Contraceptive consultations are a key part of providing safe and effective contraceptive care. The Clinical Effectiveness Unit (CEU) of the Faculty of Sexual and Reproductive Healthcare (FSRH) regularly updates and develops national UK clinical guidelines relating to contraception. These guidelines contain suggested minimum criteria for assessment and discussion during contraceptive consultations.
Initiation and review consultations for contraception offer an opportunity to discuss highly effective long acting reversible contraceptive methods (LARC), as well as ensuring the chosen contraceptive method will be safe and effective for the individual.
This article will highlight what is important to address in these consultations and how this can be achieved effectively in general practice. Remote consultations, a key part of contraceptive care since COVID-19, are also discussed.
Documentation
The FSRH have produced a service standard for record keeping in sexual and reproductive healthcare consultations (FSRH, 2019a). It recommends clear documentation of clinical history, assessment, examination (if required), investigation performed, outcome of consultation and management plan. There is also a helpful ‘record keeping checklist’ for each method of contraception, which can be used or adapted by services to guide clinicians in ensuring all important aspects of the UK medical eligibility criteria for contraceptive use (UKMEC) are assessed.
What should be completed during a contraceptive consultation?
All of the FSRH contraceptive guidelines contain advice to support clinicians during contraceptive consultations with suggested minimum expected criteria for assessment and discussion (FSRH, 2014; 2015a; 2019b; 2021; 2022) and some of the newer guidelines (e.g. progestogen-only pills (POP), combined hormonal contraception (CHC) and progestogen-only implant) have comprehensive checklists to give structure and aid efficiency in the consultation. The CHC suggested checklist is shown in Figure 1.
The consultation should focus on the provision of safe, effective contraception that suits the individual’s requirements. The method may also provide non-contraceptive benefits. The consultation provides an opportunity to assess whether the individual is already at risk of pregnancy and could require emergency contraception or pregnancy testing, to assess sexually transmitted infection (STI) risk and offer advice and testing, and a reminder about the importance of cervical screening.
Some aspects of a contraceptive initiation or review consultation are applicable to all methods.
Assessment of medical eligibility for chosen method
It is important to take a comprehensive medical history to ensure that the chosen method is safe for the individual. Using the FSRH UKMEC (FSRH, 2016) will help guide clinical decision making.
Drug history
A full drug history (including herbal remedies) is essential at every contraceptive consultation to highlight any possible drug interactions (eg enzyme-inducing drugs may reduce the effectiveness of CHC during use of the enzyme-inducer and for 28 days after stopping (FSRH, 2019b)). There may be additional considerations for patients taking certain medications, for example, patients using anticoagulants who have requested an implant or intrauterine contraception (IUC) insertion (FSRH, 2017). For patients taking teratogenic medications (eg sodium valproate), a LARC method would be recommended.
Allergies
The clinician should check there are no allergies to the content of the chosen method or local anaesthetic if applicable.
Existing risk of pregnancy
The clinician should check if there is a requirement for emergency contraception, additional contraceptive precautions or follow-up pregnancy testing.
Investigations
Investigations, if required, may include body mass index (BMI) and blood pressure (BP) for CHC and Depo-Provera. Consider STI screen prior to IUC insertion.
Non-contraceptive benefits
Discuss any possible non-contraceptive benefits of the method: for example, depending on method, amenorrhoea (the absence of periods), lighter and regular bleeds, some methods may help improve acne.
Other points
Individuals should be advised about:
- Contraceptive effectiveness (perfect and typical use). It is essential that patients are advised of the typical use failure rate of their chosen method and advised of other more effective methods (see Table 1)
- How to take pills/use patches/rings, if applicable, and management of late/missed pills. Patients can also be directed to reliable online resources for further information
- Duration of use of method, if applicable, eg implant, IUC and Depo-Provera/Sayana Press
- Any requirement for initial additional contraception
- Insertion and removal procedure for implant and IUC and associated risks
- Interaction with medicines/herbal remedies. All patients should be informed of potential drug interactions (even if they are not currently taking any medications)
- Potential bleeding patterns with their chosen method. It is important to set realistic expectations about the likely bleeding pattern. This may improve continuation of the method
- Risks of the method, eg venous thromboembolism for CHC, risk to bone mineral density and delay in return to fertility with Depo-Provera/Sayana Press. Patients should be well informed about any potential risks so that they can make an informed choice about their contraceptive method.
- Other potential side effects. Side effects are very individualised and vary between users of the same method
- Alternative contraceptive methods, including LARC. Patients should be aware of what other methods are available including safer and more effective options
- Advised when to seek review, eg problematic bleeding, pain with IUC, routine review.
Table 1 Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use
| Method | Typical use (%) (estimated) | Perfect use (%) |
|---|---|---|
| No method | 85 | 85 |
| Fertility awareness-based methods | 24 | 0.4-5 |
| Female diaphragm | 12 | 6 |
| Male condom | 18 | 2 |
| Combined hormonal contraception* | 9 | 0.3 |
| Progestogen-only pill | 9 | 0.3 |
| Progestogen-only injectable | 6 | 0.2 |
| Copper intrauterine device | 0.8 | 0.6 |
| Levonorgestrel intrauterine system | 0.2 | 0.2 |
| Progestogen-only implant | 0.05 | 0.05 |
| Female sterilisation | 0.5 | 0.5 |
| Vasectomy | 0.15 | 0.1 |
Includes combined oral contraception, transdermal patch and vaginal ring. Faculty of Sexual and Reproductive Healthcare, 2019a
Duration of prescription
A 12-month supply of all types of CHC, POP and Sayana Press can be provided to medically eligible individuals at initial and return consultations. Note that only a 3-month supply of Nuvaring can be dispensed at any time (FSRH, 2019b).
Review consultations
Patients using CHC and POP should generally be reviewed annually, and this could be either face to face or by remote consultation. BMI and BP would be required prior to a prescription of CHC and following a remote consultation this can often be achieved in a local pharmacy. Depo-Provera users should also have their BP and BMI checked annually. Users of the contraceptive implant and intrauterine contraception do not generally need to be reviewed for the duration of use, unless there are any problems or concerns from the user.
A review consultation is again a good opportunity to discuss other (often more effective) methods. During the review, medical eligibility should be reassessed, drug history should be updated, any troublesome side effects should be discussed and compliance with the method should be checked if appropriate (eg CHC and POP).
Problematic bleeding
A common discussion at review consultations for hormonal contraception is around problematic bleeding. It is important for users to understand what the expected bleeding pattern is with their method of contraception and also for clinicians to ask what the bleeding pattern was like prior to this method and prior to any hormonal contraception.
Bleeding may be caused by the method itself, compliance issues, drug interactions or complications with the method (eg partial IUD expulsion). It is also important to consider other causes and not assume the bleeding is due to the contraceptive method (FSRH, 2015b). Other causes may include infection (eg chlamydia or gonorrhoea), pregnancy, polyps or fibroids, or very rarely cervical or endometrial cancer. Clinicians should take a sexual history, drug history and cervical screening history, enquire about compliance with method, check threads of an IUD and ask about any other symptoms (eg pain, discharge, postcoital bleeding). Investigations should include an STI screen, pregnancy test and cervical screening if due.
If there are no concerning symptoms or features with the bleeding and it is within the first 3 months of using a method, then reassurance is often appropriate, with advice to return if the bleeding persists (FSRH, 2017). If no threads are visible with an IUD then a pelvic ultrasound should be arranged to exclude perforation or expulsion.
If the problematic bleeding persists for over 3 months then the clinician should reassess as above and a speculum examination should be performed to assess the cervix. Depending on age and risk factors for pathology, an ultrasound scan should be considered with possible referral to gynaecology.
Management options for problematic bleeding with hormonal contraception are limited and improvement in bleeding is very individualised. Trying a different COC may offer some improvement, but there is no evidence that one type of pill is better than another. Some clinicians try double dose desogestrel POP, but again there is no evidence that this is successful, and problematic bleeding with a contraceptive implant or Depo-Provera may be managed by a short course of COC (for medically eligible people). These options are off licence (FSRH, 2015b).
Key points for remote consultations
Remote consultations became more common during the COVID-19 pandemic and have remained in place for many services. Remote consultations should cover all the same aspects as a face-to-face consultation.
FSRH and British Association of Sexual Health and HIV (BASHH) produced a joint document ‘Standards for Online and Remote Providers of Sexual and Reproductive Health Service’ (FSRH and BASHH, 2019). FSRH and BASHH feel it is imperative that the level of clinical excellence, safety and care delivered through remote services is not compromised by barriers to this mode of consultation (eg the need for proof of identity); however, the service accessed by the user needs to be safe and of the same quality and standard that would be expected in a face-to-face consultation.
This document sets out six recommended service standards for remote consultations, which include information on safe remote prescribing, safeguarding and safety netting, appropriately trained staff, obtaining valid consent and assessing capacity (BASHH and FSRH, 2019). Box 1 has some important points to consider for remote consultations.
Box 1.Important points to consider for remote consultations
- Check speakerphone is not being used
- Confidentiality
- Are they in a safe place/alone?
- Appropriate setting or environment – quiet/no distractions, eg not on the bus
- Phone or video call?
- Should you consider a face-to-face consultation?
- Gut feeling
- Vulnerable patients
Advantages of remote consultations
Many patients prefer the convenience of phone, video or online consultations due to anonymity and the convenience of not having to take time off work or school to attend. Some patients find it difficult to attend a healthcare setting (eg due to geographical distance, other commitments and public transport), so the option of remote consultations increases access, choice, convenience and anonymity for many service users.
Disadvantages of remote consultations
There are concerns about effectively assessing safety via remote consultations. It is important to establish that you are speaking to who you think you are speaking to. This can be achieved by asking for full name, date of birth, address and phone number for example. Asking if they are alone, in a safe and quiet place to speak and for the loud speaker to be turned off so that you can privately speak to patient and ask about safety are all important aspects of a remote consultation (FSRH, 2020).
A helpful resource developed for health care professionals to recognise gender-based violence in remote contraception consultations is available on the FSRH website (Brechin, 2020).
Young people and remote consultations
Remote consultations might work for some young people but not all – the same as with older individuals. Young people are less likely to want to talk on the phone; however, a phone call might suit them better than having to attend a service face to face.
Confidentially is essential in all consultations with young people (and all patients) and this might be easier with remote consultations as there is no need to attend a clinic or surgery. However, if you feel that confidentially is being breached by someone listening to their conversation, then it is important to offer a face-to-face appointment (FSRH, 2020).
Conclusion
All contraceptive consultations – initiation and review – should include a comprehensive medical and drug history to ensure the chosen method of contraception is safe and appropriate for the individual. There should be an opportunity to discuss any side effects and the superior effectiveness of LARC methods. Remote contraceptive consultations are suitable for many patients, as long as the same high standards of care are provided as they would be in a face-to-face consultation.
CPD REFLECTIVE PRACTICE:
- Is problematic bleeding a frequent problem for your patients? Could you improve your discussion of this to manage their expectations?
- If you conduct remote contraceptive consultations, could you improve this process to make it safer?
- How will this article change your clinical practice?
KEY POINTS
- It is important to take a comprehensive medical history to ensure that the chosen contraceptive method is safe for the individual
- It is essential that patients are advised of the typical use failure rate of their chosen method and advised of other more effective methods
- Users of the contraceptive implant and intrauterine contraception do not generally need to be reviewed during the duration of use, unless there are any problems or concerns from the user
- A review consultation is again a good opportunity to discuss other (often more effective) methods