Women's health

In reply

Macarena A San Martin Porter · Steve Kisely · Rosa Alati

To the Editor: Bateson and Black1 do a great service in encouraging clinicians to discuss pre‐conception care with women of reproductive age.1 However, in relation to infection prevention, one area not discussed was cytomegalovirus (CMV) infection, which is the most common infectious cause and the second most common aetiology of all causes of severe congenital malformations.2 Mother to child transmission of CMV can result in prematurity, stillbirth, cerebral palsy and neurodevelopmental delay and is the most common infectious cause of hearing loss.2 Discussions about CMV prevention should ideally commence before pregnancy, as maternal CMV infection in the first trimester poses the greatest risk of harm to the fetus if mother to child transmission occurs. Such discussions should continue throughout pregnancy, as secondary maternal infection with a different strain of CMV can also result in mother to child transmission of virus,2 although the risk per infectious event is lower. Women can adopt simple hygiene strategies to reduce risk of CMV infection and thus reduce mother to child transmission of virus during pregnancy. These recommendations have been published3 and referenced in consensus recommendations2 and other sources.4 Strategies preventing women acquiring CMV (usually from children)3 are acceptable and inexpensive — handwashing, not sharing food or objects covered with children's saliva, not kissing children on the lips and wearing disposable gloves during nappy changes. These strategies reduce the risk of infection before pregnancy and of mother to child transmission during pregnancy;2 they do not affect reactivation of latent virus, although this is associated with lower mother to child transmission. Universal serological screening with CMV IgG to determine previous immunity is not recommended, as congenital CMV can still occur as a result of non‐primary maternal infection and reactivation during pregnancy. Women should be advised to use hygiene strategies regardless of their serological status.2 In Australia, only one in six women who are pregnant know about CMV,5 and only one in ten maternity clinicians routinely discuss CMV prevention with pregnant women.6 It is likely fewer discuss CMV prevention before conception. We encourage clinicians, women considering pregnancy and parents to increase their knowledge about CMV and its prevention.4

Antonia Shand · Pamela Palasanthiran · William D Rawlinson

In reply

Deborah J Bateson · Kirsten I Black

To the Editor: We note with interest the research letter by Taft and colleagues regarding unplanned pregnancy in Australia.1 An audit of terminations of pregnancy in our Australian metropolitan hospital service (Austin Health, Melbourne) supports the findings of the national survey while highlighting additional areas of educational need. Of 309 women (aged 15–46 years) who underwent terminations for unwanted pregnancy from January 2016 to October 2018, 145 chose surgical termination and 164 women chose medical termination. Compared with the national survey, our cohort had similar rates of not using contraception (48.2% v 56.5%) and contraception failure (51.8% v 41.4%).1 Failed barrier and oral contraception respectively accounted for 52.1% and 29.3% of contraception failures. This differs from the survey findings, where the most common contraception failure was oral contraception, followed by condoms.1 There is a paucity of Australian literature reporting long‐acting reversible contraception (LARC) usage following termination; however, a Swedish study found a rate of 34%2 and a New Zealand public hospital service reported a rate of 44.5%.3 Our post‐termination LARC rate was 58.2% (72.5% following surgical termination and 43.2% following medical termination). We attribute the higher rate to our conscientious use of tiered counselling4 (ie, presenting the most efficacious method first) to enable women to make informed decisions regarding contraception. The most common choice of contraception following surgical termination was a levonorgestrel‐releasing intrauterine device (Mirena [Bayer]) (56.0%); however, oral contraception was more popular (38.8%) following medical termination, followed by Mirena (25.9%). A British study also found that women more often chose an intrauterine device or implant after surgical termination,5 suggesting that ease of insertion under anaesthetic influences choice. Of the 134 women documented as not using contraception in our audit, three had received inaccurate medical advice regarding contraception, or had been inappropriately labelled as infertile due to age, endometriosis or polycystic ovary syndrome. A further three pregnancies occurred as a result of removing LARC without arranging alternative contraception. We support the researchers’ conclusion regarding the need to explore reasons for poor contraception uptake and determine where education would be most helpful.1 In addition to increasing access to and promoting informed choice of LARC in primary health care settings,6 greater efforts to improve practitioner knowledge of contraception management, as well as common gynaecological conditions to aid appropriate diagnosis and evaluation of fertility impact, are vitally important.

Sophie L Yeates · Charlotte V Elder · Sonia R Grover

To the Editor: Norman and Teede outline the new international guidelines on polycystic ovary syndrome (PCOS), led by Australia and involving 37 societies and patient support groups and 71 countries.1 These guidelines highlight gaps in evidence and emphasise the critical need for more research into PCOS.2 In the United States, a recent analysis of National Institutes of Health (NIH) research funding from 2006 to 2015 for PCOS concluded that PCOS research may be underfunded by the NIH.3 In Australia, the National Health and Medical Research Council (NHMRC) is the premier funder of medical research and its main funding mechanism is by way of project grants, with over 500 granted annually. Using NHMRC online data (https://www.nhmrc.gov.au/grants-funding/outcomes-funding-rounds/previous-outcomes-project-grants-funding-rounds) and searching for “polycystic” or “PCOS” in the titles of funded project grants, we found only nine grants associated with PCOS from 2003 to 2018. Additionally, while there are many not‐for‐profit organisations raising funds for medical conditions, there are none for PCOS. We have considered the issues that may affect funding for PCOS. It could be that the name PCOS does not accurately describe the condition because having polycystic ovaries is neither needed nor sufficient in order to diagnose PCOS, and the name does not indicate any of the condition's important metabolic symptoms.4 This could potentially lead to grants being assigned to panels without the full expertise required to handle such grants. Barriers to funding in Australia could also potentially include a lack of internationally competitive researchers in PCOS in Australia, but this is not the case. Australia has established an international network in PCOS and led the world by producing the first evidence‐based guidelines.2 Three individual Australian researchers are listed in the top ten in the world in PCOS research (http://expertscape.com/ex/polycystic+ovary+syndrome). This attests to the calibre of Australian researchers in PCOS. We acknowledge that the international guidelines were funded in part by the NHMRC via a Centre for Research Excellence in PCOS. The Centre's efforts have positioned Australia at the forefront of international PCOS activities and have highlighted the vital need for specific dedicated research funding. However, given Australia's leading global role in the development of PCOS guidelines and identification of knowledge gaps, we, along with patient support groups, believe that greater efforts are required to recognise the prevalence, diverse clinical impact and health and economic burdens of PCOS, and to prioritise funding for research into PCOS.

Raymond J Rodgers · Jodie Avery · Veryan McAllister

In reply

Helena J Teede · Robert J Norman · Rhonda M Garad

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