Contraception (Part 1)

Primary Care Knowledge Boost Podcast 7. Contraception Part 1. Hi there and welcome to Primary Care Knowledge Boost. Today we have part one of our two episodes with Dr Jacqueline Gatenby that cover contraception. In both these episodes there is a range of great information. So in episode one, we talk about why contraception is so important.

the types of contraception, the new ways to take the combined oral contraceptive pill. We talk about the differences in preparation of pills as well as different bleeding patterns on hormonal contraception in general and options to manage these. And then in part two...

we're going to cover when contraception becomes effective and when starting or swapping contraception types and quick starting pills and postnatal and breastfeeding considerations for contraception as well as contraception around the perimenopause. So we will talk about our learning points after the end of part two. We hope you enjoy. So hello Dr Gatenby and welcome. Would you mind just introducing yourself for the listeners?

Yes, hi. My name is Jacqueline Gatenby and I'm a GP partner at Pennygate Medical Centre in Hindley. Lovely. So you were talking to us today about contraception. Do you want to tell us how you got interested in the topic? Yeah.

I've always had an interest in sexual health, especially women's health and young people's health. I'm a firm believer that women should have... sole control over their sexual and reproductive health because I think it empowers them to make good decisions about planning their own pregnancies.

I think in the past unplanned pregnancy was seen as undesirable, but probably just from a social point of view. But I think we do know that it... is definitely associated with significant morbidity for mum and baby.

We know that pregnancy spacing is really important. You know, it's really advisable to leave it 12 to 18 months between pregnancies. In fact, I think the WHO recommend 24 months because... having babies very close together can increase risk of premature delivery etc so I think it's Personally I think it's really important that we're able to offer women accurate, very up-to-date information about contraception that's available, how it works, how they should take it, what to do if things go wrong.

so that we're not leaving women just giving up on contraception and leaving themselves at risk of pregnancy. So about 10 years ago, my colleague and I, Victoria Holm, who was similarly minded, decided that we needed to train up in the provision of larks particularly implants we were already coil fitters and also sort of to change the mindset of the practice because

At that time, first line contraception was always the pill. And as we know, especially for young people who get pregnant very easily. They find, obviously, daily pill-taking a bit of a challenge. And I think that that was, at the time, that was going on nationally. And consequently, I think we have seen a big reduction in teenage pregnancy because of provision of lark. So, yeah, so that's...

That's really where we're at now. Brilliant, yeah. And so if we just start with, can you give us an overview of the different types of contraception there are? Yep. So when I'm talking to a patient that might come in... requesting contraception, I usually split it into two, obviously the non-hormonal methods and then the hormonal methods. So non-hormonal, we've got obviously barrier methods, condoms, female condoms.

diaphragms and the copper IUD and then we have the hormonal methods so we've got pills we've got combined pills we've got progesterone only pills we have the combined patch the combined vaginal ring and then we're moving more onto your lark so we've got depo provera which is a 12 weekly injection, the implant, which is a three yearly subdermal implant and a Mirena coil, the IUS, which is a five yearly.

i think that's about it yeah it's quite comprehensive isn't it um so we thought rather than going through each of the um individual types and and kind of

being a bit more prescriptive about it that we talk more about special considerations and specific questions and problems that we can come across in primary care and so if we start with the combined pill and we've seen a bit recently about the new regimes of taking and and how it doesn't need to be

the three weeks on one week off and things like that would you mind elaborating a little bit about that no certainly so the combined pill contains an estrogen and a progesterone and traditionally when it was first brought onto the market It was a traditional way of taking it was having a pill every single day for 21 days and then not taking a pill for seven days. And on that seven day without taking a pill, which we now call the hormone free interval.

you would have a withdrawal bleed. Now, that was all well and good, but unfortunately, as we all know, not taking a pill for seven days basically wakes your ovaries up. there's a lot of people forgetting to restart the next pack or certainly forgetting any pills in that first week back on taking the next set of pills was leaving people really at risk of pregnancy and we think Possibly that this was one of the reasons why a lot of people will tell you they got caught on the pill or whatever.

And recently, there's been a bit of a change into trying to reduce that hormone-free interval. So there isn't a need to have seven days off the pill. In fact, there isn't really any physical need to have any hormone-free interval whatsoever. There's no damaging effects for that for women. And I think we need to explain that to women because I think sometimes they get an idea that there's a big backup of bleeding, which obviously doesn't occur because the endometrium remains very...

in under the influence of taking the pill. So there are various regimes. People can take it traditionally, 21 days on, seven days off. We call an extended regime where you can take the pill. for longer than your 21 days so for instance taking it for three months back to back so you'll take 21 times three pills for three months and then you might have a reduced hormone free interval of four days and the the beauty of reducing it for four days is that

you will get your withdrawal bleed, but you're not running into problems of then having the seven-day extended time where there's a chance where the ovaries will start to produce follicles and you may ovulate. That makes sense.

The other way of extending your taking the pill is to take it... all the time take back-to-back packets until you start to bleed because you will get on schedule bleeding taking the pill like this when you start to bleed and you're bleeding for three days you might then decide to have four days off

and then restart it again. And that's thought to shorten that sort of unscheduled bleeding. Or you can actually take it... the time without having any hormone free interval I think the problem we have at the moment is that obviously manufacturers of pills are still prescribing it in the traditional regime so it takes

And I think often people think that a contraception consultation is kind of short and easy. But actually, in order for people to understand... how to take the pill it actually does take a bit of time so it's really important that we explain to women how the pill actually works

reassure them that taking it in this extended way is not a problem but we we need to spend time doing that yeah yeah that's fair enough yeah definitely and I think um how do you do it then to try and fit it into a consultation It's really tricky because I've really... I balk at sort of, you know...

consulting in a very sort of patriarchal way I don't want to tell people how to take it but actually as it's just taken as that length of time for me just to explain those regimes I do try and take my time with people but I probably come down on saying, you know, why don't we try cycling for the first six months and see how you get on with that.

explain how to take it back to back for three months, four days off, back to back for three months and see how you get on. And then I would always review anyway in three months. And then we can decide to do it differently if there's been problems. Perfect. Yeah.

So moving on to talk about the different preparations. So when you're first starting somebody on a combined oral contraceptive pill, can you talk us through the different preparations there are out there? Yes. Most of the pills available, the more traditional pills, contain an oestrogen and that oestrogen is usually ethanol, oestradiol. and a progesterone. And the more traditional progesterones are...

the leavenorgestrel and the norethisterone and norgestimate. And those progesterones with the oestrogen are thought to be the pills which confer the lowest risk of VTE, if you're concerned. about that because as we know taking the combined pill does increase your risk of VTE and it is thought to be as well as the estrogen

It is also thought to be the type of progesterone that you have with the oestrogen that increases your VTE risk. So the earlier progesterones, the levonorgestrel, the norethisterone. Your risk, well, if we go to what the risk would be if you're not taking any combined hormones, your risk is two per 10,000 women a year. Okay. If you take the safest...

combined pill, your risk goes up to five to seven per 10,000. If you then go on to the newer progesterone type pills, which is your Marvellons and things like that. your risk goes 9 to 12. But we have to bear in mind that if somebody becomes pregnant, that their VTE risk, actually that goes up to 29 per 10,000. And in the post-partum period, it's 300 to 400. So there is a massive hike in the risk with pregnancy. So we need to be a little bit careful.

It's very important that we get women in to come and have their blood pressures done and their weights checked. But it's equally important that we don't suddenly refuse to prescribe the pill if somebody's run out of pills and they haven't had time to come and have a check.

check because you know clearly we don't want them to have an unplanned pregnancy yeah yeah so yeah so the newer generation Progesterones are things like desigestral, gestadine, etonogestral, which is in the ring, the vaginal ring, and a newer progesterone that's also... in the patch and as I say these newer progesterones do confer a slightly higher risk of VTE so when we're starting off prescribing combined hormonal contraception it probably sensible to use the lowest risk combined pill and

see how somebody goes and you can always change it onto something else if you want to depending on whether they suffer from various side effects with it or having some problems with bleeding.

for instance. Brilliant. In terms of the side effects profile, I always find it quite difficult to differentiate between progesterone side effects and estrogen side effects and what to do with the pill. Have you got any helpful advice about that? Yeah, I think, I mean, the main sort of estrogen...

type side effects. So the most common ones are nausea and headache and sometimes bloatedness. And then your progesterone side effects are more your kind of sore breasts, perhaps low mood, lacking libido. sort of thing um but i don't think anything's set in stone i don't think actually we you know we know for definite which is causing which but you know obviously within um combined hormonal contraception there is the opportunity to switch over to

slightly different progesterones or increasing the dose of the oestrogen slightly. When pills first came out, the oestrogen dose was much, much, much higher than it is today. And actually even a 35... five microgram oestrogen pill which is the highest we have available today is is still quite low um which is reassuring i think yeah um so you know you might decide that you want to increase the oestrogen dose for instance if some

is having a problem with breakthrough bleeding on the combined pill and the reason you might want to change a progesterone is for instance yasmin which the progesterone that is in yasmin is something called joss perinone and that is it's anti-androgenic so if somebody's got spots then you you might think that

if they wanted something to help them with acne, then that was made worse by taking a more traditional progesterone type pill, then you could maybe switch it to that. So there are, you can... You can chop and change having given somebody an amount of time to get used to a pill. Yeah. Because...

We don't want to say to somebody, see how you go for a few weeks and then we'll switch over if you're not happy. You really should give somebody probably up to three months on a combined pill. I wouldn't suggest changing it unless they were really adamant to change.

unless they're giving it a really good go, to be fair. Okay. So with the combined pills and the different types of progesterone, the newer types of progesterone have slightly higher VT risks. What are the kind of main advantage of the newer progesterones? I think that... There's a thought that some of the new progesterones, for instance, the desigestral, which, as we know, is the progesterone-only pill that people do take, also...

it might help with breakthrough bleeding. So it might stop that to some extent. But you can still get unscheduled bleeding with that pill as well. So I would say that there isn't... an absolute advantage to those different pills it's just really a matter of if one doesn't suit a woman then you may try another and it might help with whatever she was unhappy with yeah okay yeah so have a bit of a flexibility and open mind

Yeah. And we've mentioned now a bit about bleeding with them. Would you mind just going through what bleeding we would expect on all of the different types of contraception? Okay. So if we start with the pills. So it's basically breakthrough bleeding or unscheduled bleeding is common. And it's common on basically all hormonal contraception. But it's...

Very common, certainly on the progesterone-only pill. And there are two types of progesterone-only pill. The desigestral, which is the pill that gives you a slightly bit longer window if you miss a pill. You've got a 12-hour window. And then you've got the more traditional POP, which is more your leavenor gestural, north-eastern type pills. And... which only has a three-hour window. So the difference between them is that the desigestral pill actually inhibits ovulation, whereas the...

The other pills don't. They just work by thickening cervical mucus. Right. Which is why it's only a small window because the way it works, you lose that quite quickly if you don't take another pill within the 24 hours. bleeding problems are common on both of these pills certainly within the first three months and it can persist beyond three months

There are definitions of what types of breakthrough bleeding people might have or unscheduled bleeding. And I think that's fine. But... whether it's infrequent, frequent, prolonged, spotting, whatever, the most important thing is

Why is that woman particularly unhappy with it? I mean, that goes for lots of symptoms, I think, but certainly for bleeding, we need to find out what impact that's having. So you can say to women with the desigestral... pill for instance, by 12 months probably half of people will over a three-month period either be amenorrheic or you might have one or two bleeding episodes.

Okay. About three or four women out of 10 might have... slightly more bleeding episodes within that three-month period and then you might get people a smaller amount maybe one out of ten who have prolonged bleeding episodes with the desigestral pill. If you're taking the traditional POP then your bleeding problems are common but you don't tend to get as much prolonged bleeding.

But you do get frequent bleeding episodes, but they may only last a few days. There's no evidence that swapping over makes bleeding less on whichever you've... you're swapping over two, but it might give you a different bleeding pattern, which might suit you. So it's all about really, you know, finding a pattern that is acceptable for that particular woman. So there is some sense in you could...

switch over if you wanted to to the other type of POP but I wouldn't there's no evidence that actually that makes bleeding better it's just it might be a more acceptable bleeding pattern Combined pills, again, I think we covered that a little bit, that you could switch over to either... a higher dose oestrogen and that can sometimes help there i think there is a bit of evidence that the vaginal ring can help with unscheduled bleeding to some extent um and also

this changing the way that we take the pill can also be helpful because hopefully by having extended use you might you certainly won't get rid of bleeding completely but you will you you might be able to have less bleeding. There are two very new combined pills, actually, I meant to mention, Clara and Zoli. So these are sort of new pills in the last few years, which contain...

much more natural oestrogen and progesterone. So there isn't a lot of evidence at the moment but the thoughts are that these are safer. oestrogen and progesterones for women to use in terms of VTE risk and they are prescribed in an extended regime so Clara for instance is a 26 day pill with a two-day hormone-free interval. And the Zoalie is a 24 length of time with a four-day interval.

The Clara, which is the 26-2 day, is they vary the hormone level throughout the month. So yeah, there is like the triphasic pills that we used to have.

There isn't a lot of evidence that triphasic pills help with bleeding, particularly. So most women are on monophasic pills, which is the same dose every day, which Zoe Lee is. So there isn't a lot of evidence about these pills, but they are... pretty expensive so i think that's probably why they would be you know a last resort if you were going to go down that road for bleeding for bleeding changes yeah um so

That's unscheduled bleeding on pills. Things like the implant. The bleeding problems are very common again, certainly in the first three months. counseling is really, really important when we're counseling women about having an implant. I think if you can explain to them that bleeding... is okay. It doesn't mean that the implant's not working. It doesn't mean that they're any more at risk of pregnancy. But obviously...

you know, bleeding is an irritation. So if you're bleeding a lot on an implant, then, you know, it's understandable that you might want to have something done about it. So with the implant... It's off license, but the FSRH do recommend that you can try the combined oral contraceptive pill for three months.

And you can take that however you like, either back to back or have your seven day break, whichever. I normally tell people to take it back to back and then review after three months and see if that's helped because sometimes it can. And then would you continue that ongoing or would it just be for the three months? So there is very little evidence as to whether there are any problems with taking that long term and I think the FSRH probably advised that you use basically...

to use your own discretion about whether you want to continue to use the combined pill. Okay, brilliant. And what other ones? Depo bleeding pattern? So Depo, yes. So after the first injection... bleeding problems can be quite common. But you can reassure women that usually about... By 12 months, half of women are amenorrheic on the depot. And that continues with duration of use. So bleeding problems can be difficult in the first stages, but...

with subsequent injections then they are more likely to have less problem with that. There isn't really a lot of evidence about giving early depots. And we probably wouldn't give an earlier depot than a 10-week gap between the first and second injection. But sometimes that, you know, it can help to sort of reassure women that, well, let's give you another one slightly earlier and maybe that will help a bit.

We know that duration of use will lessen the problem of unscheduled bleeding on the depot. The IUS, Mirena, is very, very, very commonly causes varying amounts of bleeding, spotting, discharge in the first, probably up to the first six months of having it.

fitted and again counselling is really really important to let women know that that will happen in most women and in a few women it can persist beyond six months but obviously we do use the IUS as a therapeutic treatment for heavy menstrual bleeding so you can reassure women that over a 12-month period menstrual blood loss actually is reduced by about 90 percent so eventually most people do settle on a Mirena and they most people either don't have any bleeding at all or

have very infrequent bleeding which obviously most people can tolerate.

Brilliant. So I think that's about it for all the contraceptions and bleedings. So when should we be concerned about unscheduled bleeding or breakthrough bleeding? Yeah, so obviously it's a very common... problem because as we've just established bleeding is very common certainly when starting any hormonal form of contraception so it's like anything really I mean it's very important to take a good history don't assume that that

patient is taking it or if it is a pill that she's taking that correctly I've had a few instances where people on the progesterone only pill are taking it like a combined pill because that's how they've taken a combined pill before um which obviously isn't well it's scary in lots of ways but yeah um certainly putting them at risk of unplanned pregnancy, but probably causing a problem with bleeding as well.

And women taking the combined pill who think that they shouldn't be taking a pill if they don't stop bleeding. So they wait until they stop bleeding before they restart packets and things like that, which again is putting them at risk of pregnancy. So make sure that they're taking it correctly. That's very important. Find out again what's bothering them about the unscheduled bleeding.

Very obviously important to find out risk of pregnancy. So probably a pregnancy test you would probably consider. An STI history. Any new partners within the last 12 months, you probably would consider ruling out certainly chlamydia. Obviously, if they are eligible, making sure that they're part of a cervical screening program, which is important.

If somebody has been started very recently, they're within three months of starting a hormonal... form of contraception and you have ruled out you know other worrying things so you've asked them about associated symptoms you know unscheduled bleeding is usually just bleeding without pain but if they've got any of those other symptoms that you might be concerned about dyspareunia.

pain any dragging feeling vaginally anything like that then you change your your management basically but if you're if you're quite happy that you've ruled out most of that and you're pretty sure that this bleeding is down to starting a hormone form of contraception then you're actually okay you probably don't even need to examine them and see how they go

for a few months. If you want to treat them, you could, you know, depending on which form of contraception they're on. And obviously you would review them in a few months time. Where the story changes a little bit is... If people are having, have been on a form of contraception for a long time and that they start to have unscheduled bleeding or a changing pattern of their normal bleeding pattern on that particular form of contraception. And you're going to be more worried.

because what we're worried about here is obviously cancer yeah and you're worried about cervical cancer and endometrial cancer so For those women and for women where you're having persistent bleeding beyond the three months of starting a hormonal contraception, then it would be obviously sensible to examine them.

Certainly to have a look at the cervix, but also to do a bimanual examination if you think that's necessary. Yeah. Women that you worry about more are obviously older women, women with higher BMI, women... with diabetes and women with pcos because they are at higher risk of endometrial cancer so it's not one of those things where there's an absolute yes you do this with that person or that with the other person it's about

which is the case often in general practice, that you use your clinical knowledge and you weigh up risks of whether that person... is more likely or not to have something that you're going to be worried about. So the women that you're going to be worried about, older women... women with a higher BMI, you're probably going to be thinking about having an endometrial biopsy via histoscopy.

Ultrasound scans have their place, but obviously in pre-menopausal women, they're not brilliant at picking up endometrial cancers. So if you're worried about that, really, they do need a referral for a histoscopy. But ultrasound scans are pretty good if you're wondering about fibroids or if they've got any symptoms of that or anything, you know, anatomical, structurally anatomical that might be causing problems with bleeding. Yeah.

But if we're thinking along the cancer line and we've got that high suspicion, we should just be referring on and not relying. Indeed. I mean, yeah. And you're going to be a lot more worried about your 45-year-old woman on a Mirena who starts bleeding than you are with a 21-year-old who's taken a combined pill and is having...

a problem with persistent bleeding yeah hopefully thank you um so if we've kind of gone through all of that and we go back to our non-worrying causes of the breakthrough bleeding yeah you've mentioned a few things that we can do such as increasing the estrogen in the combined pill and things yeah and the

using the combined pill with the implant have you got any other strategies to manage and break through bleeding so sometimes with the depot if people are having problems despite having you know a few injections of depo then there is a bit of evidence that methanamic acid in its usual dose of 500 milligrams tds can help with individual bleeding episodes but it doesn't probably decrease number of bleeding episodes so you might you could try that you can try the combined pill actually

with the depot if you want to and also we've talked about it with the implant but you could also try that with the Mirena.

The FSARH has said that they would be happy with that. Yeah, other than that... don't think there is anything that is coming to mind no they're good they're good options yeah and obviously i guess making sure that they're able to take the combined pill there's not a reason that we've not given them in the first place yeah the switch you could switch over the as i say the progesterone only pills but as i you know as i said before that

It might change the bleeding pattern. It doesn't actually usually improve bleeding. But it makes it more acceptable possibly.

So we will pause our discussion there to give us a new time to process the excellent information. We'll see you shortly for part two. Don't forget, we would love your feedback. You can do this most easily through our survey link, which is in the episode description or through emailing us at primarycarepodcasts at gmail.com.

We also have a Twitter handle, which is at PCKB podcast, and we'd love to get your feedback on there too. Thank you so much for listening. Until next time. On Primary Care Knowledge Boost. Hey guys, just a friendly reminder that these podcasts are for healthcare professional education and shouldn't be used for medical advice by the general public.

They were recorded in Wigan in 2019. Guidelines can vary by location as well as over time, so always check for up-to-date local and national guidelines before making treatment decisions. The content is based on our interviewee's opinion and interpretation of current best... practice it's your responsibility to use your clinical judgment before applying or relying on information solely from this podcast check out the show notes for full details and any links we've mentioned in the episode