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

2. 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

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

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

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

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

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

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

9. Types
Barrier methods
Diaphragm
Cap
Condoms
Female condoms
Spermicides

10. Types
Natural Methods
Sterilisation
Male
Female

11. 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

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

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

14. 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

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

16. 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

17. Combined Pills
The most popular method.

18. 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

19. 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

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

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

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

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

24. Combined Pills
Heart valve disease
Porphyria
Chorea
Pemphigoid

25. Combined Pills Precautions Hypertension Raynauds Diabetes Asthma
Varicose veins

26. Combined Pills Severe depression Chronic renal disease MS Dialysis
Hyperprolactinaemia

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

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

29. Progestogen only pills
Reliability
Timing of use
Leaflets needed

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

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

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

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

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

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

36. 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)

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

38. 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

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

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

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

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

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

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

45. 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.”

46. 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.

47. 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.

48. 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?

49. 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.

50. 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.

51. 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.

52. 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.

53. 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.

54. 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.

55. 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.

56. 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?

57. 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?

58. 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.

59. 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?

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

61. 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?

62. 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

63. 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.