9 6.0 13.3 4.2 8.6 6.4 7.9 24 active hormone pills with only a 4-day hormone 0 free break. The rationale for this regimen is that it will FY 2006/2007 FY 2007/2008 reduce the risk of follicular development and Period consequently ovulation during the pill free break. Contributed by Dr Deborah Bateson Reducing the pill free break also minimizes the chance of experiencing hormonal withdrawal symptoms such as headache and pelvic pain and the Healthline extended hormone dosing schedule means that it is Our telephone information service. When you may also be useful for women with moderate acne as call, a nurse who specialises in reproductive well as the severe form of premenstrual syndrome and sexual health will answer your questions known as PMDD or premenstrual dysphoric disorder. using up-to-date information. The service is We know of course that no single contraceptive anonymous and confidential and open method, or even contraceptive pill, will suit all women so increasing the options also increases the chance of Mon-Fri, 9am-5.00pm EST . ‘finding the right fit.’ Women will be able to skip their Call on 1300 658 886 withdrawal bleeds in the same way as for all other combined pills by simply missing out the sugar pills or TTY for Deaf 02 8752 4360. and moving straight to the active pills in the next pack. Local call costs apply and may be higher from mobiles. Contributed by Dr Deborah Bateson Volume 8, Issue 4 Page 2 Healthlie: 1300 658 886 www.fpnsw.org.au

Antiepileptic Drugs (AEDs) and Hormonal Contraception

The possibility of drug interactions should be A third group includes gabapentin, ethosuximide, considered and discussed when prescribing zonisamide, tiagabine, levetiracetam and valproic hormonal contraception to women of acid; these do not alter steroidal contraceptive reproductive age. The benefits and risks of all pharmacokinetics. contraceptive methods should be considered. Lamotrigine is significantly different to other AEDs Anti-epileptic drugs can be categorised into since it primarily affects progestogen levels through three groups, based on their potential to induction of the UDP glucuronosyltransferase (UGT) cause induction-type drug interactions enzyme system, thereby lowering serum levels of involving cytochrome P 450 (CYP) enzymes. progestogen (lowers levonorgestrel by about 20 per Older AEDs (phenobarbital, phenytoin and cent) while leaving oestrogen levels unchanged. The carbamazepine) induce cytochrome P450 small studies done to date have shown no evidence mediated metabolic pathways which increases of breakthrough ovulation or reduction in efficacy the rate of metabolism of both oestrogens and when lamotrigine has been used with a combined progestogens, and therefore lowers the blood oral contraceptive. There are no studies on the use of progestogen-only contraception and lamotrigine. levels of these hormones, perhaps by 50 per cent or more (O’Brien et al: 2006). Combined hormonal contraceptives also reduce the Note: There is significant potential in this blood level of lamotrigine, which may result in poorer situation for contraceptive failure. control of epilepsy, adding to the complexity in using this particular AED. A second group of newer AEDs includes Reference O’Brien MD, Guillebaud J Critical Review; Contraception topiramate, felbamate and oxcarbazepine; these for Women with Epilepsy Epilepsia 47(9);1419-1422, 2006) are less potent as inducers of CYP isoenzymes but have been shown to lower plasma Information on anti epileptic drugs is taken from concentrations of oral contraceptive steroids ‘Contraception: a clinical practice handbook’ and, by extension, other hormonal methods of (2nd edition) to be published by SH&FPA. contraception. It should be available in early 2009. Enquiries to Healthrites on 02 8752 4307

Table 1. Antiepileptic drugs and contraceptive methods* Contributed by Dr Christine Read Anti-epileptic drugs (AEDs) AEDs that affect hormonal contraception AEDs that do not affect by enzyme induction hormonal contraception Phenobarbitone Acetazolamide Primidone Sodium valproate Phenytoin Levetiracetam Carbamazepine Gabapentin Oxcarbazepine Tiagabine Vigabatrin Benzodiazepines (clobazam, clonazepam) Pregabalin Zonisamide Methods of contraception and enzyme inducing anti-epileptic drugs (EIAEDs) Contraceptive methods affected by EIAEDs Contraceptive methods not affected by EIAEDs Combined oral contraceptive pill Depot medroxyprogesterone acetate (DMPA) Combined vaginal ring Levonorgestrel IUD Progestogen-only pill Copper IUDs Progestogen implant Barrier methods

Volume 8, Issue 4 Page 3 Healthline: 1300 658 886 www.fpnsw.org.au MEDICAL EDUCATION COURSES “Who? Why? What? of STI testing” SH&FPA Certificate in Sexual and The six hour Active Learning Module aims to enhance your practical skills in sexual history taking, HIV pre-test and poet-test counselling and Reproductive Health initial management of positive and negative test results. Ideal for GP’s This course is recognised by RANZCOG and ACHSHM. It is also wishing to improve their sexual health communications skills. recommended by the RACGP for all trainees wishing to increase their This is intended to supplement your knowledge of STI diagnosis and knowledge base and clinical skills in sexual and reproductive health . management. Dates: 8-13 March 2009 Dates: Saturday 8 November 2008 17-22 May 2009 All Family Planning NSW Time: 9.30am - 4.00pm 26-31 July 2009 Medical Education courses are Cost: $175 25-30 October 2009 exempt from GST Venue: FPNSW Ashfield Time 9.00am - 5.00pm This activity has been approved as an ALM by the RACGP QA&CPD Program for 40 Category 1 points for the 2008-2010 triennium. Cost: (from March 2009) $1850.00 (all 3 modules) The SH&FPA Certificate in Sexual & $1350.00 (theory and assessment only) (includes course materials, lunch, clinical training and Reproductive Health – Distance Mode criminal record) The SH&FPA Certificate by distance mode enables participants who Congratulations to our “Sexual Health” Quiz cannot attend the face-to-face course to complete the theory module at home at their own pace. The content is similar to the face-to-face course Prize winner Dr Romit Saha-Chaudhury of and is supported by additional readings and self-assessment activities. Campbelltown who answered all questions correctly. The course can be commenced in April and September 2009 . Here is a brief reminder of the issues covered in the quiz: It is made up of 7 modules: Chlamydia PCR testing requires a first-void specimen 1. Men’s and Women’s Sexual Health (applied physiology, cervical which means the first part of the urine stream rather than screening and breast checks, men’s health issues) an early morning specimen; 2. Aspects of Pregnancy 3. Sterilisation and Sexual Counselling Oil based lubricants will damage latex condoms so 4. Contraceptive Technologies shouldn’t be used; 5. Menopause 6. Gynaecological Problems Oral sex is a low risk activity for HIV acquisition. 7. Sexually Transmitted Infections and HIV

A module is sent out every third week with the aim of completing the Healthrites is a mail order service that supplies course in 4-6 months. Participants can join a face-to-face course to sit the examination and are then eligible to proceed to clinical training a wide range of books and other resources (Module 3) to complete the full SH&FPA Certificate in Sexual and about sexual and reproductive health. Reproductive Health. Modules can also be studied separately For more information visit our website Face to Face and Distance Mode approved for 40 Category 1 points in the www.fpnsw.org.au/resources/healthrites RACGP QA&CPD Program for the 2008-2010 triennium. Supervised Clinical Attachment is also approved for 40 Category 1 points by RACGP QA&CPD program for 2008-2010 triennium FPNSW Steroidal contraception module online Full cost is $1750.00 (from April 2009) which includes assessment, (40 Group 1 points) go to: clinical training and criminal record check. http://www.thinkgp.com.au/education

Quick “Antiepileptic drug interaction” Quiz 1. The following antiepileptic drugs affect hormonal contraception methods by enzyme induction; phenobarbitone, primidone, phenytoin, carbamazepine, oxcarbamazepine T / F 2. The progestogen implant, Implanon can be safely used for contraception in a woman taking enzyme inducing AIEDs as there is little risk of contraceptive failure. T / F 3. Combined hormonal contraceptives reduce the blood level of lamotrigine, which may result in poorer control of epilepsy. T / F Name: ……………………………………………………………………………….. Address: ……………………………………………………………………………… Contact number:.………………………….………...Email: ……………………………………………………………………. Please fax us your answers to 02 8752 4392 (answers will be supplied in the next newsletter). A draw will be made of all correct answers on the 1st December 2008 and the winner will receive a $100 voucher from the Healthrites Bookshop .

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