The role of the doctor in the context of a family planning consultation is to help a woman to make an informed choice about what would be the best and most acceptable contraceptive for her at a particular time in her life. The contraceptive that is used in her teens and 20s may not always be the best option as she moves into her 30s and 40s – either for social or for medical reasons.

Whether discussing contraception with a 20-year-old, 30-year-old or 40-year-old woman, there are certain important questions and issues that need to be addressed in the consultation:

• Why now – what has prompted her to come for contraception now?
• What are her expectations?
• What are her fears?
• What is her understanding of her fertility and contraception?
• And, most important of all, how badly does she not want to get pregnant?

Why now?

As in all consultations, it is good practice to try to establish why this woman has come today, requesting contraception. She may have just had a baby, is about to get married, has met a new partner, or has decided that she is finished her family. Sometimes the consultation has been triggered by a recent pregnancy ‘scare’.

Postnatal

In the immediate postnatal period, ovulation is not likely to occur until four weeks after delivery. During this period, condoms give full protection. If a mother is not breast feeding, after day 28, she can then start a combined oral contraceptive (COC) immediately or at the start of her first period (assuming there are no contraindications). She could also opt for a progestogen-only pill (POP), which is taken daily, without any pill-free period. Older POPs such as Noriday must be taken at the same time each day, for full protection. However, Cerazette has a more flexible pill-taking schedule, similar to the COC, making it a more attractive option. Long-acting contraceptives – Depo-Provera and Implanon – can also be used at this point but it might be prudent to allow the menstrual cycle to become more settled before using them, to reduce the risk of troublesome erratic bleeding, which can be one of the main problems with these options.

Other options such as IUD insertion and diaphragm fitting should be deferred until two to three months post-delivery when uterus and vagina have returned to normal again and until menstrual cycle has become re-established. If a mother is fully breast feeding, with no supplementary feeding, there is no risk of ovulation for at least six months post-delivery. However, many women are not comfortable relying on nature. Condoms are a good form of ‘double insurance’ in these instances.

Many women, however, start to wean babies before six months and thus may have a break through ovulation. Similarly, after six months, even when fully breast feeding, there is a risk of ovulation. The POP again is a good option for these women. There is no effect on milk production, as can happen with COC, and there is negligible transfer through breast milk to the baby.

New partner

For the woman who has a new partner and is looking for contraception advice, it is important to emphasise that no matter what option she chooses, she will also need to consider infection protection. This may mean going ‘double Dutch’, ie. using a condom along with a more effective contraceptive. However, even with 100% condom use, there is always the risk of contracting or passing on the viral STIs – herpes and warts. The message needs to be that there is no such thing as 100% safe sex, just ‘safer’ sex. 

Spacing family

For couples who already have children and are planning more, or for those who want to defer starting a family for a few years, long-acting contraceptives may not always be the appropriate choice. In particular, Depo-Provera can have a long-lasting effect, even after the 12-week active period. This is because its main mode of action is to suppress ovulation and often there is a significant delay in its return. As a general rule, if a woman is considering pregnancy in the next 18 months to two years, she should avoid using Depo-Provera. The other long-acting options (Implanon, copper intrauterine device [Cu IUD] and intrauterine system [IUS]), however, may be suitable as they do not stop ovulation but merely alter the uterine environment, making it hostile to sperm.

Family complete /no plans for family

Women who feel they have finished procreating, or never want another pregnancy, often look for a contraceptive method that they can forget about that does not involve taking daily tablets or 12-weekly visits to their doctor. Sterilisation is usually assumed to be the best option by many women. However, there are not insignificant failure rates following tubal ligation, especially in younger women. IUS insertion (Mirena) is more effective and a less risky option for many women and it avoids the necessity for general anaesthetic. However, fitting an IUS may be difficult in those women who have never had a pregnancy and a slimline Cu IUD device may be a better choice. Both systems are as effective as surgical sterilisation, especially in younger woman.

Implanon, the long-acting progesterone implant, offers three years contraception, usually with light to nonexistent menses. However, as with all progesterone-only contraceptives, erratic bleeding can be a problem. This often cannot be predicted before insertion. For those women in stable relationships, the option of vasectomy can be discussed. Many women are glad to hand responsibility over to their partners at this stage and also welcome the opportunity to stop taking hormone and allow their bodies to age ‘naturally’.

Pregnancy ‘scare’

As in any age group, the contraception consultation can often be triggered by an episode of risk-taking. While emergency contraception is now readily available through pharmacies, many women, particularly older women, prefer to come to their doctor for this, rather than discuss it with a pharmacist. Levonelle is a very safe product. It is most effective if taken within 72 hours of unprotected sex. This, however, does not mean that it cannot be used after this time period, but it is less likely to be effective. There is no evidence that if it is taken and fails to stop a pregnancy, that it results in danger to the developing foetus and it will not dislodge an established pregnancy. 

Fears and expectations

In any consultation, the patient brings her expectations and concerns. In the context of a contraception consultation, it is always necessary to try to understand these. Many women believe that there is a perfect contraceptive – one that works all the time and causes no problems. It is important to help her understand that all contraceptives come with advantages and drawbacks and the doctor’s role is to help her balance these for herself. She must be the one to make the choice and take ownership of her contraception. Many women have specific fears about various contraceptives – this may come from stories from family and friends, or from what they have read. It is important to ask her directly about her concerns and not to try to anticipate them. For many women, weight gain is a real concern and stops many women for using the COC, in particular. In general, the only method of contraception that statistically is likely to increase weight is Depo-Provera. 

While many women may put on some weight with other contraceptives, there is no evidence that it is directly related to the hormone component. Often it is related to other lifestyle changes that occur at the time of starting the contraceptive – moving from home, new partner with change in eating/exercise habits.

Understanding

As doctors, we often make assumptions about how much or how little our patients understand about their bodies and illness. When discussing contraception, age does not always correlate with knowledge! Many 30-40 year olds still do not understand the basics of the menstrual cycle and ovulation. A brief runthrough of how each contraceptive works, in plain, non-technical language, is a useful exercise and will help with compliance.

How badly does she not want to get pregnant?

This is probably one of the most useful questions in a contraception consultation. It helps to give the doctor a guide to the options to be discussed and also helps to focus the woman about her expectations.

“I absolutely do not want to get pregnant,” means discussing those options that have the lowest failure rate, such as hormonal, IUD, IUS. “Well it wouldn’t be the end of the world if I did,” opens up the option of discussing barrier or natural methods also, methods that are not quite as effective but have fewer possible side-effects.

Medical concerns

When helping a woman to decide on an appropriate contraceptive method, it is always important to establish if she is a ‘safe’ candidate for the method chosen. Women in their 30s and 40s are more likely to have medical problems or be on medications than their younger sisters. This is of particular importance when considering using oestrogen, as in the COC. The major concern here is the increased risk of arterial damage. Age itself is a risk factor for arterial disease. If oestrogen is added to this, there is a slight increase but still acceptable risk, but when it is compounded by hypertension, obesity, diabetes or cigarette smoking, the risk is no longer acceptable and a non-oestrogen option must be chosen.

Conclusion

Discussing contraception with women in their 30s and 40s is an exercise in sharing information and discussing options with the woman, in the context of her current circumstances in her life and also in light of her future plans for children. Medical issues may also limit or influence her options. Allowing her to take ownership of the final decision, increases compliance and satisfaction with the chosen method.