How to manage contraceptive provision without face to face consultations
Information from the Primary Care Women’s Health Forum
Combined hormonal contraception (combined pill/patch)
Women requesting a repeat prescription of combined hormonal contraception can be issued a repeat prescription for 6 months if they had contraceptive review in the last 6 months.
If the woman had her last contraceptive review a year ago – plan to give a prescription for three months following a basic check:
• Any unusual weight gain since last seen by the doctor or nurse (if so ask for her latest weight measured on her home scales)
• Any change in her medical status (any new medical problems or being investigated for any new medical conditions, including migraine, VTE, hypertension or change to any medication she is taking)
• Any change in her family history since she was last seen (e.g new family history of DVT /PE)
If a repeat prescription of the combined pill/patch is not appropriate or contraindicated and if face to face consultation is not possible – a safer option would be to change to a progestogen only pill (POP) (last tablet of combined pill followed immediately by POPs to avoid a break in contraceptive cover).
Combined hormonal ring
The above recommendation also applies for repeat prescription of the combined hormonal ring, but this can only be prescribed on a 3 pack basis because of storage recommendations.
Progestogen only pill
The progestogen only pill (POP) has very few contraindications and can be prescribed without review in clinic for 3 years. Triage to ensure no changes to medical history, including medication, which may reduce the efficacy of the progestogen only pill. Prescribe 12 months at a time.
Due for change of IUD/IUS
Women may panic if they are due for change of IUD/ IUS and not able to arrange the appointment.
Please check if it is an IUD with a 5 or 10 year licence. If the IUD is licensed for 5 years recommend using additional contraception as condoms or the progestogen only pill.
If the IUD is banded, such as the T-Cu380 A, with a 10 year license, this can provide contraception cover for 12 years and, therefore, does not requiring changing at this stage.
If the IUD was inserted after the woman was aged 40 there is no need to change this at all, it can remain in place until she no longer requires contraception.
There are four different IUSs with different licences. Please consult someone who understands if you are unsure.
Mirena and Levosert are licensed for 5 years use for contraception, but there is evidence to support ongoing contraceptive cover for 6 years. So there is no need to change at the moment.
Other versions of IUS (Jaydess and Kyleena) cannot be used beyond the length of their license.
If she was aged over 45 when the Mirena was inserted this can be left (unless she is using this for part of her HRT) until she is aged 55. If Mirena or Levosert are used for heavy. menstrual bleeding only it can be left for as long as it is still effective, so no need to change after 5 years. If the woman starts experiencing problematic bleeding, a course of tranexamic acid or medroxyprogesterone acetate can be added but she may need examining if there is no response.
If Mirena is inserted for the purpose of HRT, FSRH recommendation is that it can stay in for 5 years (licensed for 4 years) with oestrogen therapy but if is more than 5 years then her HRT should be changed from oestrogen only to a combined HRT preparation.
If the woman is due for change of contraceptive implant and unable to arrange the appointment reassure that there is evidence that the implant remains an effective method of contraception for 4 years. If concerned she may be started on desogestrel progestogen only pill in addition with an explanation that the hormone is similar to that used in the implant.
Depo provera continues to have a contraceptive effect for 14 weeks and no extra precautions are required if the repeat injection is delayed until then. After 14 weeks an alternative contraceptive method may be added until an appointment for the injection is available e.g desogestrel containing progestogen only pill and this should be given for a further 7 days after the repeat injection is given.
Patients who are already using Sayana press can be prescribed a repeat injection to give themselves.
If Depo provera is used ONLY for menstrual problems (especially in women with learning disabilities) the amenorrhoea may last for longer than the recommended time so no need for additional injection until the menstrual problem recurs.
Advise as usual but if she opts for emergency IUD make sure there is local access to fitting and that she is well before recommending she attends. If opting for oral emergency contraception prescribe UPA-EC or LNG-EC as appropriate PLUS quick-start desogestrel progestogen only pill with appropriate advice:
• If using UPA-EC start POP after 5 days with abstinence or condom use for further 2 days.
• If using LNG-EC start POP immediately with abstinence or condom use for further 2 days.
Recommend pregnancy test in 3 weeks.
We can reassure all women by discussing the various options through a telephone consultation and at the same time take the opportunity to discuss sexual health and use of barrier methods to prevent STIs.
Source: Primary Care Women’s Health Forum, How to manage contraceptive provision without face to face consultations [accessed on 3 April]