Family Planning

1. 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 • The IOS payments – managing and maximising. • 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. • Etc etc.

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

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 • 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. • Relatively few contraindications. • Risks of stroke and MI reduced by measuring BP before and during use.

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 PillsTroubleshooting • 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.