Dr Rebecca Mawson offers top tips on providing sexual and reproductive health care in primary care

mawson rebecca

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Read this article to learn more about:

  • screening patients for sexually transmitted infections and HIV
  • different types of contraception and when to give postnatal contraception advice
  • the needs of different communities, including people who identify as LGBT, and people who have HIV. 

This article aims to cover top tips on providing sexual and reproductive health in general practice. The topic area is vast so there are signposts to other useful resources for readers where possible; see Box 1 for a summary of these.

Box 1: Sexual and reproductive health resources

The Faculty of Sexual and Reproductive Healthcare

LGBT community resources

1. Be aware of socioeconomic effects

Sexual health services in some parts of the UK have been cut dramatically, leading to reduced availability of contraception and sexual health screening, while diagnosed cases of sexually transmitted infections are increasing.1 People who are at greatest risk of negative outcomes from reduced provision of sexual healthcare are also those who struggle most to access services. Teenage pregnancies and sexually transmitted infections are more prevalent in lower socioeconomic communities, where general health is also often worse.2,3

A report by the Family Planning Association described the economic impact of unplanned pregnancy and untreated sexually transmitted infections.3 It estimated that with current levels of provision, between 2015 and 2025 the UK health costs would be £24 billion. Additionally, if public health cuts continue, every £1 cut to sexual and reproductive healthcare could cost the government £86 in health, education, welfare, and social care outlays.3 Unintended pregnancy could have potential negative consequences such as worse child health, compromise to education, and relationship instability.4

2. Screen for infections when providing contraception

Primary care prescribes approximately 80% of contraception in the UK, yet our sexual health screening provision is poor.5 Therefore, when seeing a patient for a contraceptive check, asking them the questions in Figure 1 can help clinicians decide whether to offer them a sexual health screen.

algorithm showing questions that should be asked in a routine contraception check

Figure 1: Questions to ask during a routine contraception check to determine need for a sexual health screen

Sexual health screening in primary care is simple to carry out. The British Association for Sexual Health and HIV (BASHH) recommends specific tests for asymptomatic people according to their sexuality (Table 1). BASHH guidance provides more details about which blood tests are needed in specific patients, such as injecting drug users, sex workers, and partners of people with HIV.6

Table 1: Sexual health screening for asymptomatic people6
PatientBlood testVaginal sexAnal sex

Heterosexual woman

HIV

Syphilis

Self-taken vulvo-vaginal swab for GC/CT NAAT

Consider GC/CT NAAT

Heterosexual man

HIV

Syphilis

First pass urine GC/CT NAAT

Peno-anal: first pass urine GC/CT NAAT

Man who has sex with men

HIV

Syphilis

Hepatitis B

Hepatitis A depending on local prevalence

 

Insertive peno-anal: first pass urine GC/CT NAAT

Receptive peno-anal: rectal swab GC/CT NAAT

Receptive oro-anal: consider rectal swab GC/CT NAAT

GC=gonorrhoea; CT=chlamydia; NAAT=nucleic acid amplification test

British Association of Sexual Health and HIV (BASHH) Clinical Effectiveness Group. 2015 BASHH CEG guidance on tests for sexually transmitted infections. BASHH, 2015. Available at: www.bashhguidelines.org/media/1084/sti-testing-tables-2015-dec-update-4.pdf

Reproduced with permission

Information on screening for non-binary or trans people can be found in the Royal College of General Practitioners Northern Ireland Guidelines for the care of trans patients in primary care.7 Women who have sex with women should be managed as if they are heterosexual women if they have had previous heterosexual contact, otherwise there is no test routinely recommended.6

3. Use self-swabs

There have been major changes in the last 20 years in how laboratories detect infections, mainly moving towards using nucleic acid amplification tests (NAAT), which detect the presence of gonorrhoeal or chlamydial cell DNA or mRNA. This technique is more sensitive than microscopy and does not rely on getting fresh samples to the laboratory.8 Most areas in the UK have moved towards using NAAT rather than microscopy for detecting chlamydia and gonorrhoea. Dual testing is done using one NAAT swab and requires only one swab to be sent to the laboratory. Note that NAAT swabs might have a white, pink, or orange bottle.

‘Triple swabs’ (two charcoal swabs for culture [one of the endocervical canal, and one of the high vagina], plus a NAAT swab of the endocervix) are no longer required. For self-testing in women, a self-taken low vaginal NAAT test for chlamydia and gonorrhoea is all that is needed. In asymptomatic women there is no need to do a vaginal examination.8

The Royal College of General Practitioners and BASHH published a useful guide to managing vaginal discharge in primary care, with a move towards treating symptomatically or using litmus paper as a pH indicator to differentiate candida and bacterial vaginosis.9

4. Update your knowledge of HIV

HIV is one of the medical good news stories of our lifetime and yet some healthcare professionals still stigmatise the condition. Unfortunately, medical school teaching over the last 20 years has helped fuel myths around HIV, including a need for ‘thorough’ pre-test counselling for HIV and warning of risks such as mortgage and life insurance issues.10 This has sadly led to patients either not being offered HIV screening or, in worse cases, being turned away when they ask for testing in primary care.

A report published in 2016 on HIV stigma in primary care exposed concerning practices, such as refusing to take blood or carry out smears on people with HIV and the practice of double gloving for procedures or single gloving for simple external examinations.11

In England, approximately 12% of people with HIV are undiagnosed (prevalence figures for the UK are due to be published in early 2018).12 In Europe, people diagnosed and started on treatment at the age of 20 years in 2010 had an average life expectancy of around 68 years.13 If people with HIV are on effective antiretroviral treatment there is minimal risk of transmission. The PARTNER study evaluated 58,000 distinct occasions of penetrative sex that included one person with HIV on effective treatment and on follow up after a median 1.3 years, there were zero HIV transmissions to their partners after having sex without using condoms.14

5. Offer HIV testing

NICE Guideline (NG) 6015 offers very clear guidance for general practice to offer opportunistic HIV testing in at-risk groups, but unfortunately there has been limited uptake of the guidance in clinical practice.11 NICE NG60 recommends testing for HIV in general practice according to the area’s local HIV prevalence:15

  • all practices, regardless of local prevalence of HIV, should test patients with symptoms indicative of HIV and/or who have known risk factors
  • high-prevalence practice areas (HIV prevalence of 2–5 per 1000 people aged 15 to 59 years) should offer an HIV test to patients when registering at the practice or when coming for blood tests for other reasons if they have not had a test in the last year
  • extremely high-prevalence practice areas (HIV prevalence of 5 or more per 1000 people aged 15 to 59 years) should test as for high-prevalence practice areas, and should also consider HIV testing at every consultation.

Clinicians can find out the HIV prevalence of their practice from the public health team within the local authority or CCG, or by accessing Public Health England’s Sexual and reproductive health profiles online.

6. Recommend long-acting reversible contraception

Long-acting reversible contraception (LARC) is more than 99% effective at preventing pregnancy.16 The contraceptive pill remains the most commonly prescribed contraceptive in the UK; however, much more effective products are available.16–18

In 2005, it was estimated that if 7.7% of women switched from using the contraceptive pill to LARC it could save the NHS £102 million by reducing the number of unintended pregnancies.19

Not only does user error affect the efficacy of the combined pill but also the regimen of using it for 3 weeks then stopping for 7 days is likely too long a period to suppress ovulation in some women.20 For women who do wish to use combined hormonal contraception, many clinicians are moving towards extended regimens, as recommended by the Faculty of Sexual and Reproductive Healthcare (FSRH) (Table 2). Note that use of extended or continuous regimens of CHC is currently off licence (December 2017).

Table 2: Tailored regimens for use of combined hormonal contraception20
Type of regimenSuggested regimenCHC-free period

Extended use

Tricycling (three cycles taken continuously back to back, i.e. three pill packets or three rings, or nine patches)

7 days taken after finishing the third packet, third ring or ninth patch

Shortened pill-free interval

3 weeks of CHC use

4 days taken after each packet of pills, each ring, or third patch

Extended use with shortened pill-free interval

Method used continuously (≥21 days; pill, patch and ring-free weeks omitted) until breakthrough bleeding occurs for 3–4 days

4-day interval

Extended use with regular pill-free interval

Method used continuously (≥21 days; pill, patch and ring-free weeks omitted) until breakthrough bleeding occurs for 3–4 days

7-day interval

CHC=combined hormonal contraception

Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit. Combined hormonal contraception. FSRH, 2012. Available at: www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception

Reproduced with permission

7. Consider the needs of lesbian, gay, bisexual and trans people

Research has shown that members of the lesbian, gay, bisexual, and trans (LGBT) communities feel poorly served by healthcare professionals. People who identify as LGBT still experience stigma and their needs are often poorly understood.7,21–23 For further guidance on this topic, please refer to the Guidelines in Practice article Inclusivity is the key in the care of lesbian, gay, and bisexual people.23

8. Provide earlier postnatal checks

In January 2017 FSRH published a guideline on Contraception after pregnancy, which highlighted the need for earlier advice on contraception postnatally.24 It is common practice to see women for their postnatal check at 8 weeks; unfortunately this is too late for most women requiring contraception. Women should be advised to start their chosen mode of contraception after delivery but definitely before 21 days postpartum. Women can be reliably informed that any form of progestogen-only contraception is safe to start straight after birth, regardless of breastfeeding status. If the woman is breastfeeding and would like to use combined hormonal contraception, recommendations suggest to wait for 6 weeks postpartum mainly due to thrombotic risk.24 If women want to use the lactational ammenorrhoea method, they must ensure that it is within 6 months of delivery, they do not have a period and they are exclusively breastfeeding.24 Women should also be advised that an interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth and low birthweight.24 For further information refer to the Guidelines in Practice article Contraception should be offered promptly following pregnancy.25

9. Don’t forget women over the age of 40 years

There has been an increase in sexually transmitted infections and abortions among women in their 40s and 50s, likely linked to an increase in relationship changes during this time of life.26

Menopause can cause a great deal of confusion with regard to contraception. Recommendations from the FSRH about contraception in women aged over 40 years help to clarify issues (see Table 3). An article on this guideline will be included in the January 2018 issue of Guidelines on Practice.

Table 3: Contraception for women aged over 40 years26
Contraceptive methodAge 40–50 years Age >50 years

Non-hormonal

Stop contraception after 2 years of amenorrhea

Stop contraception after 1 year of amenorrhea.

Combined hormonal contraception

Can be continued

Stop at age 50 and switch to a non-hormonal method or IMP/POP/LNG-IUS, then follow appropriate advice.

Progestogen-only injectable

Can be continued

Women ≥50 should be counselled regarding switching to alternative methods, then follow appropriate advice.

Progestogen-only implant (IMP)

Progestogen-only pill (POP)

Levonorgestrel intrauterine system (LNG-IUS)

Can be continued to age 50 and beyond

Stop at age 55 when natural loss of fertility can be assumed for most women.

  • If a woman over 50 with amenorrhoea wishes to stop before age 55, FSH level can be checked
  • If FSH level is >30 IU/l the IMP/POP/LNG-IUS can be discontinued after 1 more year
  • If FSH level is in premenopausal range then method should be continued and FSH level checked again 1 year later.
 IMP=progestogen-only implant; POP=progestogen-only pill; LNG-IUS=levonorgestrel intrauterine system; FSH=follicle stimulating hormone

Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit. Contraception for women aged over 40 years. FSRH, 2017 (updated November 2017). Available at: www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/

Reproduced with permission

10. Refresh your knowledge of emergency contraception guidance

In the UK there are three forms of emergency contraception: two oral medications (ulipristal acetate and levonorgestrel) and the copper intrauterine device (IUD). The copper IUD is by far the most effective method and provides ongoing contraceptive protection.27 The main mode of action of the oral medications is to delay ovulation, whereas the copper IUD prevents implantation. The FSRH guideline, published in March 2017, provides useful algorithms for when to offer which forms of emergency contraception.27

An emergency contraceptive consultation should not just include protection from pregnancy, it must also include a screen for sexually transmitted infections and an offer of better contraception, preferably LARC, moving forwards.

11. Understand UKMEC risk categories

The UK Medical Eligibility Criteria for contraceptive use (UKMEC) was updated in 2016 and helps guide contraceptive choices by categorising risk.28 It includes a new section on women with comorbidity that reflects the changing UK population. Clinicians should have the guidance available to use when prescribing contraception.

References

  1. Robertson R, Wenzel L, Thompson J, Charles A. Understanding NHS financial pressures—how are they affecting patient care? London: The King’s Fund, 2017. Available at: www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Understanding%20NHS%20financial%20pressures%20-%20full%20report.pdf 
  2. The Marmot Review. Fair society, healthy lives. Institute of Health Equity, 2010. Available at: www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf 
  3. Lucas S, on behalf of the Family Planning Association (FPA). Unprotected nation 2015—an update on the financial and economic impacts of restricted contraceptive and sexual health services. FPA, 2015. Available at: www.fpa.org.uk/sites/default/files/unprotected-nation-2015-full-report.pdf 
  4. Wellings K, Jones K, Mercer C et al. The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) Lancet 2013; 382 (9907): 1807–1816.
  5. All-Party Parliamentary Pro-Choice and Sexual Health Group. A report into the delivery of sexual health services in general practice—a survey by the All-Party Parliamentary Pro-Choice and Sexual Health Group—October 2007. FPA, 2007. Available at: www.fpa.org.uk/sites/default/files/all-partyparliamentarypro-choiceandsexualhealthgroupreportintosexualhealthservicesingeneralpractice2007.pdf 
  6. British Association of Sexual Health and HIV (BASHH) Clinical Effectiveness Group. 2015 BASHH CEG guidance on tests for sexually transmitted infections. BASHH, 2015. Available at: www.bashhguidelines.org/media/1084/sti-testing-tables-2015-dec-update-4.pdf
  7. Royal College of General Practitioners Northern Ireland. Guidelines for the care of trans* patients in primary care. Belfast: RCGPNI, 2015. Available at: www.rcgp.org.uk/-/media/Files/RCGP-Faculties-and-Devolved-Nations/Northern-Ireland/2017/RCGPNI-Trans-Patient-Guidelines-for-GPs-2017.ashx?la=en
  8. British Association of Sexual Health and HIV (BASHH) Clinical Effectiveness Group. 2015 UK national guideline for the management of infection with Chlamydia trachomatis. Int J STD AIDS 2016; 27 (4): 251–267.
  9. Lazaro N, on behalf of the Royal College of General Practitioners (RCGP) and the British Association for Sexual Health and HIV (BASHH). Sexually transmitted infections in primary care—second edition. RCGP/BASHH, 2013. Available at: www.bashhguidelines.org/media/1089/sexually-transmitted-infections-in-primary-care-2013.pdf 
  10. Barber T, Menon-Johansson A, Barton S. How can we remove barriers to HIV testing outside of a GUM setting? Br J Gen Pract 2008; 58 (550): 365.
  11. Forni J. HIV stigma and discrimination in primary care. Slide set. ViiV Healthcare, 2016. Available at: www.bhiva.org/documents/Conferences/2016Manchester/Presentations/160420/JohnForni.pdf 
  12. Brown A, Kirwan P, Chau C et al. Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK. Public Health England, 2017. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/659618/Towards_elimination_of_HIV_transmission_AIDS_and_HIV_related_deaths_in_the_UK.pdf 
  13. Trickey A, May M, Vehreschild, the Antiretroviral Therapy Cohort Collaboration. Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies. Lancet HIV 2017; 4 (8): e349–e356.
  14. Rodger A, Cambiano V, Bruun T et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016; 316 (2): 1–11.
  15. NICE. HIV testing: increasing uptake among people who may have undiagnosed HIV. Clinical Guideline 60. NICE, 2016. Available at: nice.org.uk/ng60 
  16. Secura G. Long-acting reversible contraception: a practical solution to reduce unintended pregnancy. Minerva Ginecol 2013; 65 (3): 271–277.
  17. Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit. Intrauterine contraception. FSRH, 2015. Available at: www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception/ 
  18. NICE. Long-acting reversible contraception. Clinical Guideline 30. NICE, 2014. Available at: nice.org.uk/cg30
  19. NICE. National cost-impact report—implementing the NICE clinical guideline on long-acting reversible contraception. Clinical Guideline 30 Tools and Resources. NICE, 2005. Available at: www.nice.org.uk/guidance/cg30/resources/cost-impact-report-pdf-194835421
  20. Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit . Combined hormonal contraception. FSRH, 2012. Available at: www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception 
  21. Hinchliff S, Gott M, Galena E. ‘I daresay I might find it embarrassing’: general practitioners’ perspectives on discussing sexual health issues with lesbian and gay patients. Health Soc Care Community 2005; 13 (4): 345–353.
  22. Royal College of General Practitioners Northern Ireland. Guidelines for the care of lesbian, gay and bisexual patients in primary care. Belfast: RCGPNI, 2015. Available at: www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/RCGPNI-Guidelines-for-the-care-of-LGB-patients-in-primary-care-2015-web.ashx?la=en 
  23. Holloway M. Inclusivity is key in the care of lesbian, gay, and bisexual people. Guidelines in Practice 2016; 19 (6): 26–32. Available at: www.guidelinesinpractice.co.uk/jun16-lgb 
  24. Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit. Contraception after pregnancy. FSRH, 2017. Available at: www.fsrh.org/standards-and-guidance/documents/contraception-after-pregnancy-guideline-january-2017/
  25. Cooper M, Cameron S. Contraception should be offered promptly following pregnancy. Guidelines in Practice 2017; 20 (4): 23–34. www.guidelinesinpractice.co.uk/sexual-health/contraception-should-be-offered-promptly-following-pregnancy/453177.article
  26. Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit. Contraception for women aged over 40 years. FSRH, 2017 (updated November 2017). Available at: www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/
  27. Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit. Emergency contraception. FSRH, 2017 (updated May 2017). Available at: www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-emergency-contraception-march-2017/ 
  28. Faculty of Sexual and Reproductive Healthcare (FSRH) Clinical Effectiveness Unit. UK medical eligibility criteria for contraceptive use, UKMEC 2016. FSRH, 2016. Available at: www.fsrh.org/standards-and-guidance/uk-medical-eligibility-criteria-for-contraceptive-use-ukmec/