eTG Sexual and reproductive health guidelines

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Hi, and welcome to the Australian Prescriber podcast. Today's podcast is on sexual and reproductive health. I’m Dr Justin Coleman, a GP on the Tiwi Islands. If you hop on the back of a crocodile at Darwin Harbour and head towards East Timor, you can hop off about 1/8 of the way and you'll hit my town, which used to be called Nguiu, now it's called Wurrumiyanga. But I'm interviewing someone in Sydney, which is some sort of town down south of me. That is Deborah Bateson. Deborah is a clinical associate professor at the University of Sydney and Medical Director of Family Planning New South Wales. Welcome, Deborah.

Thank you. It's a pleasure to join you.

Deborah, we're talking about a topic which is dear to your heart. I must confess for listeners, it is one of the topics I know least about of all the Therapeutic Guidelines topics, possibly because I'm a male and I've worked in Aboriginal health for the last 15 years. I've worked with some fantastic female GPs and all the women seem to go to them. I'm going to ask the occasional question, which may sound a bit basic, but it's nice for the listeners to think that they know more about the topic than the interviewer.

That sounds great.

No worries. We will be covering contraception, and endometriosis, and infertility, and menopause. Then we'll talk a little bit about medical abortion, and finally something for the blokes, some testosterone deficiency. The Therapeutic Guidelines now has replaced the Australian Clinical Practice Handbook of contraception. It's really everything you need to know about what to prescribe, and how to prescribe it, and start with something even I know a little bit about, because it's been around for a very long time, the oral contraceptive pill. The new guidelines talk about ways of starting the pill quickly and managing disruptions to the scheduled use and also continuous use. Just looking at the timing of the pill, what's important for GPs to know there?

Yeah. I think one of the key things is to have the idea of this concept, we call it Quick Start. Traditionally, if we look at the product information that says, "Wait until the first five days of your period to start the pill", but of course that can be very inconvenient. While women are waiting to start the pill, there's a risk of pregnancy. We now advocate for what we call Quick Start, which is starting at other times. Talking about, can you exclude pregnancy? But we know that the pill is not teratogenic, it's not going to cause harm to a pregnancy. It's weighing up the pros and cons of starting straight away. It's not going to be immediately effective then. You've got to then wait for seven days for it to become effective, but that's just a really useful way of potentially reducing unintended pregnancies while people are waiting to start the pill.

Then the other bit that you mentioned actually, Justin, is continuous or extended use of the pill. The pill was traditionally set up with 21 days of hormone pills and then a seven day gap. We know that actually, sometimes women forget to start that first pill in the new pack. That does put them at risk of unintended pregnancy because they may be just on the edge of ovulating, and we know there's no good reason for having that seven day break. In fact, it was just the way the pill was set up in some ways and so we really now advocate for that continuous use. People can do it for three months. Women can continue it for 12 months. It means that women won't have a withdrawal bleed, and when we explain that there's nothing to have a bleed with, many women were obviously very happy with that idea.

How enthusiastic would you say we should be about pushing for continuous use? Is it sort of just one of the options, or do you think we should actually encourage it?

I think it's one of the options. It does come down, like with everything to do with contraception really, it comes down to that personal choice. You can take it with that gap and then you'll get that withdrawal bleed. But there's other ways and you can take it continuously and avoid those withdrawal bleeds. To answer your question, I think we should certainly be talking about it. I don't know that we should be promoting it over any other way of taking it, but I think we certainly need to raise awareness so women can make that informed decision for themselves.

Thank you. That's a good perspective. Moving on now to the long-acting methods. What's the feeling about the utility of the long-acting methods? Do you think Australia is using them as much as you think we should be?

The LARC as we call them, the long-acting reversible contraceptives. I mean, it is a bit of a global movement, a global trend really, so the world is really recognising their benefits. They can be used by almost all women. There are either progestogen only, or no hormones. They've got those benefits in terms of being highly effective. You don't need to remember to do something on a frequent basis. They're also very cost-effective as well. What we do know is that in Australia, it's just the current data that we've got, does still suggest that we do lag behind some other parts of the world. Certainly there are still... There's low awareness, but there's also a lot of misinformation, misperceptions about the implants and the IUDs. For instance, [some people incorrectly believe] IUDs are not suitable for adolescents or women who haven't had pregnancies. I think we've still got a little bit of a way to go. That's where the Therapeutic Guidelines are really helpful in just highlighting these benefits, and that they can be used by women across the reproductive life of course. From adolescents postpartum and in that perimenopause as well.

As a male GP, and as I say, quite limited in my experience compared to probably the average female GP, I've certainly done many, many implants and never done an IUD so I tend to head towards implants, but where's the balance lie between those two?

Yeah. The latest data suggests it's a little bit balanced, but we do know that as you absolutely say, Justin, most GPs, in fact all GPs, will have that skillset to be able to insert an implant, whereas to insert an IUD does require that bit of extra training. You've got to feel confident about inserting the device through the cervix, into the uterus. We know that there are some trainings, sort of bottlenecks in a way as well. That's why it's great to raise this awareness because we know that when people do do that training they love to be able to offer that service to women. We certainly are seeing increasing demand. In family planning organisations like ours, we've got long waiting lists now for IUD insertions as women are becoming aware of their benefits. With the hormonal IUDs it's not just for contraception of course, they can... They're very effective at reducing heavy menstrual bleeding. They've got these other benefits including actually for endometriosis. People are recognising the benefits, women are recognising them, and I think it's really important that we're able to increase the number of people that can insert them so we can meet that demand.

I was very pleased to see that there's a new and fairly simple, for people like me, outline on how to choose between the various contraceptive methods and how to switch from one to the other.

It's a wonderful thing, isn't it? To have all that information in one place. Obviously, as doctors, as GPs, obviously we've got to do our job, which is to ensure that someone is medically eligible to use that particular method. The guidelines linked to the UK Faculty of Sexual Reproductive Healthcare at the so-called MEC or medical eligibility criteria guidelines, which match a woman's medical history, her circumstances with the contraceptive methods, so that's really important. But there's all sorts of other things that feed into it. I mean, obviously efficacy is important, but there's also things like the non-contraceptive benefits. Things... What's the impact on acne or menstrual bleeding, for instance. What about discretion? We know that some women will experience sometimes coercion around their methods. They want to have a method that's hidden and so that may feed into the choice, as well as things like costs, and how accessible it is. But of course it all comes down a bit like before, it will comes down to that personal preference. Our key is to be able to provide all the information about the different options in an easy way.

Yeah, and I think GPs are particularly good at individualising treatments for people in front of us because we have so broad a range…

Absolutely. GPs are excellent at doing that. I think, again, just to highlight, you mention, Justin, the switching table as well, which is a really useful resource because we know that obviously many of our patients will be changing from one method of contraception to another. This table just gives you that information about the advice, about how to make that seamlessly happen without putting someone at risk of unintended pregnancy during that change over.

Well, moving on Deborah Bateson. Apparently there's more to sexual and reproductive health than just the pill, and endometriosis is one of those things. There's an increasing push towards intervening early for endometriosis. What's the evidence that's based upon… what outcomes differ when you intervene early?

The early intervention really is mainly, I have to say, around that early symptom control and ensuring that women are not suffering in silence. We know it's underdiagnosed, under-recognised. We know from many sort of consumer stories, there's some very active community groups, that women sometimes take years to get to that diagnosis. I think it's really about that symptom control. Well, guessing the correct diagnosis, and appropriately managing it with analgesia, and usually with hormonal treatment, but then also recognising the impact it has on the fertility as well.

Yes. Whereas there are some diseases and conditions where one class of drugs soon becomes a front runner, I get that with endometriosis there are various ways of treating it, but none of them are really a stand-out compared to any other?

I think that's right. The nice thing in the guidelines is that there's a lovely flow chart which does go through the options. Again, I think it comes down to that personal preference. One of the key factors will depend on a woman's fertility intention. Whether she needs contraception or whether she desires to fall pregnant. As you say, there's no head-to-head trials. In fact we mentioned it before, actually, when we talked about this continuous use of the pill. Women are doing it for a variety of reasons, because they want to avoid that withdrawal bleeding, but also of course, for symptom control for something like endometriosis as well. We would always advise that the pill would be taken in a continuous way. You don't want to have breaks where you're going to get breakthrough pain.

While we're talking of fertility, and in fact, infertility, there's some new sections in the Therapeutic Guidelines, particularly looking at the lifestyle factors when someone comes to their GP with infertility and also making sure we consider both partners in that issue.

I think that's right. When I'm running an infertility consultation and sometimes it's with one partner, sometimes with both, I find it helpful to have a very systematic approach. What are the causes of both female and male factor infertility? Is it something to do with anovulation? Could it be endometriosis, or is there a tubal factor going on? Obviously with males, we need to think about what's happening for them as well, of course, in terms of their past history. But again, the other key thing, we talked about lifestyle and obviously that's very important, is to ensure that couples do understand around the fertile window and the timing of intercourse. Indeed there may well be sexual difficulties that are impacting as well on their fertility. It's just having a systematic approach. In fact, in the guideline, there's a very useful table actually, with the investigations to think about. It links to some excellent resources, government-funded resource, Your Fertility from Victoria, which I use a lot and that goes into those lifestyle factors in particular as well.

We won't go much into postpartum lactation promotion, but a little snippet is, in order of importance for promoting lactation, are first non-drug measures, and second domperidone, and metoclopramide has been relegated to third place, I take it.

You're absolutely right. You start with those sort of non-drug measures that's important, but domperidone’s actually got fewer side effects for the patient. It's transferred in small amounts to the infant, no negative effects there. Yes, so metoclopramide does cross the blood–brain barrier and it can have some of those significant effects. The other thing is just around people often ask, should we be stopping straight away or do we taper down? There's nothing really to choose, but there's appropriate ways forward with both of those approaches.

Just a brief dot point summary of non-drug measures. What sort of categories are we looking at there?

It's encouraging more frequent breastfeeding from both breasts, and assessing and treating breast engorgement and any nipple trauma. Obviously, all that advice around positioning and attachment. The other key thing is about regular expression after breastfeeds and for additional breast stimulation and drainage, that's really important. Obviously if needed, referring to a lactation consultant.

Thank you. I'm talking with Deborah Bateson, the Medical Director of Family Planning New South Wales. We'll move on now I think to medical abortion. I was interested to read in the new Therapeutic Guidelines that about 25% of pregnancies in Australia are unplanned, and of those pregnancies, about a third are unwanted. Certainly, medical abortion has been around for general practitioners now for quite a few years for gestations of up to nine weeks. Not all that many of us are taking up the challenge, and I guess it is a bit of a challenge. Although, you could argue no more difficult than many other things we GPs tackle.

Yeah. Justin, you're right. We've had the medical abortion medications. They've been available since around 2013, but really, out of all the 40,000 or so GPs, we know it's only roundabout two to 3000 who have done the required online training. I think it seemed to be a big step and that's why it's actually great that we've got these guidelines now. Hopefully sort of instill that confidence really, that it is something that GPs can provide. It's a very rewarding part of your practice to be able to provide this for your patients. The guidelines takes you through all the things that you need to know about it. But even if you're not providing it, it also is really important and really helpful to know what's going on and what may happen.

How common are complications? I mean, how worried should we be about providing it in our general practice?

They're very rare. I mean, we know that the complications for medical abortion and we're talking up to nine weeks is up to 5%. The commonest complication is retained products of conception. They could be managed expectantly, or sometimes by extra dose of misoprostol, or sometimes surgically. The other complications are very rare. The serious complications like, well sometimes, hemorrhage requiring a transfusion much less than 1% serious infection. Again, these are very rare complications. And a failed medical abortion, so where it hasn't worked, and then you could repeat the medications, or sometimes someone may choose to go for a surgical abortion. I've been providing this now for... We started our service probably just at the beginning of COVID, actually. I oversee all the medical abortions that we provide, and I've seen that the doctors become very confident in managing these medical abortions. Of course, with the vast majority of women, there are no complications at all.

The topic does talk about the initial assessment, the pros and cons of it, how to prescribe, the expected effects, the complications, and how to follow up, so it's a good step-by-step guide.

And it's actually got a very helpful information sheet if you are providing it, to give to your patients as well, about what to expect. As you say, we've got to give those realistic expectations to support a woman in making the decision about whether to have a surgical or a medical abortion, if she's made that decision.

Moving on to menopause now, and I guess we're talking about women mainly younger than 60 years of age who have menopausal symptoms. What sort of considerations influenced the decisions as to whether we should start menopausal hormonal treatment?

There's been certainly some waxing and waning with menopausal hormone treatment, but certainly there's been a lot in the media and I'm seeing increasing numbers of women coming in and actually asking for it, which is interesting. I think one of the key things is obviously, we've got to exclude any contraindications. As you said, those are the clear-cut cases. We don't start after 60, but we use it for vasomotor symptoms, so those terrible flushes, also to protect bones. I think we need to be able to discuss it with all women.

There are a few of those grey cases, as you say, where perhaps people have risk factors for VTE or obesity or smoking. But what we know is that the transdermal preparations can be a very suitable choice for those women in that sort of grey zone. Obviously, the key thing with menopausal hormone therapy, you've got to take that thorough history, we'll be doing some investigations because obviously at that stage of life there's comorbidities, there's higher risk of those. Transdermal therapy can be a very appropriate choice, but it does come down to that personal choice again. I'll see some women who are just adamant, despite me talking them through the risks and the benefits, they're adamant they don't want to use hormones. We have got some other alternatives, non-hormonal alternatives for hot flashes too.

Thank you. Let's move on finally, and with some relief on my part, to a topic I know a little bit about. Which is something for the blokes, which is male androgen deficiency or low testosterone, as most of us call it. This has always been a bit of a challenge in the sense that when I started my medical career, virtually no one had testosterone. Then there was a peak, a sort of ridiculous peak in some ways, I reckon probably about 10 years ago, where everyone seemed to want their testosterone to make them fitter, stronger, faster, smarter, and better in bed. I think since then, there's been more sensible conclusions as to who actually benefits. Testosterone deficiency, its non-specific symptoms. Testosterone does go up and down in men depending on how well they are, and their weight, and other illnesses, and even the time of day. There's a strong encouragement to make sure we get the diagnosis of true testosterone deficiency right.

That's perfect. The guideline really is about that, because you're absolutely right, where you've got a clear-cut case with testicular disease or pituitary failure that's clear, but the challenges in those where you've got the low testosterone in mid age and the older men who don't have those conditions. It's about following those guidelines, and again, the Therapeutic Guidelines set it out very clearly. Initiation of testosterone therapy has to be by a specialist, but obviously in general practice you can continue that therapy. Because you're right, it did get a bit out of hand, I agree with you, a few years back, but now there's obviously this very sensible guidance. The corollaries, as you've said, are really around ensuring that you're not just looking at something which actually could be corrected in other ways. Thinking about the differential diagnosis, obesity and diabetes, depression, all of those sorts of things. There's a really good table as well about monitoring clinical responses and serious adverse effects as well of this replacement therapy.

Yeah. We don't cover politics on this podcast, but I do think in some ways, us as a profession did shoot ourselves in the foot a little bit with that, the incredibly overenthusiastic prescribing. I think the restriction to specialists was probably necessary at that time. I'm not sure whether it should remain in place over time, but certainly getting that fasting morning serum, total testosterone level, and then if that's low, you repeat it on some other day, some other time. Make sure they're well at the time, because as you say, those intercurrent illnesses can lower it artificially. Despite what your aging male who likes to go to the gym might tell you, or might have read on the internet, it really isn't indicated for just some low libido, or erectile dysfunction, or not lifting enough gym weights in older men who really aren't overly deficient.

Well, thank you so much, Deborah Bateson, it's been a delight talking to you in particular because you answered all my questions very thoroughly and I didn't have to really know all that much about the topic to get reams of fantastic information about sexual and reproductive health from the new Therapeutic Guidelines. Thanks so much for talking to me today.

It's been an absolute pleasure. Thank you for inviting me.

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My guests' views are their own and don't represent Australian Prescriber, and my views are certainly all mine.