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The Bayer Women’s Health Annual Lecture is known for its ability to provide valuable information and training to GPs with an interest in women’s health. Now in its 15th year, the focus of the most recent event was on two highly topical issues within the area – contraception and female mental health.
Cork GP and specialist in women’s health, Dr Zelie Gaffney, chaired the meeting and she told the packed room that GPs are “still learning how to optimise women’s health”.
‘Talking IUC with your younger patients’ was the title of the talk given by Dr Tina Peers, Consultant in Contraception and Reproductive Health, Surrey, UK. She explained that although intrauterine contraception (IUC) is one of the safest and most effective forms of contraception, uptake remains low. This is due to plethora of reasons; many myths and misconceptions about this form of contraception prevail and GPs are still not recommending it to all suitable women, she said. “For example, a recent global survey found that just half of doctors recognised that nulliparous women are eligible for IUC.”
While for many, the default option is the oral contraceptive pill, this is not suitable for everyone. While the perfect use failure rate of the pill is less than 1 per cent, this rises to 9 per cent in typical use, Dr Peers told the room. Indeed, recent research by Bayer found that more than two-thirds of women forget to take their contraceptive pill once or twice a month.
“The women of today are busy and stressed. Unintended pregnancies aren’t always teenagers — they are often women in their 20s and 30s whose contraception has failed. These may then go on to have termination,” she explained.
Intrauterine contraception, on the other hand, is ‘fit-and-forget’ contraception. The failure rate, which is less than one in 2,000, is identical in both perfect and typical use, as there are no compliance issues, said Dr Peers.
Yet myths persist around IUC among GPs, such as difficulty of insertion, the risk of perforation and the risk of expulsion. These have not been borne out in the evidence, however, Dr Peers pointed out. “Many concerns around the use of IUC can be reduced through a greater understanding of the available evidence,” she explained.
For example, pain with IUC insertion was shown in a study of younger women to be lower than feared for most patients — 20 per cent said they had no pain at all, while 70 per cent reported the pain to be “mild-to-moderate”. Among nulliparous women, the majority describe the pain of IUC insertion as similar in intensity to that of menstruation.
According to the European Active Surveillance Study for Intrauterine Devices (EURAS-IUD), a very low risk of uterine perforation is associated with IUC, at a rate of around one in 1,000 placements. The risk of perforation is independently associated with breastfeeding and time since last delivery, with a slightly greater chance of perforation in the first 36 weeks. Dr Peers explained to the GPs present that even if a perforation does occur, it takes just two weeks to heal, after which insertion can be re-attempted.
In terms of choice, it has been shown that if younger women receive appropriate counselling prior to choosing a contraceptive method, this can increase acceptability and interest in IUC, continued Dr Peers.
The US Contraceptive CHOICE Project looked at reducing barriers to long-acting reversible contraception; this study found that when women were offered all options, free of charge, more than half chose a form of IUC. It was then shown that 88 per cent of women persisted with the method after one year — in some studies involving the pill, the corresponding rate of persistence is as low as 44 per cent, she noted.
The US Contraceptive CHOICE Project looked at reducing barriers to long-acting reversible contraception; this study found that when women were offered all options, free of charge, more than half chose a form of IUC
Dr Peers advised the GPs that counselling can be quick and easy, while also being comprehensive. The Global INTRA group is a panel of independent physicians with expert interest in IUC, and of which she is a member.
Dr Peers explained that the INTRA group has devised six key steps that form the basis of an effective counselling session about IUC. These involve communicating the potential benefits of IUC, reassuring the patient, and addressing her concerns — a handy infographic of these six steps was disseminated to the attendees at the meeting.
She concluded her presentation by saying she “truly believes that IUC is a gift to women”.
“It is the best there is, so why should GPs save the best for last?”
Dr Peers was followed by psychologist Dr Allison Keating, who delivered her talk titled ‘Female mental health — helping you help your patient’. She began by stating her belief that people in Ireland seem more willing to contact their GP in relation to mental health than specialists; hence, GPs have a “pivotal role” in this area.
Echoing Dr Peers, Ms Keating agreed that millennials are far more stressed and anxious than previous generations. Having a “psychological toolbox” that patients can utilise is key — 4×4 breathing, where they take four deep breaths four times, can be particularly helpful, for example.
“It calms down the body’s ‘fight or flight’ response and makes the patient feel like they are doing something to help themselves.”
She spoke of the power of positive psychology and explained to the attendees that her focus is on cultivating personal responsibility for mental health — while the GP can be the gatekeeper who opens the patient’s awareness to presenting their issues, they can then provide the next step of medication or referral. “The patient’s initial sense of being understood is immensely healing,” she noted, but added that some patients can misuse their GP as their psychologist and should instead be referred to therapy.
Mental health is a complex and dynamic construct that relies on a mix of inherited disposition, learned behaviour and individual personalities; it can also be affected by external triggers such as grief, financial concerns or marital stress, for example, explained Ms Keating.
She placed specific emphasis on motherhood as a risky time for mental health problems. “I often see fear of flying in women who have just had their first child — it is triggered by them being frightened that they will die and leave their baby behind.”
Female health and hormones have a “massive” impact on mental health, a fact that women often dismiss, admitted Ms Keating.
“Motherhood is a big transition and the resulting hormones can play havoc with existing mental health conditions, such as anxiety,” she explained.
According to Ms Keating, stigma still persists in relation to receiving medical treatment for depression or anxiety. “There is no stigma with taking insulin for diabetes, so why should there be stigma associated with taking antidepressants?” she asked.
While negative thoughts are evolutionary, and exist to protect us, many women can get into the habit of having more negative thoughts than positive ones.
“Cultivating resilience is learning how to persist in the face of challenges — this will help you keep perspective.”
Seemingly simple solutions, such as improved sleep, can be of critical importance; learning good “sleep hygiene” by going to bed and getting up at the same time each day can be immensely helpful. “You may not sleep the whole time you are in bed so you have to manage sleep expectations, but I tell my clients that even just lying there is a rest.”
In addition, textures are important — simple things such as clean sheets, comfy slippers and cosy blankets can have a not-insignificant impact on mental health.
Ms Keating also directly addressed mental health and stress in GPs, saying “self-care” is hugely important. GPs can suffer from “compassion fatigue”, which has been described as the cost of caring for others in physical and emotional pain. This can occur as a result of a single exposure or the cumulative impact of exposure, and is essentially a state of physical and emotional exhaustion, leading to diminished empathy.
She also told the audience that the evidence shows burnout happens very differently in female GPs compared with males. While both will suffer emotional exhaustion, followed by depersonalisation and cynicism, men tend not to reach stage 3 of the process, which is reduced accomplishment and doubting the quality of their practice. “Male GPs do not suffer the same existential crisis that female GPs often will. Men still feel like they are a good doctor, despite suffering burnout.” She advised that GPs need to be acutely aware of which particular patients “drain” them and warned that this could essentially be a reminder of a personal issue they themselves have.
“Maintain boundaries for yourself, exercise self-care and engage in active self-compassion,” she told the audience.
Date of preparation: January 2017