Family Planning

Or

Odd PC for ContraceptionDr 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

The IOS payments – managing and maximising.

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.

Etc etc.

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

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

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.

Relatively few contraindications.

Risks of stroke and MI reduced by measuring BP before and during use.

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 PillsTroubleshooting

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 methodTemperature methodCervical 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.