Or Odd PC for Contraception Dr Bruce Davies Family Planning Or Odd PC for Contraception Dr Bruce Davies

Important 70% plus of women get their contraceptive advice from GPs An area where GPs may be the real experts Specialists in FP are available in some areas

Big Issues Too big for one tutorial Too many areas for one tutorial

Big Issues Too big for many 10 minute consultations Spread the load ! Patient information sheets

Possible Topics Gillick competance. Follow-up consultations. Audit of care. Scope of services. Peri-menopausal contraception.

Possible Topics Postnatal women. Women with learning problems. Emergency contraception. Cultural considerations. Pre-conceptual counselling. Return of fertility / infertility. UK MEC scores

Types Hormonal Combined oral contraceptive Progestogen only Depot injections Implants Emergency oral

Types Intrauterine devices Copper coils Intrauterine systems ( Mirena ) Emergency contraception

Types Barrier methods Diaphragm Cap Condoms Female condoms Spermicides

Types Natural Methods Sterilisation Male Female

First Requests People often have pre-conceived ideas of what they want …other methods may be more suitable GPs need up to date knowledge and current “scares” Need to know where to refer for specialised contraceptive care

First Requests Issues regarding choice Age Efficacy required Ease of use Smoking status UK MEC score

First Requests Topics to cover for each method Efficacy Individual suitability Absolute contra-indications Side effects Adverse reactions

First Requests Advantages other than contraception Mode of use Onset of action Follow-up arrangements Timing of return to fertility Protection against sexually transmitted disease

First Requests History to help work out UK MEC score Existing medical problems Regular medication Family history Menstrual history Obstetric history Previous contraceptive use

First Requests Often too much for one consultation Useful to have packets and coils to show Comparative leaflets useful Should aim for a joint decision

Combined Pills The most popular method.

Combined Pills Highly effective Increased risk of venous thrombosis Not for use in smokers over 35 years May raise blood pressure Cannot be used while breast feeding Caution with liver enzyme inducers Caution with broad spectrum antibiotics

Combined Pills Reduces ovarian cancer Reduces endometrial cancer Reduces benign breast disease Accelerates the presentation of breast cancer but probably does not increase absolute risk RCGP study results

Combined Pills Complicated starting instructions Seven day rule Etc etc Backup of leaflets essential

Combined Pills Non-contraceptive uses Acne Polycystic ovaries Cycle control Menorrhagia Dysmenorrhoea

Combined Pills Contraindications Previous DVT etc Breast or gynaecological cancer Any liver disease Any ischaemic heart or Cerebrovascular disease Gross obesity

Combined Pills Pulmonary hypertension Sickle cell disease Otosclerosis Focal migraine Haemolytic uraemic syndrome

Combined Pills Heart valve disease Porphyria Chorea Pemphigoid

Combined Pills Precautions Hypertension Raynauds Diabetes Asthma Varicose veins

Combined Pills Severe depression Chronic renal disease MS Dialysis Hyperprolactinaemia

Combined Pills Troubleshooting Failure Weight gain BP Migraine Breakthrough bleeding Spotting PMT symptoms Malaise

Progestogen only pills Reversible Needs to be taken daily May cause menstrual irregularity May be used in hypertension May be used while breastfeeding

Progestogen only pills Reliability Timing of use Leaflets needed

Depot progestogens Every 2-3 months Very effective Delay fertility return May cause weight gain May cause menstrual irregularity

IUD / IUS Contraindications Unexplained vaginal bleeding PID or recent PID Uterine distortion Risk of endocarditis (I.E. Murmurs etc)

IUD / IUS Heavy periods Specialist skills needed Counselling re problems IUS costs IUS initial symptoms IUS loading device diameter

Barrier Methods Protection against STD “Messy” Loss of spontaneity No drugs No side effects Reliability depends on usage

Barrier Methods Condoms Caps and diaphragms: specialist skills needed, to fit and educate about use. Non-hormonal Non-invasive Used only when necessary

Sterilisation Non-reversible At discretion of the surgeon to people who have no children

Sterilisation GPs need to know the pros and cons Need to understand the follow-up requirements post vasectomy Post-op care Myths (heavy periods, prostate cancer, de-sexed etc etc)

Natural Methods Women rarely ask Rhythm or calendar method Temperature method Cervical mucus or billings’ method The electronic “persona” A combination “Symptothermal method”

Natural Methods Usually beyond the scope of GPs Need to know the pros and cons Need to know where to refer for help Should not dismiss these methods Sensitive to patients beliefs and needs

Special Groups Underage Peri-menopausal Postnatal Emergency Changing method Cultural differences

Homework Prepare a patient information leaflet explaining the “7 day rule”. What exactly did the Gillick ruling say?

Homework What would you cover in a consultation about pre conceptual counselling?

Homework Personal list of COP to use and reasons for selection Personal list of POP to use and reasons for selection

Homework Draw up a list of problems people come back with about the COP, causes and possible solutions.

Homework Need for further reading Courses Diploma in Family planning and reproductive health care

Stories Maria, a 37-year old mother, had her second child 6 months ago. She wishes to discuss contraception with you. “I don’t really want to back on the pill, but I’m not sure that we want anything more permanent yet.”

Stories Elizabeth a 21 year old shop worker consults with a single episode of an extra bleed between her normal bleeds with Microgynon. She has had one smear 18 months ago which was normal.

Stories Jill, a 42 year old manager is using Micronor, her periods have become increasingly heavy, she has 2 children. She is fearful of operations.

Stories Susan a 41 year old with a Mirena IUS for the last 3 years consults because of 2 episodes of post-coital bleeding. What do you discuss? What are the options?

Stories Susan, a 15 year old, comes to ask you to be put on the pill. Her sister aged 17 has just had a STOP. She smokes 10 a day.

Stories A 26 year old consults about contraception, she has been using sheaths since her first child was born 2 years ago. She wants to go back on the OCP. Her notes suggest she may have had migraines in the past.

Stories Helen, a 21 year old student has been on the OCP for 3 years, she is worried about long term use and side effects. She is definite she doesn’t ever want children.

Stories Sarah a 18 year old student comes to talk about contraception, she has never been pregnant but her mother died of a PE following a DVT. She wants to have a coil as. She doesn’t like the idea of Depot.

Stories Rose, a 30 year old married researcher, has always used condoms but wishes to avoid the mess. She wants children but her partner is less keen.

Stories Helen a nineteen year old on Microgynon comes to see you about her acne. She has tried topical preparations and wants antibiotics like her friends.

Stories Mary, a 18 year old who is about to go travelling before university has been sent by her mother to be put on the pill. She smokes about 20 a day.

Stories Margaret a 40 year old business trainer comes for a pill check, she has been on Logynon for the last 10 years. Should she continue? What else do you want to know? What should you discuss?

Stories A 22 year old comes for a pill check, she says she wants to change (from Microgynon) as she is always tired, her hair is greasy and it just doesn’t suit her. What sort of problems are these? What alternatives are there?

Stories A 20 year old is complaining about breast tenderness, weight gain. She is Slim and a keen Gym user. She is on Loestrin 20.

Stories Rebecca comes to see you about an abnormal smear report. Actinomycoses has been found on her routine smear. She has had a Novagard IUCD for the last 2 years. What do you discuss? What are your options?

Stories Clare,28 has just had her first child, before then she used the COP. She wants to go back on it.

Stories A 23 year old comes to see you, she has just had 4 days of D+V. She is on Loestrin 20 and is mid-cycle. She wants something for the diarrhoea. What do you need to know? What are the options?

Audit Ideas Income maximisation What should be covered at OCP follow-up? What brands of OCP are in use? Why? Contraceptive failures Leaflets, ? Understandable? Clear? Used? Useful? IUD / IUS continuation rates

Further Reading Contraception: a users handbook Szarewski & Guillebrand, OUP, 1998 RCGP handbook of sexual health in primary care. Carter et al RCGP 1998 Family planning handbook. IPPA 1997.