It is now a year since the government published the first ever Women’s Health Strategy for England. The strategy highlights many of the barriers and health inequalities that women face, promising to tackle the poor experiences and worse health outcomes that women have suffered for far too long.
In terms of waiting lists, gynaecology remains one of the worst hit specialities, with outpatient waits at 18 months or longer in some parts of the country. Last year TV presenter Davina McCall most definitely got the conversation going around women’s health when she made two documentaries exploring menopause. Then last month she set out to tackle another crucial area of Women’s Health – contraception - in her Channel 4 documentary Davina McCall’s Pill Revolution.
In the programme Davina attempts to explore the apparent impact of the many ‘alarming’ side effects of the pill. She highlights the need for further research and development into contraception, and does well to throw the spotlight on some of the many barriers and lack of funding that affect the viability of contraception services.
But, as Davina dashes up and down the country to hear many women’s stories, one can’t help but notice that we seem to be in an era where anecdotal stories carry far too much weight when compared to science and medical research.
As the programme ended, I was left rather apprehensive that many viewers will be tempted to discontinue reliable contraception and run the ‘Russian roulette’ of hoping they ‘won’t get caught this month’. These very patients would then have to face the many hurdles (that the programme itself highlights) of trying to access a health care provider to sort out an alternative contraceptive option.
Pros and cons of contraceptive pills
I’m not for a minute dismissing that there are many potential side effects of contraceptive pills, however these are often symptoms that many women experience throughout their monthly menstrual cycle anyway (to varying degrees).
We know that menstrual-related exacerbation of psychiatric symptoms occur most commonly during the premenstrual and menstrual phases, and that, for some symptoms, progesterone-to-estradiol ratios play an important role in this relationship.1 We also know that hormonal contraception may indeed have a role in managing these conditions,1 hence conveying the challenge of how difficult it is to lay out the full facts of the matter.
The benefits of the combined contraceptive pill (COC) for common gynaecological conditions are well documented. We know that there’s plenty of evidence that COC is an effective treatment for menorrhagia2 and tailored regimens enable women to have more control over their menstrual cycles.
COC is also recommended for the treatment of endometriosis3 and has been shown to be helpful in treating premenstrual syndrome (PMS). There is evidence that Yasmin® (drospirenone 3mg and ethinylestradiol 0.030mg) is particularly effective for this condition, however other newer generation COCs may also be of benefit.4
Long-acting reversible contraception
As well as discussing the benefits and potential side effects of contraceptive pills, it is important that we also educate patients on the full range of contraceptive options.
Long-acting reversible contraception (LARC) can be a great option for many women, without the worry over remembering a daily pill. Intrauterine systems (IUS) are hugely popular, managing menstrual disorders and some of these devices can be used as part of certain hormone replacement therapy regimes.
The copper coil (or hormone-free coil) is a good option for those who want to avoid hormones, however it is important to warn patients that their periods could become heavier or longer.
The contraceptive injection is still a popular choice for many women, but of course it is important to advise women that it may take a few months for their periods (and hence their fertility) to return on stopping.
The contraceptive implant is another great option for many women. It is easily fitted, last three years and has the lowest failure rate of all contraceptives.
It is so important that any discussion around potential side effects of hormonal contraception is weighed up against the risk of an unplanned pregnancy. Every contraceptive will have some potential unwanted side effects; however we have more contraceptive options on the table than ever before yet sadly, we continue to face growing abortion rates in this country (1 in 4 pregnancies in England are terminated and 1 in 3 women will have a termination in their lifetime5).
How to tackle growing concerns
So how do we tackle the very real growing concern of many patients about the potential side effects of hormonal contraceptives?
Many women are terrified of the thought of the impact of hormones on cancer risk and yet we have a great deal of education still to do around the impact of obesity and alcohol on cancer risk (I often use this handy tool from the British Menopause Society to educate patients).
We know that there is clear evidence of poorer mental health outcomes for women who experience unwanted pregnancies after having completed their families,6 and having a termination is likely to have a significant impact on a woman’s mental health as well (although little research has been done in this area).
So, when our time and resources are so stretched, how on earth do we help our patients make the right contraceptive choice? There are many great patient information leaflets available – Sexwise and The Lowdown are two examples.
Many of the common side effects of the pill will settle with time and (as is often the way) real life medicine is frequently a case of trial and error. For example, switching to a COC with a lower dose of estrogen can help if estrogenic side effects are the problem. Likewise the newer generations of progestins have more anti-androgenic effects, if patients are struggling with mood change or skin issues.7
It is interesting to note that some studies have even reported a negative change in mood after a hormonal free copper coil, suggesting just how complex and multifactorial mood change can be when evaluating the impact of using different contraceptive methods.8
Conveying accurate information and reliable evidence to patients, is no easy feat, especially in this age of social media and anecdotal stories.
How to improve contraception services
Chronic underfunding, fragmented commissioning and increased barriers to training, are just some of the many challenges that impact on the poor patient experiences that we hear about all too often. Improved access and adequate funding (such as ‘fair fitter fees’) need to be prioritised.
Of course, cuts to funding haven’t just affected primary care but also sexual and reproductive services too, with many clinics only able to fit LARC for contraception and not for gynaecological conditions.
We desperately need more support for women’s health services and this message does come through loud and clear in Davina McCall’s documentary.
One of the hopes of the strategy is to address some of these needs through the evolution of Women’s Health Hubs, with the government announcing £25m of new funding to support their development.
The provision of contraception services is at the very heart of many of the hubs, with the majority of these hub models evolving out of local primary care services that began by delivering LARCs.9
You can find out more about Women’s health hubs and learn about some of the models being developed, from the Women’s Health Hub Toolkit on the Primary Care Women’s Health Forum.
In addition to the health hubs, this year will also see the launch of the NHS Pharmacy Contraception Service Pilot, enabling women to access various contraception through their local pharmacy.
With these changes we will hopefully start to see better access to all forms of contraception, which will enable women to choose the option that is right for them.
- Dr Cook is a GP with a special interest in women's health in Liverpool and clinical lead for Liverpool Women's Health Hubs
- Handy AB, Greenfield SF, Yonkers KA, Payne LA. Psychiatric Symptoms Across the Menstrual Cycle in Adult Women: A Comprehensive Review. Harv Rev Psychiatry 2022; 30(2): 100-117.
- NICE. Heavy menstrual bleeding: assessment and management. NG88, May 2021.
- NICE. Endometriosis: diagnosis and management. NG73, September 2017.
- NICE Clinical Knowledge Summaries. Scenario: Management of premenstrual syndrome. May 2019.
- Office for Health Improvement & Disparities: Abortion statistics, England and Wales: 2021. May 2023.
- Herd P, Higgins J, Sicinski K, Merkurieva I. The Implications of Unintended Pregnancies for Mental Health in Later Life. Am J Public Health 2016 106(3): 421-9.
- Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of Hormonal Contraception With Depression. JAMA Psychiatry 2016; 73(11): 1154–62.
- Daniel K, Lucy L, Bousfield J, Taylor B. Early evaluation of Women’s Health Hubs. Interim summary report. University of Birmingham.