The topic of contraception has always been a bone of contention among medical circles – the risks attached to combined hormonal contraceptives (CHCs) are constantly pitted against their veteran status as one of the most effective forms of contraception going.
But a rash of recent media reports highlighting the dangers of using CHCs has breathed a new lease of life into the debate, bringing it to the forefront of public attention, and prompting new reports by medical regulatory groups concerning its safety.
We get a doctor's perspective on the debate, focusing our discussion on the combined contraceptive pill, contraceptive patch and vaginal ring.
Risks associated with prescribing contraception
Media attention has focused in particular on the risk of developing venous throboembolisms (blood clots) which is highest during the first three months of taking a CHC. Blood clots most commonly develop in the deep veins of the leg, although they can be carried to the lungs and heart with fatal consequences.
For a digital healthcare pioneer like LloydsPharmacy Online Doctor, the risks associated with contraception pose some clear obstacles to a vision of healthcare grounded in patient proactivity and responsibility.
We have to ask ourselves whether a move away from paternalistic healthcare is possible in the case of contraception. Are CHCs too risky to prescribe online? Has high profile media attention merely blown the risks associated with contraception out of medical proportion? How can online doctors rely on patients to accurately and honestly self-report on important medical indicators necessary for prescribing contraception?
The online contraception service provided by LloydsPharmacy Online Doctor has been able to safely prescribe contraception to approximately 37,000 women each year – over the course of seven years – without any report of serious incidents. However, as Dr Gigi Taguri points out, ‘the interests of patient safety must always be the priority of any healthcare provider.’
Online medicine is increasing and our doctors have been looking at ways of making our service even safer. As the scope and popularity of digital healthcare continues to grow, online medical providers need think long and hard about how to ensure the safest possible experience for their patients.
Making prescribing contraception online safer
This clinical concern has led to a positive development in our online contraceptive service, making it even safer whilst retaining its overall convenience for patients.
As of August 2015, all forms of medication using synthetic oestrogen and progesterone – including CHCs and Period Delay medication – prescribed by our doctors require in-store collection at a Lloyds Pharmacy. Upon collection, patients will have their blood pressure, height, and weight checked for free by a pharmacist before medication can be dispensed, to ensure accurate and safe readings.
As per medical guidelines, these readings will remain valid for a period of up to 12 months, in which time a patient will be able to request a repeat prescription of the same pill without requiring tests.
Our doctors also stipulate in-store collection and checks for new starters who have completed a 3-month course and would like to move on to a longer course, as well as for anyone changing to a different contraceptive pill.
The key push behind this initiative lies with the risks involved in accurately reporting important quantitative risk indicators – particularly blood pressure.
Our doctors are concerned that many people do not know their blood pressure, height or weight and by the associated risks of patients reporting inaccurate readings.
‘These hormone-based medications do increase blood pressure in a small number of women which can increase the long-term risk of stroke, kidney damage, heart problems and blindness’, explained Dr Taguri, ‘and that’s something that really needs to be emphasised.’ Without having an accurate reading of a patient’s height, weight and blood pressure, their relative risk of developing a blood clot or heart failure through CHCs use cannot be safely concluded.
But with the number of blood pressure monitors on the market, why can’t patients simply send in an image or their readings to our doctors?
Unfortunately, the level of machine and user error here are too great for this to be a reliable measure. Proper medical training is required to use a medical-standard blood pressure monitor, and these machines also need to be calibrated regularly to ensure accurate results.
Having trained staff to administer the checks provides our doctors with the medical and operational assurance they need that test results will be accurate.
Importantly, in-store checks also act as a safeguard against fabrication of key health indicators. Dr Taguri explained, ‘we have to accept the reality that some patients knowingly sending us inaccurate readings – this is usually quite obvious when they try and order from us multiple times.’
Contraception’s place within digital healthcare
But in view of all the risks, why should digital healthcare companies go to the trouble of making similar service changes? Couldn’t other forms of contraception which carry smaller risks be championed instead? Indeed, is there any truth behind the idea that GPs tend to prescribe CHCs as the default form of long-term contraception?
Although Dr Taguri agrees that long-acting reversible contraceptives (LARCs) are now recommended options for many women, she feels that CHCs are a medication worth defending. ‘CHCs are an extremely safe and reliable method of preventing unwanted pregnancy, if properly prescribed and taken correctly.’
Despite renewed investigations, a November 2013 report on CHCs by the European Medicines Agency offered very little new insight. They concluded that the benefits of CHCs still continue to outweigh the risks, and the only legally binding decision required pharmaceutical companies to update CHC product information to highlight risks.
As such, as long as a patient’s suitability for CHC is thoroughly assessed at the point of prescription, the 3.5 million UK women currently using combined oral contraceptives can continue to do so safely.
But some have argued that GPs should encourage patients to use non-hormonal forms of contraception, such as LARCs, over the more risky CHCs. LARCs, such as the coil, injection, and implant, are seen as advantageous since they do not affect a patient’s blood pressure, and they reduce the margin for potential human error.
The problem with this argument is that there is no ‘one size fits all’ with contraception. Whilst LARCs have many benefits, they are not necessarily suitable for every woman.
‘There are pros and cons for every type of contraception’, argues Dr Taguri. ‘Patients should always be given the option to choose the form of contraception that is best for them’. Indeed, despite their advantages, many women experience significant side-effects to LARCs – such as continuous spotting and irregular periods – and the invasive nature of the implant and coil pose problems for some.
A service worth defending
If the promise of a patient-centred model of digital healthcare is to succeed, we need to ensure that patients have a range of different health options, as well as detailed information to help them make their choice. Protecting the place of CHCs among other forms of contraception prescribed online is therefore crucial.
And online contraception really should be protected. Not only can digital healthcare make getting contraception more convenient for women – offering a service completely tailored around their schedule – it also improves accessibility. Online prescription removes important barriers which can impede women’s access to contraception: long waiting times, a scarcity of GP surgery appointments, logistical problems in getting to a practice for a specific time, and want for discretion to name but a few.
The online prescription of routine, long-term medications like contraception holds great potential to help primary care overcome the burdens it currently faces.
For one, the online consultation process is much more efficient and extends patient reach. Online doctors are able to help more patients with similar medication requests than they would through traditional face-to-face consultations in a practice. Migrating routine medications like contraception to online healthcare could also help free up GP surgery time for the most critical appointments.
Dr Taguri points out that LloydsPharmacy Online Doctor’s particular set up is ideal for supporting this – ‘we have a valuable network of excellent community pharmacists, allowing our patients to talk face-to-face with highly experienced health professionals who are potentially more accessible than General Practitioners.’
What’s more, partnerships with online doctor services could make the provision of routine medication like contraception much more affordable for the NHS, saving expensive face-to-face GP time for more critical appointments.
Contraception is the exact type of prescription medication that works perfectly within the online model. The advantages it brings demonstrate that it is clearly a service worth saving – from increased access to contraception, to patient convenience, and potential to reduce primary care costs.
Our doctors are proud to be able to continue to provide their patients with a highly-valued service in the safest online environment possible. But the real test of whether contraception can secure its future within digital healthcare depends on whether other online providers can adequately respond to the increasing demands of patient safety online.