How to consult remotely: contraception

Continuing our series, Dr. Carrie St John Wright advises how to optimize remote consultations for contraception

The way we start and review contraception has transformed in the Covid-19 pandemic. After adapting to remote consultations out of necessity, we are now seeing that patients appreciate the ease and effectiveness of remote contraceptive check-ups. New digital tools that allow quick access to information have given us more confidence to prescribe birth control remotely, while the use of self-administered birth control injections in particular can free up time in the clinic. Here are my tips for using remote consultations to start and review contraception safely and effectively.

Is remote consultation appropriate?1

Start with this checklist:

  • Ask the patient if they are in a private space where they cannot be heard.
  • If they indicate that they are not alone, ask them if they feel comfortable discussing personal medical information – are they with someone they trust or a support worker?
  • Check if the patient might be vulnerable – is he under 16 or is there a history of abuse recorded?
  • Be alert to any risk of coercion.
  • If in doubt, arrange a face-to-face consultation.
  • Verify that the patient is in the UK. Some compensation providers do not cover general practitioner consultations if the patient is abroad.

Also establish that the person has enough understanding and ability to make decisions on their own. It may be best to have the conversation in person, with independent medical capacity support or advocate. If so, record and verify that person’s identity separately.

Starting a combined oral contraceptive pill (COC)
The usual precautions should be taken before starting the COC. Take a full medical history to rule out venous thromboembolism (VTE), high blood pressure (BP) and other factors in the UK Medical Eligibility Criteria for Use of Contraception (UK MEC) from the Faculty of Health reproductive and sexual health (FRSH).2 Make sure the patient has no history of migraine with aura and document it.

It may be necessary to record weight, body mass index (BMI) and blood pressure remotely for safe prescription. Patients can report these observations themselves with measurements at home or with readings taken in pharmacies or the waiting rooms of general practitioners’ offices.

The COC prescription is safer if the BMI is less than 34 kg/m2; above 35kg/m2 there is an increased risk
of VTE.2

The benefits outweigh the risks of treatment at BP measurements up to 140/90 mmHg. Above that,
it may not be safe to prescribe it, especially if the readings are above 160/100 mmHg. Remote readings may be worth checking with a calibrated blood pressure monitor.

Key history

  • Smoking Being over 35 and smoking more than 15 cigarettes a day is an unacceptable risk for starting COCs. Discuss the risks and benefits if the patient is over 35 and has quit smoking within the last year.
  • Recent illness Especially in the case of myocarditis due to Covid-19 or as a side effect of the Covid-19 vaccination.2 Note any new or recent diagnoses that are not yet coded in the notes – for example,
    new breast cancer or a personal history of VTE (the two absolute contraindications to COCs). Family history may also be relevant, as may recent immobility and surgery.
  • Recent delivery Current advice is to wait six weeks after birth before starting the COC if breastfeeding, and at least three weeks otherwise, unless there is a risk of VTE, in which case a discussion of the balance of risks is necessary.
  • Recent termination of pregnancy There is no recommended time frame for initiating contraception after termination of pregnancy, and early initiation may be appropriate to reduce the risk of another unwanted pregnancy.
  • Medication history COCs can interact with medications, such as lamotrigine.3 Screen for new drugs and recent use of emergency hormonal contraceptives (EHCs) – with some EHCs, eg ulipristal acetate (UPA), early initiation may reduce the effectiveness of both. Also ask about drugs used off-label to improve concentration, such as modafinil; these are often purchased online and can reduce the effectiveness of COCs.

It is no longer necessary to check BP after three months of COC, according to FSRH guidelines,4 thus, a full year scenario can be issued, provided the patient knows to return if something goes wrong. Although this may result in some medication wastage, overall costs and resource use are reduced by eliminating unnecessary follow-up appointments.

It may, however, be appropriate to provide a limited supply – for example, three months – in patients who would benefit from early follow-up, such as those with significant medical conditions.

Repeat COC prescription
If the patient has been on the COC for some time and is happy to continue, it is still important to have a visit at each prescription refill to check that nothing has changed in their history. New medications and illnesses or family history should be checked, especially migraine with aura. Up-to-date blood pressure and weight (or BMI, if required) and smoking status should be recorded annually.

Start a progesterone pill (POP)
There are fewer risks associated with POPs. The main things to rule out before initiation are:

  • Diagnosis of current or past breast cancer – current is contraindicated, past requires discussion of balance of risk.
  • Several risk factors for cardiovascular disease, current ischemic heart disease or liver tumor – all require discussion of the balance of risk, but are not totally contraindicated.

It is important to check drug usage to report any enzyme inducers that affect the effectiveness of POP. Patients wishing to start POP after stopping enzyme-inducing drugs should be advised to use condoms until 28 days after the last dose of the enzyme-inducing drug. Alternatively, patients can start POP on day 1 through day 5 of their menstrual cycle without additional precautions, but if they start after day 5 they must use condoms for 48 hours. Fast Start requires a pregnancy test at least three weeks after last unprotected sex (UPSI). Patients can start POP directly after EHC with levonorgestrel (LNG) but must wait five days after taking UPA.

Potential side effects of POP include an altered bleeding pattern, especially in the first three months. POP can be prescribed for 12 months initially, with advice to return in case of unwanted bleeding or any other problem.

Self-administered contraceptive injections
Sayana Press subcutaneous (SC) injection 13 weeks5 has become more widely used since the pandemic because patients do not have to come to the office to get their next dose. As with medroxyprogesterone acetate (DMPA) intramuscular (IM) depot, SC injection of DMPA is highly effective, but takes seven days to become effective if started after day five (see box below).

Sayana Press comes in a prefilled injector and should be shaken vigorously and then administered into the front of the thigh or abdomen, avoiding bony areas and the umbilicus. A video available online can be used to teach patients remotely.5 A competent adult should be present for the first and second doses in the event of an allergic reaction.

Explain that self-administration may cause an injection site reaction (reported in 9% of patients in one study).6 Women should also be advised that the return of menses may be slow and return to fertility may take up to a year after stopping DMPA IM or SC.6 The FSRH suggests a review every two years to reconsider the benefit/risk balance for bone mineral density, especially for those under 18 and over 40. Other side effects include amenorrhea and reduced or irregular bleeding. You can prescribe three months of COCs (if the patient is eligible) or mefenamic acid for troublesome unexpected bleeding.

Weight gain can be a problem with DMPA; if more than 5% of body weight is gained during the first six months of use, patients are likely to continue to gain weight. Acne, decreased libido, mood swings, headaches, hot flashes, and vaginitis have also been reported with DMPA.

Start of self-administered DMPA SC

How to start

  • Days 1 through 5 – no additional precautions required
  • If starting after day five – condoms required for seven days
  • Quick Start – requires pregnancy test three weeks after last UPSI. Note that amenorrhea due to depot injection may mask pregnancy; breakthrough bleeding can be mistaken for a period
  • Can start soon after EHC if other oral methods are not acceptable (immediately after LNG, five days after UPA)

Dosage and drug interactions

  • There is a 13 week interval between doses for SC administration
  • Can be administered up to a week late without additional precautions
  • No increased risk of pregnancy has been demonstrated in users of injectable DMPA with higher body weight, although data are limited in women with a BMI ≥ 40 kg/m2
  • The efficacy of DMPA is not reduced by the concomitant use of enzyme-inducing drugs

Dr Carrie St John Wright is a GP and Assessor in Bristol

References

  1. Patel R and Munro M. Standards for Online and Remote Sexual and Reproductive Health Service Providers. Sexually transmitted infection 2019;95:475-476. Link
  2. FRSH. UK Medical Eligibility Criteria for Contraceptive Use (UK MEC) 2016. Link
  3. FSRH CEU Guidelines. Drug interactions with hormonal contraception 2017. Link
  4. FSRH. Recommendation – Combined hormonal contraception. BMJ Sex Reprod Health 2019;45: Supplement 1. Link
  5. Inject Sayana Press. 2022. Link
  6. FSRH. Clinical guideline: Injectable progesterone alone. 2020. Link

Other Resources

  • Women’s Health in Primary Care Forum (PCWHF). Remote contraception services 2020. Link
  • PCWHF. Covid-19 Community Contraception Guide 2020. Link
  • FSRH. Guidance for providing contraceptives after Covid-19 lockdown changes. May 2020. Link

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