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SEXUAL HEALTHCARE
SEXUAL HEALTHCARE IN IRELAND DURING A PANDEMIC
Nicola Cochrane, a GP based in Wicklow, highlights how sexual healthcare has adapted in general practice since the emergence of Covid-19
As the Covid-19 pandemic began, few of us could have envisaged the dramatic changes to our working world in general practice during 2020. Provision of sexual healthcare was not an immediate priority for most practices as the move to telemedicine and community assessment hubs evolved in March and April this year. However, people contacting GP practices during lockdown increasingly asked about menopause, contraception, symptoms of sexually transmitted infections and unplanned pregnancies.
In Ireland GPs with a special interest in sexual and reproductive health very quickly connected with our UK colleagues in the Faculty of Reproductive and Sexual Health and devised guidance for doctors.
It was an opportunity to adopt a robust evidence based approach to prescribing regarding review intervals, what aspects of clinical examination are essential and red flag symptoms suggestive of reproduc-
tive cancer or infection.
Telemedicine
GP bodies, such as the ICGP, have historically been conservative regarding telemedicine. This was largely due to new companies offering online consultations to people new to their service. The introduction of telephone and video consultations in general practices as a consequence of Covid-19 was significantly different, as the patients were well known to their GP and practice nurses who had access to medical records, previous laboratory results and hospital reports. The doctor patient relationship was well established and levels of patient trust and confidence were high. Non-Covid related consultation rates climbed throughout April and we were able to maintain regular prescribed medications with the new legislation facilitating electronic prescribing where a GP created a healthmail prescription sent to a pharmacy healthmail account. Since healthmail had already been widely adopted by GPs as a secure platform to send confidential medical information to each other and our hospital colleagues, the transition to electronic prescribing was extremely simple.
Emergency contraception
Guidance on provision of emergency contraception recommends the provision of either ulipristal, levonorgestrel or copper IUD as normal via telemedicine or face to face consultation for insertion of copper IUD.
Oral contraceptive pills, rings and patches
We had previously been advised that women who established on a hormonal contraceptive product need only annual reviews 2 for blood pressure, BMI and risk review. During Covid-19 we are advised that we can continue prescriptions for 12 months without any review. For women where they are exceeding 12 months and require remote consultation a self reported blood pressure result with a British Heart Foundation approved blood pressure device or a result from another healthcare professional (HCP) are sufficient for further prescription of medication to be provided. For many women the progesterone only pill is an excellent bridging or ongoing choice where doubts exist about cardiovascular risk, new focal migraine or high BMI. Progesterone only formulations require no clinical examination whatsoever. 3 Most people are already ready familiar with guidance on continuous 365 combined pill prescribing and this is the recommended regime 4 .Troubleshooting bleeding problems can be done remotely unless they describe post coital bleeding or altered bleeding patterns after a long phase of problem free pill taking where an examination is recommended and investigations with referral to gynaecology may be indicated.
LARC during Covid-19
Subdermal rod or Nexplanon users can be advised that the incidence of pregnancy is low in the 4th year of their device but where they have a high level of concern we can arrange replacement of their device using remote consultation for pre-procedure counselling or bridging with progesterone only pill.Women in year three to four can replace their device without the need for a pregnancy test, but condoms are advised for the first seven days after insertion. Women with a device >4 years in place should have a pregnancy test and use condoms for the first seven days. Bleeding conundrums can be managed by remote consultations as per combined hormonal contraception. Deep impalpable Implanons can be left in situ this year and a new device inserted in the other arm.The referral for removal can be arranged at a later date.
Intrauterine devices require device specific advice. Mirena (Levonorgestrel 52mg device)can be left in place for six years while advised the patient that contraception cannot be guaranteed in the sixth year and bridging or replacement can be arranged where preferred. Kyleena use cannot be extended beyond five years as it contains only 19mg levonorgestrel. Copper devices licenced for 10 years can be advised to continue for 12 years, but again contraception cannot be guaranteed in the extra years and replacement or bridging provided should be where preferred. The five year licenced copper devices must also be replaced or women can be offered bridging contraception.
Women can be advised to perform their own thread check after insertion to minimise unnecessary attendances.
Dep Provera injections can be extended to 14 weeks rather than 12 without the need for any added precautions.
Healthcare professionals are advised to don appropriate PPE during LARC procedures, minimise time for patients in the rooms and keep equipment to a minimum necessary for the procedure.
Menopause care during Covid-19 Women presenting with new onset menopause symptoms can be supported with remote consultations and prescribed HRT where indicated following the recommended prescribing guidelines, but face to face consultations should be arranged where indicated for examination or onward referral for breast or gynaecological investigations. It is important to emphasise to our patients that their menopause care should not be impacted by Covid-19 and that although there have been difficul-
ties in accessing specific brands of HRT that alternatives are available and electronic prescriptions can be provided to ensure they have a continuous supply of their chosen medication. Increasingly doctors have moved towards transdermal oestrogen preparations which do not add any risk of VTE. 6 This has opened hormone replacement therapy to a group of women who were previously considered high-risk because of high BMI (>30), borderline blood pressure, previous venous thrombo embolism and smoking. Menopause consultations for women with reproductive cancers are vital as these women face the added challenges of young age, emotional upheaval of cancer diagnosis with complexity of prescribing where they have been treated with anti oestrogen medication such as tamoxifen (some antidepressant SSRI medication can interact with tamoxifen reducing the efficacy). Women are recommended to aim for a BMI <27,take regular exercise, avoid alcohol and smoking as these have all been identified as exacerbating factors for vasomotor symptoms. A discussion on natural remedies, such as Black Cohosh and Red Clover should be conducted as these may interact with prescribed medication particularly tamoxifen and women should be advised to avoid them 7 . Agnus Castus ( Chasteberry or Monkspepper) has been found to be helpful for vasomotor symptoms but we have no accurate data on doses, interactions or adverse effects 8 .
Sexual assault
Sexual assault rates dropped dramatically during lockdown in Ireland, but sexual assault and treatment units around the country have reported rising incidence of attendees since easing of the lockdown. The closure of bars and nightclubs may have been the most significant factor, however, although we have seen a rise in incidents of domestic violence these make up only 20 per cent of people seen in sexual assault treatment units (SATUs). It is inevitable that telemedicine may inhibit people
from disclosing domestic violence or recent sexual assault and so GPs and practice nurses should maintain a high level of vigilance in women attending for emergency contraception, unplanned pregnancy and sexually transmitted infections.
Termination of pregnancy
Unplanned pregnancy occurring during lockdown introduced a challenge for GPs in supporting these women and guidance was rapidly delivered from ICGP, START, RCOG, and FSRH on the use of telemedicine in provision of abortion. The systems and protocols were adapted to record cycle details, first date of positive pregnancy test, previous gynaecological and medical history, allergies and medication by telephone or video consult as Visit 1. Notification and certification were completed as usual. Women are asked to attend for examination or blood group where indicated and an ultrasound arranged if required, but for many women a subsequent teleconsultation for Visit 2 three days later can cover all the detail on how to take medication, what to expect, when to worry or attend hospital and arrangements can be made for collection of medication. Although provision for Termination of Pregnancy was provided by the Minister of Health under emergency Covid-19 legislation many doctors are hopeful that we will be able to continue to use telemedicine for this purpose on an ongoing basis. We have no data on rates of medical termination of pregnancy during 2020.
Pregnancy and antenatal care continues unchanged and postnatal check ups are done as normal in GP practices. The challenges for parents with limited time together during delivery in hospital has added stress to their birth experience and maintaining their relationship with their GP and practice nurse is reassuring for both parents and healthcare professionals. Infant vaccines are continuing as normal at present. During lockdown, for many practices, mothers and babies were the only people attending their buildings.
REFERENCES
1. FSRH guidance for contraceptive provision after changes to
Covid-19 lockdown 2. FSRH Guideline CHC 2019 3. Guillebaud, Contraception
Today 4. https://www.rcgpac. org.uk/wp-content/ uploads/2017/10/
Enhanced-efficacy-withcontinuous-use-of
COC-v-10-10.pdf 5. https://www.fsrh.org/ news/fsrh-rcog-rcgp-andbms-statement-access-tohormone-replacement/ 6. BMJ 2019;364:k4810 Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases 7. BMS Consensus Statement 2020 Non-hormonalbased treatments for menopausal symptoms 8. Electronic Physician (ISSN: 2008-5842) http://www.ephysician. irJanuary2017, Volume:9,
Issue:1, Pages:3685- 3689,DOI:http://dx.doi. org/10.19082/3685
Systematic Review of
Premenstrual & Infertility
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