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Not just a “pill check”

The "pill check" is a common practice nurse responsibility. However, the term oversimplifies the complexity of the consultation. Many practice nurses provide contraceptive care without training, which may affect quality of care. Sarah Challinor demystifies the contraceptive consultation and argues that it is time for more practice nurses to undertake relevant training and improve care

Sarah Challinor
BSc(Hons) Dip(HE) RN
Contraception and Sexual Health Nurse

The terms "family planning" and "contraceptive care" are used interchangeably. Contraceptive care is the preferred modern term. However, family planning is used where appropriate.

It is estimated that 76% of women are using contraception to prevent pregnancy. Oral contraceptives remain the most popular method in Great Britain with 27% (3.7 million) using it during 2006/2007.(1) Clinic attendance and prescribing data analysis shows that the majority (76%) obtain care from general practice.(2) This trend has not varied over the years and it is reasonable to assume most repeat consultations will be with practice nurses. Indeed, almost 100% of practice nurses surveyed provide contraception services.(3)

Preparation for practice
The Working in Partnership Programme (WiPP) recently identified that only 47% of practice nurses had completed a family planning course.(4) The situation has changed little; research in 2000 found that 42% of nurses had completed family planning training and less than 50% in 1992.(5,6)
Practice nurses are ideally placed to provide contraceptive care. However, nurses working in specialised contraceptive services possess a recognised qualification. There is good reason for this as it ensures that they are prepared for practice and meets RCN guidance, which states that nurses should not provide family planning without appropriate training.(7) It seems ironic that most women access care from general practice, which has the least trained professionals.

A thorny issue
Ideally, all nurses should undertake training before assuming a contraceptive role. However, in today's climate of training budget cuts it seems unlikely that everyone will gain access to education. It is possible that some nurses offering "pill checks" do not fully understand the rationale of the consultation. This could expose a nurse to accusations of failing to work within their limits of competence.(8)
Clearly this is a complex area; nurses must consider whether they should provide contraceptive care and ought not to feel pressurised into doing so. In spite of guidance, some nurses have provided contraceptive care for significant periods without adequate preparation, perhaps through on-the-job training. In such circumstances it is vital that they are able to demonstrate safe practice, especially if providing similar training to new practice nurses.
There has to be a practical and workable trade off between guidance and service requirements. It is improbable that untrained nurses will stop providing care or that general practice will relinquish contraception. The crisis that would occur if all practice nurses were formally required to undertake training before undertaking "pill checks" is easy to imagine.

The value of protocols
Some practices insist that nurses have a contraceptive qualification before giving advice, but this is not widespread. Training shortfalls have been addressed in some areas by implementation of clinical protocols to inform care, and this seems a good compromise between the lack of training and the need to provide care. Protocols can be useful, but should be written by a professional with contraceptive expertise and should never be considered equal to formal training.
Protocols must reflect current best practice and be user-friendly enough to support clinical decision-making. Protocols become outdated quickly and should be reviewed regularly. Furthermore there should be adequate support and guidance to ensure that the rationale and practice implications are understood.

The consultation
The consultation is not a list of items to be checked off such as a quick BP and weight or the handing over of a prescription. Oral contraceptives are not without risk, it is essential to re-establish suitability and elicit problems. A 15-minute consultation is ideal, and those struggling with less must negotiate locally with employers. Consultations should contain certain components underpinned by medical eligibility criteria or good practice such as that published by the Faculty of Sexual & Reproductive Health Care (see Resources).
This is an ideal opportunity to promote health and provide education. Women should understand the mode of action of contraception and recognise the importance of regular review. Opportunity to establish sexual difficulties that women may not have the courage to voice is desirable. The following guide is not exhaustive but designed to alert nurses to the complexity of contraception.

Medical history review
Contraceptive eligibility is determined by UK Medical Eligibility Criteria, which enables re-evaluation of continuing eligibility.9 Guidance is updated periodically; any protocol should contain current information to prevent medicolegal problems.
 Patient notes should not be relied upon when assessing medical history. Recent changes and medications, including herbal remedies such as St John's Wort, which can weaken the effect of the combined oral contraceptive (COC), need assessing.(10) Reports of chest, lower abdominal or calf pain will require medical review. It is also important to ensure that patients know what to do if experiencing severe chest, lower abdominal or calf pain.
Family history should be checked, as conditions, such as familial hypercholesterolaemia, will indicate that risks outweigh the benefits.(9) Family histories change, therefore initial assessments should not be relied upon. Changes should be documented with clear indication that medical history has been reviewed to demonstrate continuing eligibility.

Headaches and migraines
It is not uncommon for women using the COC to experience headaches; however, it is important to determine whether this is related to pill use. Careful questioning can elicit timing and frequency. It may become apparent that headaches are only present during the pill-free interval (PFI) due to oestrogen withdrawal. This can be minimised by using the tricycle regimen of three packets in succession or by a change of pill brand.(10)
It is useful to suggest that a headache diary is kept for a month with an earlier review to pinpoint the exact cause. The woman could note how she is feeling on particular days to detect whether stress may influence headaches.
Identification of migraine type is crucial as contraception may be changed unnecessarily. Migraine with aura is an absolute contraindication to COC use due to increased risk of stroke. Women under 35 years who do not suffer aura may possibly continue with COC if there are no other risk factors such as smoking.(11) The patient should be asked if she experiences vision problems, numbness or tingling with or preceding headache or migraine.(12) It can be difficult to identify the type of headache and therefore it seems sensible to arrange a GP review following any reports of questionable headaches.

Blood pressure
Blood pressure (BP) readings must be checked at each visit as hypertension with COC increases risk of myocardial infarction and stroke.(13) Readings above 140/90 are unacceptable, indicating that the risks outweigh the benefits.(9) New users need careful monitoring as COC can cause a slight increase in BP, and any sudden change will necessitate earlier review to ensure that safe limits are maintained.(14)
Hypertension does not contraindicate progestogen-only pill (POP) use; however, the presence of other risk factors for cardiovascular disease, such as smoking, must be considered.9 Although the POP does not affect BP in the same way as the COC, it is necessary to record measurements. Some women are anxious in healthcare environments, it is important that BP is not recorded at the start of the consultation.

Age
Age needs checking against eligibility criteria. Some mistakenly believe that oral contraceptives must be stopped by a certain age, which can cause distress. Most women can continue to use the COC until they are 50 years old if no other risk factors are present, and many can continue to use the POP until 55 years.(13,15) A flowchart detailing contraception options for women over the age of 50 is available (see Figure 1).(15)

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Younger users may need assistance in establishing pill-taking routines, as they may be less likely to discuss contraceptive use with parents. The nurse may be the only source of information and the consultation should be used effectively. Nonconfrontational questioning can identify factors affecting contraceptive efficacy (and indeed personal safety) such as excessive alcohol consumption or low self-esteem. Those working with under-16s need to ensure that best practice guidance (commonly referred to as Fraser guidelines) is followed.(16)

Weight and BMI
Weight and body mass index (BMI) should be measured and recorded at each visit. Obesity (BMI > 35) is a contra-indication to COC use; however, there are no such limits with POP use.(9) It has been suggested that failure rates are higher in women weighing over 70 kg using certain types of POP.(10) A double dose of POP or change of pill to a desogestrel-type pill may be needed.(17)
Patterns in weight gain and loss should be observed. If a woman is gradually gaining weight sensitive counselling about the prospect of a contraceptive change will be needed. Weight loss strategies can be discussed, and in some cases an unwanted change in contraception is incentive to tackle weight gain.

Smoking
Some women may be unaware of the impact of smoking upon contraceptive use. Smoking is one of the main risk factors affecting contraceptive eligibility. At 35 years, smokers are no longer eligible for COC because of increased risk of venous thromboembolism.(9) As with weight, it is better to prepare women in advance - it is not helpful to alert women just before their 35th birthday (although not always avoidable). Younger women should be reminded that smoking will affect continuing eligibility, with advice given about smoking cessation. Smoking history should also be put in context with weight and family history and form part of general health promotion.

Menstrual pattern
Recording of last menstrual period demonstrates that the woman is not pregnant at the time of prescription reissue. Enquiries about bleeding pattern, breakthrough bleeding (BTB) and postcoital bleeding (PCB) are necessary. BTB with COC can occur because of inconsistent pill taking but may be due to vegetarian diet or unsuitable hormone concentrations.(12)
The cause of BTB or PCB must be excluded and documented carefully. Chlamydia infection can cause bleeding problems; a detailed sexual history and sexually transmitted infection (STI) testing will be required.(18) The date of last cervical smear should be checked and offered if due, although it is a screening test and should not be relied upon for diagnostic purposes. Abnormal bleeding not due to inconsistent pill taking, infection or hormone concentration requires examination of the cervix for abnormalities such as polyps with referral to colposcopy made if indicated.
POP bleeding can be more erratic ranging from amenorrhoea to intermittent light bleeding with little predictability.(14) Bleeding problems or concerns should be taken seriously and not blamed on contraception. Identification of STI risk factors should also be made with testing offered if indicated.
 
Pill routine and missed pills
It is always helpful to revisit pill taking routine to ensure that pills are correctly taken within recommended timeframes. Missed or late pills should be noted detailing action taken. There is greater flexibility with the COC which has a 12-hour window in which to take the pill. POP (excluding Cerazette [Organon] which has 12 hours) must be taken within a three-hour window. There may be patterns to late or missed pills such as regularly staying away from home or shift work. Strategies can be suggested such as mobile phone alarms and keeping the pill with their toothbrush. Details of where to obtain emergency contraception should be provided.
Up-to-date missed pill guidelines should be reiterated with written information provided. Some women maintain that they are aware of what to do, but it is worth finding out exactly what is understood of the guidelines as there may be confusion or reliance upon outdated guidance. It is also worth ensuring the woman's awareness of extra precautions following vomiting or severe diarrhoea within two hours of taking the pill.

Sexual health screening
While effective at preventing unwanted pregnancy, oral contraceptives offer no protection against STIs. Consultations ought to encompass contraceptive needs and overall sexual health. It should not be assumed that women have regular partners, women should be asked if there has been a change of partner since the last appointment and offered STI testing where indicated. There is no need to be afraid of offending women as there is a risk that STIs may go undetected if not carefully questioned. Women may also need reassurance about the effect of contraception on vaginal secretions, which may prevent unnecessary testing and anxiety.
Condoms are to be encouraged in those changing sexual partners more frequently. Availability of condoms can significantly increase usage, if condoms are not available, women should be directed to free services such as contraceptive clinics or young people services.
Contraceptive pill use is associated with a small increase in cervical cancer; it is not a cause but a co-factor such as cigarette smoking.(10) If women express concerns about cervical cancer, they should be encouraged to use condoms to prevent HPV infection if there are frequent changes of partner.

Breast care
Consultations provide an ideal opportunity to give breast care advice. Breast tenderness can occur with COC and POP usually resolving within the first three months of use. If tenderness persists a change to different hormone concentrations may be indicated.(12)
The evidence of effect of oral contraceptive use on risk of developing breast cancer is often contradictory.(14) However, it is good practice to ensure that all women know how to check their breasts on a regular basis.Demonstration of breast checking techniques and written information will support discussion.

Documentation
The consultation must be documented accurately, preferably in the woman's presence so that she can see what is recorded. Absence of symptoms in addition to any problems reported should be noted, for example "no headaches or migraines reported, no breakthrough bleeding, no abnormal discharge".
The NMC stance on record keeping makes reference to the legal approach that "if it has not been recorded, it has not been done".(19) Failure to document accurately could result in accusations that such questions were not asked. Statements such as "pill check as per protocol" are unacceptable, failing to reflect the uniqueness of the particular consultation.

Contraception training
Higher education institutions provide modules (see GUNA educational database) at Level 3. Most courses run over one term or semester and in addition to time spent in class, practical placements of 12-15 clinic sessions are required. Some may argue that a course is too advanced or indepth. However, it is the very fact that training is so comprehensive that enables provision of higher-quality care.
Nurses should approach employers with clearly identified learning needs with benefits to the practice and patients described. PCT education departments, university lecturers and sexual health leads can give advice on availability of training and funds.

Essential resources
An up-to-date drug formulary, address book of resources and condom demonstrator are essential. A BMI calculator, scales and fixed tape measure are needed for accurate measurements. Leaflets should be available to enable access to information from home and checked regularly to ensure they are up to date.
Breast care and screening leaflets are necessary as are contact details for sexual health websites such as FPA, Brook and r u thinking? Details for agencies dealing with issues such as rape, menopause and relationship difficulties are useful. There is much information available on the internet to support consultations, but nurses must satisfy themselves as to the quality of the information provided.
 
Conclusion
Contraceptive services are provided by practices as additional services under the new GMS contract. By agreeing to provide such care it is not unreasonable to suggest that the nurses who provide contraceptive care should be appropriately trained. Women using oral contraceptives have a right to receive care from knowledgeable and experienced practitioners.
This article has hopefully highlighted the complexity of contraceptive care. Practice nurses should reflect on the care they provide and identify gaps in knowledge base.

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Case study
As a new practice nurse I received little training on the necessary content of "pill checks". I soon found that I was unable to help many women with the problems they were experiencing using oral contraceptives. Often I would perform a pregnancy test on a woman using the POP, quite unaware that amenorrhoea is quite normal. I would also panic every time a woman reported a headache, and it was soon apparent that I was not providing the best possible care. Although a "pill check" protocol was available it made little sense as I had no understanding behind the rationale and I felt like I was giving task-oriented care rather than practising evidence-based care.
Access to contraceptive training was not easy and I was unable to secure funding. On reflection I don't think I put my case strongly enough or explored alternative options. Fitting in the course required some adjustment, as I had to attend university for 10 weeks with full day sessions. In addition to classroom time I had to arrange 14 clinic sessions of three and a half hours, and complete a learning workbook and two reflective essays.
So was it worth it? Absolutely! I think it is very true that quite often you are not aware of what you don't know until you learn it and I now realise why I experienced so many problems in practice. There was such a shortfall in my knowledge and with hindsight I can see how I would have managed many problems differently. I know that my case is not unique and I hope that others in similar situations are able to persevere and undertake training. Our patients deserve it!

References

  1. HMSO. National Statistics Omnibus survey report No 33. Contraception and sexual health. 2006/2007.
  2. National Statistics. NHS Contraceptive Services England 2006-07. 2007. Available from http://www.ic.nhs.uk
  3. Durex. What do your colleagues think? Available from http://www.durexchange.com/ncw/survey.php
  4. WiPP. The WiPP snapshot survey. Supporting nurses and practice. A national survey investigating employment conditions and professional development support for nurses in general practice in the UK. February 2008. Available from http://www.wipp.nhs.uk/uploads/GPN/Final%20Report%20SNAPshot%20Survey.pdf
  5. Stokes T, Mears J. Sexual health and the practice nurse: a survey of reported practice and attitudes. Br J Fam Plann 2000;26:89-92.
  6. Family Planning Association. Sexual health and family planning services in general practice. Report of a qualitative research survey in England and Wales. London: FPA; 1993.
  7. RCN. Contraception and sexual health in primary care guidance for nursing staff. London: RCN; 2004. Available from  http://www.rcn.org.uk/__data/assets/pdf_file/0005/78575/002016.pdf
  8. NMC. The Code Standards of conduct, performance and ethics for nurses and midwives. London: NMC; 2008. Available from http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=3954
  9. Royal College of Obstetricians & Gynaecologists. UK medical eligibility criteria for contraceptive use. Aberdeen: University of Aberdeen; 2005. Available from: http://www.ffprhc.org.uk/admin/uploads/298_UKMEC_200506.pdf
  10. Guillebaud J. The pill and other forms of hormonal contraception. 6th ed. Oxford: Oxford University Press; 2005.
  11. MacGregor EA. Hormonal contraception and migraine. J Fam Plann Reprod Health Care 2001:27:49-52.
  12. Everett S. Handbook of contraception and reproductive sexual health. 2nd ed. London: Ballière Tindall; 2004.
  13. Faculty of Family Planning and Reproductive Health Care. FFPRHC Guidance. First prescription of combined oral contraception. 2006. Available from http://www.ffprhc.org.uk/admin/uploads/FirstPrescCombOralContJan06.pdf
  14. Guillebaud J. Your questions answered. Contraception. 4th ed. London: Churchill Livingstone; 2004.
  15. Faculty of Family Planning and Reproductive Health Care. FFPRHC Guidance. Contraception for women aged over 40 years. 2005. Available from http://www.ffprhc.org.uk/admin/uploads/ContraceptionOver40.pdf
  16. Department of Health. Best practice guidance for doctors and other health professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health. London: DH; 2004. Available from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
  17. Faculty of Family Planning and Reproductive Health Care. At what weight or body mass index should a woman be increasing her dose of the progestogen only pill? 2007. Available from http://www.ffprhc.org.uk/admin/uploads/No2084.pdf
  18. Edwards A, Sherrard J, Zenilman J. Fast facts sexually transmitted infections. 2nd ed. Oxford: Health Press; 2007.
  19. Nursing and Midwifery Council. Record keeping. Available from http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=4008

Resources
Brook
Provides free and confidential sexual health advice and contraception to young people up to the age of 25
W: www.brook.org.uk

Faculty of Sexual & Reproductive Healthcare
W: www.ffprhc.org.uk

FPA
W: www.fpa.org.uk

Genitourinary Nurses Association
W: www.guna.org.uk

National Association of Nurses for Contraception and Sexual Health
W: www.nancsh.org.uk

Rape Crisis
W: www.rapecrisis.org.uk

Relate - relationship and sex therapy
W: www.relate.org.uk

r u thinking?
W: www.ruthinking.co.uk