Contraception in Practice
Authors: Sam Rowlands
Journal: Journal of the Royal Society of Medicine (2001)

The approach of Contraception in Practice is refreshingly different from that of existing texts. Instead of covering the methods one-by-one, it selects medical conditions and patient groups and looks at their contraceptive needs and the interaction between disease and method. The book highlights the many benefits of contraceptives, often badly neglected in textbooks. The topics seem to have been chosen somewhat at random, but they are all situations encountered quite often and are therefore relevant to many clinicians. Medical conditions range from cancers to subfertility. Patient groups include those at risk of sexually transmitted infections and couples whom nothing seems to suit. The editor has chosen five chapters of gynaecological orientation, reflecting his own interest. Equally he could have examined physical disability, autoimmune disorders, diabetes, inflammatory bowel disease, haematological disorders, psychiatric disorders or epilepsy—all of which present complex management issues. Anyway, the contributors have been picked because they are leading authorities and the approach is very practical—what you do with the patient in front of you.

Throughout, the diagrams are exceptionally clear and the references are comprehensive. Each chapter ends with two case histories which are well presented and give a sense of how the guidance can be used in the sometimes confusing world of clinical practice where there seem to be limitless numbers of situations to be faced. Detracting from this is inconsistent editing, with IUCD being used as an abbreviation in some chapters instead of the internationally approved IUD for intrauterine device, and sexually transmitted diseases in some chapters instead of the more up-to-date sexually transmitted infections.

The chapter on arterial disease (chapter 4) seems to me the least satisfactory, and its deficiencies are aggravated by the use of crossheads which I suspect were not proof-read by the editor. Some of these, I think, summarize the publisher's interpretation of what the authors mean, but in fact have a rather different sense.

The authors of chapter 4 do not quote the MICA study which shows no difference in risk of myocardial infarction for combined oral contraceptive (COC) users taking gestodene or desogestrel pills compared with levonorgestrel formulations. This is not because the book was written before this paper was published since it is cited in the previous chapter. The crosshead announces that ‘COCs containing third generation progestogens may have a lower rate of myocardial infarction’. On stroke, the crosshead states ‘modern low dose COCs do not increase the risk of any kind of stroke in healthy non-smokers’. The consensus summarized by a World Health Organization (WHO) Scientific Group is that the risk of ischaemic stroke is increased 1.5-fold in those without risk factors and more in those with risk factors.

Next, the authors of chapter 4 quote from the WHO publication on medical eligibility criteria for contraceptive methods, reassuring readers that it is safe to prescribe the combined oral contraceptive pill to well-controlled hypertensives. In my view this should be qualified a bit more to read something like ‘young women with uncomplicated mild essential hypertension whose blood pressure is well-controlled by therapy may on occasions be given low-dose combined oral contraception under close specialist supervision’.

Later these authors, who are based in the USA, claim that obesity is not a contraindication to oral contraception. This conflicts with advice in the UK which generally regards a body mass index of 40 and above as an absolute contraindication to the combined pill because obesity is a risk factor for both arterial disease and venous thromboembolism. Finally, it is said that the antidiabetic troglitazone (not available in the UK) increases the metabolism of contraceptive steroids, implying that this agent might cause breakthrough pregnancies. In fact, thiazolidinediones and other antidiabetics have their hypoglycaemic effect antagonized by oral contraceptives but there is no clinically important effect on steroid levels.

Elsewhere the book is well written and informative. Overall I enjoyed it and would recommend in particular the elegant chapter on migraine and the sensitively written chapters on teenagers and those with learning disability.