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.