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
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 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 dont really want to back on the pill, but Im 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 doesnt 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 doesnt 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 doesnt 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.