When and When Not to Prescribe Contraception Remotely Under the Spotlight

The progesterone only pill is generally safe to be prescribed remotely, because recent blood pressure and weight are not required according to a session on remote prescribing in women’s health at the Royal College of General Practitioners (RCGP) annual conference.

Speaking at last week’s meeting, Dr Toni Hazell, GP who practises in Tottenham, London, addressed the issue of long-term contraception and how to manage it during remote consultations – mainly on the telephone.

After a surge during lockdown, remote consultations look set to stay. However, figures from July and August show that nearly 6 out of 10 appointments were actually in person according to the RCGP. The need for in person versus remote consultation varies by the patient’s needs, and knowing when to bring a patient into the surgery is not always an easy call to make.

In Thursday’s Women’s Health session, contraception as well as other issues including endometriosis were discussed in terms of when it was suitable to consult remotely and when it might be necessary to consult in person.

Despite the media attention given to the topic of the public wanting face-to-face appointments, Dr Hazell pointed out that in her experience, many patients are so busy with working or caring duties that they actually request a phone call as opposed to an in person visit. “The drive for face-to-face is possibly not as great as the politicians think it is. I also think remote consultation in some form is here to stay. It’s convenient for many, and a phone call has worked for emergency contraception for years, given the time sensitivity.”

When Remote Contraceptive Consultations Aren’t Possible

Some situations, for example, fitting an implant or intrauterine device (IUD) cannot be done over the phone, said Dr Hazell, adding that an up-to-date blood pressure or weight reading might be needed, or a translator required. "Some patients for whom English is not their first language find it easier to communicate in person when there are other body cues, but on the phone, it can become too difficult to fully understand what is being said."

Domestic abuse was higher during lockdown, noted Dr Hazell, pointing out that it was always worrying if this was suspected because, on the phone, you do not know whether the woman is being coerced and whether she can speak openly and safely. "I suggest asking a closed question such as ‘do you feel free to talk?’, to which they can give a yes or no answer, but an abuser might be making them speak on speakerphone. Or, if you think it fails the insomnia test and will keep you awake at night then bring the patient in."

Considerations Around Remote Contraception - POP

Referring to the UK Medical Eligibility Criteria for Contraceptive Use (UK MEC) categories for prescribing contraception, Dr Hazell explained the risk levels related to the patient, stressing the UK MEC levels related to safety not efficacy. Level 1 is ‘fine, no problem [to prescribe]’, level 4 is contraindication which represents an unacceptable health risk; 2 is relative contraindication but the relative benefits outweigh the risks; level 3 is relative contraindication/s but risk probably outweigh the benefits; "I have prescribed on a UK MEC 3 but never on a UK MEC 4," she said.

Turning to the progesterone only pill (POP), Dr Hazell said it was generally safe and could be prescribed remotely because it does not require a recent blood pressure or weight reading. "It is a useful method of contraception to prescribe remotely or just to bridge the gap, for example if someone needs a LARC [long-acting reversible contraception] and they can’t get an appointment for a few weeks."

Asked whether it was safe to use remote blood pressure and body mass index (BMI) measurements if needed, Dr Hazell said: "We use blood pressure and BMI to make decisions on safety to prescribe and we can now easily ask for this information by text."

Combined Pill and BP and BMI Measurement

In terms of safety related to blood pressure and BMI measurements when prescribing the combined pill, Dr Hazell summarised that a woman with BMI over 30kg/m2 would be considered in the UK MEC 2 risk category; while 35 kg/m2 and over falls within the UK MEC 3. "Interestingly there is no BMI for contraception which falls in the category UK MEC 4," she said. "I would be very reluctant to ever prescribe on a UK MEC 4 and in fact, I take people off COC [combined oral contraception] if necessary."

She explained that for blood pressure, it was less of an issue in the younger population seeking contraception, but there will be some with higher blood pressure. UK MEC 3 applies to those with systolic 140-159 mm Hg or diastolic 90-99 mm Hg, while UK MEC 4 applies to those with systolic 160 mm Hg or diastolic of 100 mm Hg or over, she said.

"I’ve sometimes felt the patient isn’t always being straight with me," said Dr Hazell. "In the past I have taken people off combined oral contraception because they’ve bought it abroad and they have absolute contraindication," she cautioned. "Some have stormed out and said they’ll get it elsewhere and not say I’ve had a blood clot."

Dr Hazell asked the Medical Protection Society (MPS) where does the responsibility lie if someone says they are 70 kgs [remotely] and the GP prescribes COC, only to find out later that they have a pulmonary embolism and that their weight was actually 95 kg? "Effectively, they [MPS] said you need to convince yourself that you have adequate knowledge of the patient’s health. So you might want to think, on the second or third prescription, whether it is worth having a face-to-face meeting for blood pressure and weight, especially if their BMI is creeping up to the boundary."

Contraceptive Injection (Depo-Provera), Implant and Other Intrauterine Contraceptive Methods

During COVID-19, the duration of keeping an intra-uterine device (IUD) in was extended. "The risks of pregnancy during a fourth year of implant or the sixth year of a 5-year IUS [intrauterine system] were probably outweighed by risk of catching COVID infection by coming into the practice," shared Dr Hazell.

She added that the Faculty of Sexual and Reproductive Healthcare (FSRH) have changed this and said that in non-COVID times, they do not yet have the data to extend the use, so the implant needs to be removed after 3 years, and a 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) at 5 years.

In summary, Dr Hazell, said copper IUD duration was 5 years for 5-year devices and 10 years or until menopause for 10-year devices and if fitted in a patient over 40 years. Mirena is 5 years normally, 6 years during the pandemic, or until menopause in those 45 or over. Mirena for the progesterone component for HRT is 5 years.

Jaydess should be left implanted for 5 years, Kyleena is 3 years, and Levosert is 6 years.

"We stopped fitting LARC and implants during COVID restrictions, but restarted refitting quite quickly because we’re aware of a responsibility to our populations to prevent pregnancies," said Dr Hazell. "I counsel on the phone and send a link to a leaflet, ideally I only have the patient in the room if there are concerns about infection, or they need an interpreter, or are very young, or have learning difficulties. I give the couch, chair and doorknob a quick anti-viral spray afterwards."

Finally, Dr Hazell explained that Sayana Press was effectively a subcutaneous version of Depo-Provera that the patient self-administers. "They don’t have to come into the surgery if they find that difficult due to work or caring responsibilities."

POP – Why Monitor Blood Pressure and BMI at All?

A question from an unnamed delegate was sent to the Chair, Dr Rowena Christmas, a GP from the Wye Valley Practice, and related to clarification of the need to monitor blood pressure and BMI in women taking the POP.

The delegate asked: "Why in the NICE [National Institute for Health and Care Excellence] Clinical Knowledge Summary for the POP, does it suggest to monitor weight and blood pressure? Are uncontrolled blood pressure and high BMI, contraindications for the POP?"

Dr Hazell clarified: "The FSRH doesn’t say you have to do it. I always say to trainees, don’t do a test if it won’t change that patient’s management. You won’t stop the POP if the blood pressure is high or the woman has obesity, so why check it?" she said.

"Yes it is a general health promotion thing, and yes if the woman’s in the room, I’ll probably do it, but you don’t need to bring her in specifically to do it, and you don’t need to delay the prescription."

In follow-up Dr Hazell was asked whether an annual POP check was necessary. "Only if they’ve moved on and want a LARC or pre-conception advice for example, but it’s not an absolute must if you are pushed."

COI: Dr Hazell has declared no conflicts of interest.

Presented at the Royal College of General Practitioners (RCGP) annual conference 2021. Thursday, 14 October, 2021.

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