If one considers that, on average, a doctor will practice medicine for several decades, certain sectors will have changed radically not only from a conceptual viewpoint but also in terms of diagnostics and treatments. For example, a 60 year-old (very young!) gynecologist will have studied medicine at a time when in vitro fertilization (not to mention pre-implantation diagnosis) was not even considered.
The information that is necessary to practice medicine today is:
- being constantly renewed
- growing in volume
- coming from an increasing number of sources, where Internet is the physician’s best (and worst) information tool and... from the patient, who is an increasingly informed consumer Moreover, the relevance of information (often totally contradictory and challenged in the short term) is increasingly uncertain and disquieting for the physician, in particular when he works alone and is not part of a structured group. This offers the opportunity to emphasize how important it is to set up learning networks, often consisting of the team with which the physician first took specialization training. This is why the education dispensed in medical schools must undergo a radical change based on the following:
- During the first phase of medical studies, there should be more focus on the basic sciences which do not evolve as quickly as practical concepts but which are essential to understanding physiologico-pathological mechanisms.
- The second phase of medical school should, of course, be devoted to acquiring knowledge and skills, but also to learning how to access and critically assess data. For this purpose, the critical appraisal of an article test that was recently introduced in France for the nationally ranked examination (the exam prior to becoming a resident), although not a panacea, is intended as an initiation to critical thinking with regard to scientific publications as well as information provided by the pharmaceutical industry (indeed, it is sometimes hard to tell the difference!). Such critical thinking must also apply to the relevance of new additional tests, new treatments, and all diagnostic and therapeutic strategies.
- Physicians must learn to place this discussion within the framework of a broader public health strategy, which must also be an integral part of their training.
- Lastly, doctors must keep their minds constantly open to new learning; a doctor has to remain a student his entire life! Universities need to fulfill this role in close cooperation with learned societies and boards. Meetings such as the congress organized by the European Society of Gynecology in Rome are therefore essential as they provide access to information presented by authors who, a priori, have experience in the field under discussion. This information is evaluated by other professionals in the same field and specialists from neighboring fields; such is the importance of a multidisciplinary perspective. In practical terms, doctors need to receive academic training in critical thinking and on how to continually update their knowledge base. We must also address the problem of how doctors acquire new practical skills, in a way that is structured and shaped to enable practicing physicians to participate in actual internships in facilities that are able to teach them “the new techniques.” Finally, although in recent years doctors have been trained to make evidence-based decisions (whenever possible), they still need to take up a new discipline: predictive medicine, which will make it possible to adapt diagnostic and therapeutic strategies to each individual and his or her particular circumstances. Medical schools must have the new educational resources that are needed for this “cultural revolution” to occur, and must create genuine educational research entities. The study of medicine will then be as much about acquiring knowledge as it is about learning how to manage this knowledge.

As for me some of these hot issues may be the following:

1. In the field of the pill, a newcomer, the natural estrogens

Qlaira® the first combined oral contraceptive (COC) that delivers natural estrogens instead of ethinylestradiol (EE) is now in the market. This quadriphasic pill contains an antiandrogenic progestin with a pronounced endometrial focus, the dienogest (DNG), and a natural estrogen, estradiol valerate (E2V). Qlaira® has 26 days of active treatment followed by 2 placebo tablets. This pill provides good contraceptive efficacy and cycle control and is associated with shorter and lighter bleeding compared with the pill EE 20µg/levonorgestrel 100 µg. This new pill has a minimal impact on metabolic and hemostatic parameters.

• Qlaira® will probably be followed by the second pill containing a natural estradiol, the NOMAC/E2 pill (nomegestrol acetate and 17b estradiol). This promising monophasic pill has 24 days of active treatment followed by 4 placebo pills.
• After Qlaira® and NOMAC/E2 pills containing a natural estrogen, we will probably have the E4 (estetrol) pill. This foetal estrogen seems to have not only a favourable metabolic tolerance but also favourable impact on breast tissue according some preliminary results.
• In theory, the rational to use natural estrogen instead of ethinylestradiol is to minimize the hepatic metabolic impact of the COCs, in order to minimize cardiovascular impact of the pill. However further data from clinical and epidemiological studies, mainly large postmarketing surveillance studies, are needed before conclusions can be drawn regarding the relative safety of these “natural”pills particularly with regards to rare clinical events such as venous and arterial thromboembolism.
• If these first new COCs containing a natural estrogen keep their promise, they will certainly open a new chapter in the history (always on the move) of the contraception. In that case the COCs contraindications will probably be modified.

By the way, the World Health Organization fourth edition (2008) of “Medical Eligibility Criteria for Contraceptive Use” is just published. This expected new edition will be disponible this autumn 

2. Another hot issue in contraception may be the use of modern (mainly hormonal) contraception as treatment or prevention of several gynecological or non-gynecological disorders by women without need of contraception.

This concept has been inaugurated mainly by the levonorgestrel intrauterine system (LNG-IUS) Mirena®, thanks to its mechanism of action, principally, atrophy of the endometrium. The contraceptive and therapeutical indications of this device have just been actualized : contraception in 117 countries, menorrhagia (+ contraception) in 110 countries, HRT (+E2)
(+ contraception + menorrhagia) in 107 countries. This LNG-IUS is proposed by the NICE (National Institute for Health and Clinical Excellence) (UK) and the CNGOF (Collège National des Gynécologues et Obstétriciens Français) as first line medical treatment of menorrhagia. This LNG-IUS presents also an alternative to hysterectomy for many women. Other therapeutical indications of the LNG intrauterine systems (Mirena®, and probably tomorrow, CLS®, Fibroplant-LNG®, Femilis®, Femilis Slim®) are possible : endometriosis, adenomyosis, inherited bleeding disorders…
Outside the LNG-IUS, COCs, through suppression of ovarian activity or endometrial proliferation, can be used to prevent or to treat a range of gynecological or non-gynecological disorders. However only a minority of OCs has been approved for non-contraceptive therapeutical indications such as acne or PMDD (premenstrual dysphoric disorder). Nevertheless, some pharmaceutical companies are, as I know, eying use, then approval, of the pills for treatment of dysfunctional uterine bleeding, withdrawal symptoms, dysmenorrhea or sexual disorders, etc...
Of course research is needed on the acceptability, the safety and need for (long term) use of hormonal contraception for therapeutical indications by women without need of contraception.

3. “To bleed or not to bleed” (this title is due to E. Coutinho) by users of contraception may be also considered as a hot issue in contraception.

• This new concept is linked to the concept of “extension”.

• In brief, this concept consists to manipulate hormonal contraceptives in order to menstruate at will for personal reasons or for medical reasons (for example improvement in cycle-related symptoms).

• Physicians and health providers must help women who want to use this concept, using their contraceptives with variable “extension” in order to bleed every month, or every
  4 months (Seasonale®…) or not at all (Lybrel®…).

• This concept “TO BLEED, IF I WANT, WHEN I WANT” may be considered as the second liberation of women after their first liberation, I mean acquisition of free and safe contraception and abortion.

4. Long-acting reversible contraception (LARC)

The LARC are contraceptives methods that require administration less than once per cycle or month. The copper intrauterine devices (Cu-IUD), the progestogen-only intrauterine systems (LNG-IUS), the progestogen-only injectables (DMPA and the new DMPA-SC) and the progestogen-only subdermal implants (Implanon®, the future Implanon-NXT®, the future Jadelle®) represents the actual LARC. To use more frequently the LARC due to their cost-effectiveness aspect particularly by women who have compliance problems and to fight against their use barriers has to be considered in my opinion, as a hot issue in contraception in the year 2010.

I have arbitrarily selected these four hot issues in contraception because they are subjects of the day. But several other hot issues in contraception in development merit to be cited. They may include the following.

• Use of PRMs (Progesterone Receptor Modulators) in contraception : for instance the
  PRM VA2914 in continuous oral low dose, or the PRM ZK 230-211 released by intrauterine systems, or the PRM Ulipristal (VA2914) as emergency contraception (EllaOne®)...

• The One’s a month injectables.

• The Nesterone vaginal ring (duration of effectiveness = 1 year).

• The Gestodene patch (Fidencia®), smaller than Evra® and transparent.

• The procedure Essure® for hysteroscopic sterilization (14000 procedures by year in France in 2008). Etc...

These promising innovations in contraception will probably be related in detail during the next (9th) congress of the European Society of Gynecology (Denmark, 2011).