Making the most of the the routine Pill check
A routine follow-up for the combined pill (COC) is more than a chance to catch up, it’s an opportunity for sexual health promotion and safety netting, says sexual health GPSI Dr Meg Thomas
A routine follow-up for the combined pill (COC) is more than a chance to catch up, it's an opportunity for sexual health promotion and safety netting, says sexual health GPSI Dr Meg Thomas
1 Check the patient is comfortable with her contraceptive method. Minor side-effects are poorly understood in terms of hormonal significance. I've yet to come across good evidence that sex steroids affect sexual function, mood or weight. There's not much science involved in changing pills. But androgenic side-effects like acne and hirsutism should respond to use of a more oestrogenic pill. A third-generation pill should be tried before Dianette, which has a venous thromboembolism (VTE) risk fourfold that of second-generation pills1.
The Royal College of Obstetricians and Gynaecologists Faculty of Family Planning and Reproductive Health Care provides useful advice on changing pills2, while Professor John Guillebaud's book The pill and other forms of hormonal contraception is a great guide to tailoring pills to the individual – including the management of irregular bleeding3.
2 Check the past medical and family history to exclude contraindications. Breast and genital cancer and cardiovascular events, including VTE, are uncommon in this population of women4 but cardiovascular risk factors may well be present. Cardiovascular risk is low in women of reproductive age and not increased by the COC if no risk factors are present. But with multiple risk factors the COC is likely to lead to unacceptable risk. To assess risk in a wide variety of clinical settings see UK Medical Eligibility Criteria for Contraceptive Use 2005/6 at www.ffprhc.org.uk4 or downloadable here (right).
Classifications used in the UK Medical Eligibility Criteria for Contraceptive Use are:
• UKMEC 1 – Unrestricted use
• UKMEC 2 – Benefits outweigh risks
• UKMEC 3 – Risks generally outweigh benefits
• UKMEC 4 – Unacceptable health risk.
A family history of VTE (in first-degree relatives aged under 45) is ranked UKMEC 3.
A thrombophilia screen is recommended but a negative result does not change the category. Patients with thrombogenic mutations are classified UKMEC 4, although some haematologists would disagree. COC use in this situation leads to a VTE risk up to 20-fold that of non-users. GPs should let women make an informed choice. COC users with a family history of breast cancer have no increased risk (UKMEC 1), unless they carry the BRAC1 gene.
3 Although older women face higher cardiovascular and cancer risk, the COC can be continued up to age 50 for women with no risk factors5. Promote breast awareness for the over-30s and cervical screening for patients over 24. Discuss preconception care when relevant. For young people, give safer sex advice and offer chlamydia screening, as well as HPV vaccination to teenagers in the target group. Document Fraser Competence in under-16s. You can and should act confidentially. Explore any possible child protection issues, particularly in under-15s6 .
4 Smokers aged under 35 are classified as UKMEC2. Women aged 35 or over are classified as UKMEC3 if they smoke fewer than 15 cigarettes a day and UKMEC4 if they smoke 15 cigarettes a day or more.
5 Remember that cases of COC risk as a result of high BMI are often missed. VTE risk doubles if the BMI is above 30, and quadruples if it exceeds 40, when the COC is contraindicated. These cases are often missed in practice, as obesity is becoming common.
6 If BP has risen above 160 systolic or 95 systolic then it needs to be controlled before prescribing further COC. COC users with hypertension are at increased cardiovascular risk4,5. Measure BP at least annually. When the systolic pressure is consistently greater or equal to 160 or the diastolic is greater or equal to 95, hypertension should be controlled before further COC is prescribed.
7 Ask if the patient has significant headaches – any new headache should be evaluated. Classical migraine – migraine without aura – leads to a two- to four-fold increased risk of stroke in COC users. Focal migraine – or migraine with aura – has a six-fold risk for non-smokers and a 14-fold risk in smokers. Women who develop simple migraine while on the COC are classified as UKMEC 3 if they are under 35 or UKMEC 4 if they are 35 or over. Complicated migraine at any age is UKMEC4.
8 Check to see if the patient has started taking any interacting medication since the last review. Enzyme inducers – such as rifampicin, griseofulvin, St John's wort and most anticonvulsants – reduce effectiveness. Valproate and lamotrigine don't seem to have this effect. Encourage the use of condoms or change to the injectable method or copper IUCD. The contraceptive effectiveness of COCs is not affected by most broad-spectrum antibiotics4. Nevertheless current advice is to use alternate contraception during short courses and for seven days afterwards3.
9 Make sure the patient knows how to take the medication. More than half of women requesting abortion claim to have been using a method of contraception at the time they became pregnant, usually the pill or condoms. Between 30% and 50% of women miss more than three pills in a month8. Lack of reinforcement of learning is the likely explanation for poor knowledge7.
10 Make sure the patient knows the symptoms of problems that would lead to immediate discontinuation. These are:
• Migraine with aura
• Major surgery
Dr Meg Thomas is a GP in Newbury, Berkshire, with a special interest in sexual health
Competing interests None declared
Minor side-effects are poorly understood in terms of hormonal significance. Pills