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Contraception request/advice

Specialties > General practice

Differential Diagnosis Schema 🧠

Hormonal Methods

  • Combined oral contraceptive pill (COCP): Suitable for most women but contraindicated in those with a history of thromboembolism, migraine with aura, or smoking over the age of 35.
  • Progestogen-only pill (POP): Preferred in women who cannot take oestrogen, such as those with a history of thromboembolism, breastfeeding women, or those with cardiovascular risk factors.
  • Injectable contraceptives (e.g., Depo-Provera): Long-acting, reversible method, suitable for women who prefer not to take daily pills, but associated with weight gain and bone density loss with long-term use.
  • Implantable contraceptives (e.g., Nexplanon): Long-acting, reversible, inserted under the skin, with few contraindications but may cause irregular bleeding.
  • Hormonal intrauterine system (IUS) (e.g., Mirena): Long-acting, reversible, reduces menstrual bleeding, suitable for women seeking long-term contraception.

Non-Hormonal Methods

  • Copper intrauterine device (IUD): Long-acting, reversible, non-hormonal, suitable for women who prefer to avoid hormones, can be used as emergency contraception, but may increase menstrual bleeding.
  • Barrier methods (e.g., condoms, diaphragms): Non-hormonal, also provide protection against sexually transmitted infections (STIs), but require correct and consistent use for effectiveness.
  • Natural family planning: Involves tracking menstrual cycle and identifying fertile days, requires regular monitoring and commitment, less reliable than other methods.
  • Sterilisation (male/female): Permanent method, suitable for those who have completed their families, involves surgical procedures (vasectomy, tubal ligation).
  • Withdrawal method: Involves withdrawal before ejaculation, less reliable due to the possibility of pre-ejaculate containing sperm.

Key Points in History 🥼

Contraceptive Needs and Preferences

  • Family planning: Determine if the patient is planning to have children in the near future or if they desire long-term contraception.
  • Previous contraception use: What methods have been used before, any side effects or reasons for discontinuation.
  • Lifestyle factors: Consider daily routine, ability to adhere to a daily regimen, and preferences for short-term versus long-term methods.
  • Menstrual history: Regularity, heaviness, and pain associated with periods, which may influence the choice of method (e.g., hormonal IUS for heavy periods).
  • Sexual history: Number of partners, need for STI protection, and frequency of intercourse can influence the choice of contraception.

Background

  • Past medical history: Assess for conditions that contraindicate certain contraceptive methods, such as a history of thromboembolism, migraines with aura, or breast cancer.
  • Drug history: Review current medications, including over-the-counter and herbal remedies, to identify potential interactions (e.g., enzyme inducers reducing the effectiveness of hormonal contraception).
  • Family history: Relevant genetic conditions, such as a family history of breast cancer or clotting disorders, may influence the choice of contraception.
  • Social history: Smoking status, alcohol use, and any recreational drug use, as these can influence the choice and safety of contraception.
  • Obstetric history: Previous pregnancies, mode of delivery, and any complications may influence contraceptive choices, particularly regarding IUD/IUS insertion.
  • Personal preferences and concerns: Discuss any concerns about weight gain, mood changes, or other side effects associated with contraceptive methods.
  • Partner considerations: Whether the partner is involved in contraceptive decisions, and the level of support and communication about contraception.

Possible Investigations 🌡️

Initial Assessments

  • Blood pressure measurement: Essential before prescribing combined hormonal contraception due to the risk of hypertension and thromboembolism.
  • BMI calculation: Body mass index may influence the effectiveness of certain contraceptives, such as the transdermal patch, and can affect the risk of side effects.
  • Sexually transmitted infection (STI) screening: Recommended if there is a risk of STIs, particularly before IUD/IUS insertion.
  • Cervical screening: Ensure the patient is up-to-date with cervical smear tests, especially if considering IUD/IUS insertion.
  • Pelvic examination: May be necessary before IUD/IUS insertion to assess uterine size and position.
  • Liver function tests: Consider if there is a history of liver disease or if the patient is taking enzyme-inducing drugs.
  • Fasting glucose/lipid profile: Consider in women with risk factors for cardiovascular disease if prescribing combined hormonal contraception.

Follow-Up and Monitoring

  • Blood pressure monitoring: Regular checks, especially during the first few months of starting combined hormonal contraception.
  • Review of side effects: Monitor for any adverse effects, such as mood changes, weight gain, or breakthrough bleeding, and adjust contraception as necessary.
  • STI re-screening: Periodic screening for sexually active individuals, especially those not in monogamous relationships.
  • Menstrual diary: Useful for tracking changes in bleeding patterns, especially with methods like the implant or hormonal IUS.
  • Bone density monitoring: Consider in long-term users of injectable contraceptives (e.g., Depo-Provera) due to the risk of reduced bone density.

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General practice