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In this episode, I speak to Dr. Amy Morgan. She is a GP based in Drogheda and has a special interest in women's health and sexual health.
We talk about the range of both temporary and permanent contraceptive options available, the factors to consider when choosing a form for yourself and how to approach these discussions with your doctor, so as to get the best outcome for your own situation.
These are recommended websites for more information -
Episode Transcript:
Mgt O Connor 0:13 Welcome to the Are Kids For Me podcast. This podcast is for you if you have ever asked, or are currently asking yourself this question, it's a big question which can be hard to answer for lots of reasons. And I am hoping to provide you with some information that can help. In each episode I will speak to people with personal and/or professional experience in this area. My own name is Margaret O'Connor. I'm a counselor and psychotherapist who offers specialist counseling on this topic. I conducted my master's research and how women in Ireland make the decision to become mothers or not. And I really love talking about this topic, I hope you find it useful. Today I am talking to Amy Morgan. She's a GP based in Drogheda, and she has a special interest in women's health and sexual health. Even though there's a lot more information available, making decisions about contraception, can feel confusing and overwhelming. Recent research conducted by the Dublin Well Women's Center in Ireland found that while pregnancy prevention was the most important factor for women, over half of those surveyed were using forms of contraception most linked with failure. They also found a lot of misinformation and misunderstanding around contraception and its use. We talk about the range of both temporary and permanent contraception options available, the factors to consider when making your own decision, and how to approach these discussions with your doctor in order to get the best outcome for your own situation. I'm also including links to recommended sites in the podcast information. So I suppose I really want to thank you, Amy, for taking time out of your very busy schedule for to join us today. It's brilliant to get a doctor's perspective on this issue. So thanks for joining me. Amy Morgan 2:02 No problem happy to be on. Mgt O Connor 2:03 Perfect, so as I was saying this, I suppose, the issue of contraception is obviously quite important for people who are maybe not sure if they want to have kids or have decided that it's it's definitely not something they want. And it comes up a lot in, you know, the different child free forums. And there's a lot of questions on it. So I just thought it would be interesting to, to maybe have an episode on it and see what what issues we can address. So we kind of said we'd start off maybe with the general contraception information. So I suppose sometimes it feels a bit overwhelming, with so many different types. And would you be able to kind of summarize that a bit for us, Amy? Amy Morgan 2:44 Yeah sure and it definitely can be overwhelming.. and then I suppose a lot of people might have just one particular experience of one form of contraception and that's all they've heard about and they're not too sure about anything else. And anything else they've heard about it has maybe been you know, they've maybe heard word of mouth or from a friend of a friend so that it's a lot of people come to me sometimes actually, it's funny how little they know, you would kind of think with you know, with media and increased resources that the information would be out there but I suppose a lot of people maybe don't know where to start. So like broadly speaking, I suppose we divide contraception into in terms of its different forms into hormonal and non hormonal. So hormones obviously you know, that means obviously the use of hormones to produce a contraceptive effect and prevent an unplanned pregnancy and then within that and then within that group obviously then we're talking about.. I suppose your standard more short term measures such as the contraceptive pills so that's the combined contraceptive pill, the two hormones together and and then something like the mini pill, which is progesterone only. So it's just one hormone and and then separate to that then is another group within hormonal contraceptive methods called, we kind of call them the larcs. So they're the LARCs, so they are the long acting reversible contraceptives and they are you know and so they would be a coil. So that coil can either contain hormones or not, it can take the form of a copper coil, or you would be talking about really something like the implant. So the subdermal implant or or the bar as it's commonly known amongst different people. So and they have to be inserted by obviously a trained professional. So a GP with usually a special interest in the area who has the accreditation to do it. And then you'll be talking then about other methods, more intermediate methods like something like the Depo injection or or the shot or you know, as people would would know it as, and that's an injection given usually in a GP practice by a nurse or GP, to a woman containing one form of hormone and that's given usually every every three, three months. So they are the broad overall types of contraceptives that are available to us on the market. And the ones that we would commonly prescribe and then fit in general practice, and then obviously, separately you have your non hormonal methods so and so condoms as being the most popular, so barrier protection, really we call it and then diaphragms and spermicides and all that sorts of stuff. But, generally speaking, the ones we have most experience with in terms of prescribing are obviously you know, the contraceptive pill, and then, you know, we're seeing an increasing amount of women who are seeking and having LARC devices fitted in the practice as well. So that's the general gist of it really yeah. Mgt O Connor 5:37 Okay. Do you think people are getting more informed if they're seeking out different types or have you any idea why that is? Amy Morgan 5:44 Yeah, I think so, I think women who come to me seeking a LARC, as opposed to me counselling them about it, and letting them come around to the decision themselves, they may have had one before obviously, so they may have gone to a standalone family planning clinic and had one done before. And, or they may have done their own research and just realize that the contraceptive pill in terms of its format, as something you take every day, or you take a small break from, it just isn't going to suit them or their lifestyle, and they want a more robust, more permanent option. So that's when they kind of come around to the coil. We're actually seeing a lot of women then as well, and explore the option of the non hormonal coils that would be standard, the copper coil. And because they are not keen on the idea of taking hormones every day, for whatever reason, it's usually not a medical reason they would be basing that on, it's maybe something that they have had a bad experience with another form of contraception, and they really want to go down the hormone free route. So and actually, it's a lot of younger women who are requesting that as an option as well. So when I say younger, I mean, like, you know, late teens or early 20s. So we are seeing an increased demand for that in in practice, anyway. Yeah. Mgt O Connor 7:05 Okay, and what are the kind of factors I suppose that you would take into account? Like how to decide maybe what would be the best option for somebody? Amy Morgan 7:14 Yeah, sure. So I think generally, when someone is starting off, and, you know, obviously, everyone's an individual, and we would say that to someone from the offset, you know, there's no one set choice for one particular person, and you know, how you react to this, or how you how this fits into your life may be completely different, you know, compared to another person. So, it really is definitely, you know, I really approach it from a shared decision making perspective. I know, that sounds quite cliche, but it's really important when you're embarking upon taking any form of contraception that, you know, someone knows what they're taking, why they're taking it, and, and how I suppose, because of how hormonal contraceptives work, particularly in the pill format, and they need to be reliably taken otherwise, you know, their, their efficacy is completely diminished, and, or substantially diminish should I say, so, you know, you'd need to have a good picture that someone can tell you something about them and their lifestyle, that this pill that I have to take every day, am I going to remember to take it, I'm quite busy, you know, I may miss days. And so with that only comes about really from having an honest discussion about where someone is, you know, at this particular stage in their life, so.. so and then obviously, if they feel that and, you know, they want to maybe do a trial of hormones first or something that they can I suppose, easily come off and come back to. I suppose, generally, we might start someone off in a trial of the contraceptive pill, to see how they get on. But that's not an absolute, like someone may have had no prior exposure and be very definite that they are not going to take a pill and they may not remember to take it and really unplanned pregnancy is the absolute primary thing they want to prevent, in which case there is no barrier to them if they have done their research and we've had a good discussion about it from them, you know, having it having a LARC prescribed and fitted by me, you know. Mgt O Connor 9:08 Okay, okay. Yeah. And it was it just shows how important that relationship with your doctor is. So, you know, having that conversation.. Amy Morgan 9:16 Yeah absolutely. It can't be something that's you know, I suppose, that is doctor centered, you know, like, it has to be if, you know, particularly, you know, the fitting of something like a subdermal implant, you know, it's a minor surgical procedure. And, you know, at this time in Ireland, a lot of women will have to pay, you know, a certain amount of money to have to buy the item and then obviously, to have it fitted because, unfortunately, we don't have universally free access to contraception. So, you know, there's a cost involved for the woman as well. So, you know, we need to make sure that this isn't something that she's going to get fitted and not like and be and be back to me, and you know, in three or four weeks, you know, asking, you know, for it to be removed. I mean, that's the outcome that we will certainly facilitate that, but it's something I suppose isn't really satisfactory for either her or me, you know. Mgt O Connor 10:12 Yeah I hadn't thought about that actually. So that's another factor as well. Yeah. Okay. Um, okay. And so, yeah, there is a range of options to be looked at. And then it was something you know, as I was saying, it's a very hot topic in a lot of the child free forums, kind of looking at more permanent options around contraception for people and there's loads of terms, I've written down a few of them. And so some options that are available, and I know these might be different terms used in different countries. So you've got tubal ligation, bilateral salpingectomy, hysterectomy, tubal occlusion, and vasectomy then for men, so, would you be able to explain a few of those in a way we can understand please (laughter)? Amy Morgan 11:00 Yeah sure, so the first thing you mentioned, is a tubal ligation. So and so that is a procedure, obviously, to effectively I suppose, and, you know, in common parlance, would have been referred to as having, you know, tubes tied doctor, you know, and, and essentially, it's, it's a pretty simplistic way of describing, you know, essentially what does involve, like ligating you know, the fallopian tubes. So obviously, that is considered a permanent option for, for a woman who has completed her family, let's just say. It's obviously done by a gynecologist, and it certainly is something that a gynecologist would want to see a woman, assess a woman, take her full kind of previous gynecological history, you know, it obviously is regarded as a, you know, a major surgical procedure so there's risks involved. So it's, you know, it's definitely something that I suppose a woman would come to, I suppose, a decision made with her family or her partner or just herself, obviously, and, and that, you know, with her gynecologist as well, so I suppose we don't see it a lot in general practice, I certainly don't see a lot of my patients going forward for it or having that procedure performed, but it is a service that is out there, and certainly a woman if she wishes to be assessed for that, should have that wish, requested, you know, so really, it is a conversation to that, obviously, one would need to have with their GP to access a referral to so yeah, and that's that. And then, obviously, you mentioned vasectomy. Now, I would include that as part of my standard family planning consultation, it's often missed out, it's often you know, something because it's seen as a man's issue, or it's a procedure that's done to the male, and that we don't include it in our standard consultation, or maybe someone is not coming to it with that in mind, and often they're not. And when I mention it, you know, women tend to be a bit surprised, but it's important that it's put out there, because it's an extremely effective form of, I suppose, what is regarded as, you know, a permanent measure for a man, and again, that's performed by a, you know, a doctor who has specific training in that area. So there'll be some GP's who do have that and level of training. And so, you know, certain GP's might inter refer from one to the other, or in a specialized clinic, or whatever. And it's regarded as a minor surgical procedure, as opposed to the tubal ligation. And so the downtime from it is pretty short. And obviously, in terms of there's usually a cost involved, it depends on someone's medical card status or their health insurance, etc. And, but it's an option that, you know, I would certainly include in my family planning consultations, because you know, it's often it's often left out,. Then the salpingectomy or the BSL, I suppose what it's called usually, we usually encounter that in patients who've had a, you know, had a.. obviously it refers to the removal of both ovaries or you know, in terms of so they.. by a gynecologist, there's a surgical procedure and it's usually done following a diagnosis possibly of either a cancer or a malignancy or either some type of scenario where they weren't happy about maybe certain appearances on ovaries and possibly a woman they feel has, you know, fertility is not a concern for her anymore, and it's so it can be regarded often as a preventative measure. And then also as well in terms of some cancer genetics and some people who are regarded as high risk so for breast and ovarian cancer, so that's obviously you know, a decision that's come to from, you know, involving multiple specialists. So that's where we usually would see our patients having had that procedure performed yeah. Mgt O Connor 15:02 Okay, okay. And, and I suppose and again, I'm not sure what the situation here in Ireland is but sometimes people can say that they find they do find it a struggle maybe to get referred for these more permanent options. And is that because of the kind of invasiveness of the surgery or have you any idea why that might be? Amy Morgan 15:29 And yeah, I am, I probably wonder whether maybe it's something that people find difficult to bring up in the first instance. So ehm to be fair, maybe it isn't on the radar of the doctor sitting across from them during a standard family planning consultation. So probably it probably does require an effort on on the individuals prior to maybe bring it up themselves in the first instance. So you know, ahm that can be difficult. And there may be factors involved, like, you know, if this is your family doctor, and you're not sure what the reception will be, so we have to take into account maybe there are some factors like that, and maybe just be cognizant of that. And there shouldn't be, like I said, a difficulty if, you know, you've tried other routes, and, you know, this is something that is regarded as, you know, something you want to explore, there's nothing wrong with that. And that's it, that's the wish of, that's your wish as a patient, so, you know, we should be able to refer, there shouldn't be any barrier to us as a as a general practitioner, referring someone onwards to a gynecologist to have that assessment. And, you know, I know, obviously, it's, like I said, it's usually something that we would, you know, we shouldn't be negatively counseling a woman against one form of contraception or the other, ultimately it is her decision, but it's important that she arrives at it, you know, with all the right information and guided by the appropriate medical specialists, you know. Mgt O Connor 16:59 Okay right. So, yeah, so I suppose people need to put some thought into their own situation, do do a bit of research, and then think about how to how to approach that, I suppose with with their GP. I suppose I'm aware, I think for, you know, from talking to some Irish people in particular, you might have your GP from when you were a child, so I do get that sometimes it could be a bit awkward, or can feel a bit awkward maybe later on. Have you any advice on how to raise this topic? Or have these discussions with with a GP? Amy Morgan 17:33 Yeah well..I think like I, you know, I understand that, and, you know, sometimes a, you know, it can be seen as a negative in that, how would I possibly bring this up? What are they going to think of me? Well, I suppose, you know, I'm speaking from my own perspective, and from just colleagues I know, you know, really, the guiding principles will be from a consultation is that, you know, most GP's that I would know of, and certainly from my own perspective, we're meant to approach these consultations in a non judgmental manner, everyone's choice is individual, and, you know, should be respected, like, respect is the fundamental of the, you know, the, you know, the relationship that we have between the doctor and the patient. And sometimes it can actually be really positive that, you know, that, that you know your patient so well, because you can really judge the, the, I suppose, the level of confidence they have about their own decision, you know, this is someone you hopefully have built up a relationship with, and maybe over months and years, so you can kind of get a good sense of who they are. And, you know, you know, say, well look, you know, that is a decision that I know that you have come to yourself, and I respect that and I honor that and look, you know, particularly as well, if your GP doesn't have, you know, all the knowledge in a particular area that a patient wants to explore, there's nothing wrong with, you know, saying well, I don't know a lot about that, and I'm going to find out, and I'm going to get back to you, you know, and I think that's really only comes from having that element of trust between between you and your patients. So I would say I would just encourage people, if it's on your mind, don't, don't be afraid to to bring it up. Even if it the reaction mightn't be one that you would typically expect. You know, a lot of people don't know how to react in these situations. So it can often take a little bit of time, but definitely, and you know, you should be looked after. Mgt O Connor 19:28 Okay..so this is even when we were talking before you you said you know, people are usually coming, it may be the opposite, you know, it's how to get pregnant so this isn't always the, it wouldn't always be on the mind of the GP maybe that's somebody thinking well, that's definitely something I don't ever want to do yeah. Amy Morgan 19:46 Absolutely yeah. You're usually having a conversation to be honest with you, yeah, either as a you know, a fertility consultation and they're becoming more more common and or, you know, I don't want to get pregnant for for now. And you know, so and so it does probably take.. and the more people who maybe who come to us and speak on this issue, the more experience we're going to have, if we feel that we have a deficiency over exploring this area, we can go and find out more information ourselves, you know, and definitely in general practice, we're always learning, there's always something to find more out about. So, you know, it can be it can be beneficial for both parties, I think, you know, to actually, to come forward with this, you know, and explore it more. Mgt O Connor 20:31 Yeah because you were saying in your own training, which was a few years ago, it wasn't really something that was named, around that there will be people who really just don't want to have children.. Amy Morgan 20:42 Yes, correct. Yeah. Or, you know, I suppose maybe that, particularly the more permanent measures were maybe regarded as someone framed in the context of I suppose someone's family is complete. Now, I suppose that's different things to different people. So a family, it could be family might be no children to one person, it might be five children to another, but it's wildly different. I think we have to be cognizant of I suppose how people live now. And, and, and, like I said, their own individual preferences. And we shouldn't be, you know, while I wouldn't say my teaching was patriarchal in any sense, but, you know, I think obviously, areas like gynecology, you know, have had a legacy of maybe those issues, or, you know, and it's still something maybe that we have to shake off, so, and so I think, you know, definitely education, we should be providing more education, certainly to our medical professionals about this area. Mgt O Connor 21:40 And I know, it's something that came up in another episode, I was interviewing some women who had different experiences around endometriosis. Amy is originally from America, and she said that we're all very compliant as Irish people so that we might need to advocate for ourselves a little bit more. And (laughter) seek other advice, if we're not necessarily happy. Amy Morgan 22:01 Absolutely yeah. Oh, yeah. Yeah, no, I definitely agree with that. And I think as well, endometriosis is one of those conditions as well, that a lot of Irish women, you know, will really struggle with, still struggle to get a diagnosis for it. It does bring up issues around fertility, you know, sometimes at an early age and people are having to make forward planning decisions or have that kind of.. they weren't it wasn't on their mind. And yeah, I think women's experience of getting their endometriosis managed in the Irish system can often be difficult. So definitely I find the perspectives of women who have endometriosis and and, you know, the Association, the Endometriosis Association of Ireland is really, really helpful in this. I think their perspectives are really actually quite enlightening and, you know, can be applied to a lot of other conditions of women's experience of the health system, you know. Mgt O Connor 22:56 And I suppose, just as a check in, obviously, with COVID and everything else at the moment, and I suppose I'm just wondering, would that be putting people off or maybe just to kind of..I presume people can still make appointments and still, you know, it is important to keep on top of these issues, just not to be maybe put off by that, is that right? Amy Morgan 23:15 Yeah, absolutely. I think when initially during the first phase that lockdown, we were, we were definitely postponing, you know, I suppose the face to face consultations and face to face, and, you know LARC fittings, and we were getting specific guidance, that was allowing us to bridge that gap for some women who may have been due, you know, fittings, or whatever. And we were extending their, their current form of contraception. But you know, that has, since that point, we are now seeing women again, and we have been for a couple of months now. And just done obviously, with standard precautions, and and, you know, hygiene protocols and patient safety protocols. So, yeah, if you do think that you want to discuss this, we are usually doing telephone based systems first, just to chat things over and then obviously making and arrangements for face to face consultations or fittings where appropriate. So if you are thinking about it, just don't put it off, general practice is open, you know, so we here are here to provide those services. It was initially kind of like I said, paused for a moment but normal services have resumed. Mgt O Connor 24:25 Okay okay..And one other question because I think I see that sometimes and I'm not sure if I understand it correctly... And, you know, you might be advised to review your your choice of contraception as you get older, and I'm not sure. Is that related to because you might be thinking about having children or is that just something because, as you said, some people might be on the one form since they started, like, is that okay, or is it something that people should should check in on and kind of review as they get older? Amy Morgan 24:53 Yeah so..age is just one factor for someone's eligibility for contraception. And like I said, there's multiple other factors and there may have been historically, you know, a, I suppose, an attitude previously that the older a woman got, you know, we may need to urgently switch her from one form of contraception to the other. I suppose that really stems that's really only relevant to hormonal contraception specifically and and the issue of estrogen and its its risks in terms of, you know, side effects and stuff as a woman gets older and you know, there's thinking that that could be compounded by a woman's advancing age, but like I said, you know, we work off and criteria from the UK from the FSRH, so the Faculty of Reproductive Health. And they give us specific guidelines, they're called the MEC guidelines, and they stipulate who is eligible for what. And it's really just to ensure safe prescribing and, and it takes into account stuff like blood pressure, you know, your ehm your BMI, smoking history, and other things like that, and then maybe other others associated conditions. So that's where contraception reviews come in. For us, it's not really just age at all, it's to ensure that you know, I suppose you don't exist out there without any review whatsoever whilst you're being prescribed something and often sometimes you might pick up a woman who by bringing her in for review, you might find out things like you know, her smear test or and what we call now the cervical screening, cancer screening test is out of date.. And so it is providing us opportunities to actually link in and and you know, do a general women's health checkup, essentially. Yeah. Mgt O Connor 26:36 Okay, okay. Yeah, no, that sounds good. Okay, well, look, thank you, I suppose that, hopefully, will clear things up a little bit for some people, but I suppose it's good to know that there are a range of options out there. And I suppose that people can educate themselves a little bit. But also, I suppose really just trying to have a really open kind of conversation with their, with their own GP and see what suits them best. I suppose that's really what..it's very hard, isn't it, I think, you know, you read about how maybe how other people are getting on, but it just seems to be such an individual thing. And you have to find what works for you and suits you. Amy Morgan 27:10 Completely yeah, I find it's often helpful if a woman has maybe gone on to one of the HSE websites or the the sexual well being site is actually very, very good. It's very user friendly. It gives real common simple use language. So I suppose, you know, looking and exploring that because it quite nicely breaks down all the different forms versus maybe coming in with, you know, a friend of a friend told me this. So you know, it's just an easier common ground to work off. So if someone was wanting on their own time to explore their options, I'd probably recommend they start with something like that. I'll put a link to that at the end. Thank you. And yeah, is there anything else you think we need to cover or is that enough? No, that's yeah. Oh, yeah, that's it. Mgt O Connor 27:59 Okay. Well, look, that's really helpful. Thank you for making it very accessible and understandable. And, yeah, some good advice there for people. So thanks a million. I really appreciate it. Amy Morgan 28:09 No problem. No problem, Margaret thanks. Mgt O Connor 28:19 Thanks very much to my guests for taking part and to you for listening. I would love to hear your feedback and any suggestions for other topics you would like to see covered in this series. I would also love to build a community of like minded people, so please follow the Are Kids For Me pages on Facebook on Instagram, if you want to find out more in this topic. I look forward to hearing from you and watch out for the next episode soon. Transcribed by https://otter.ai