Contraception during perimenopause: HRT, the pill and the Mirena coil

In this episode, Dr Louise is joined by Dr Clair Crockett, a GP and menopause specialist at Newson Health. Dr Clair has completed diplomas in Obstetrics and Gynaecology, and Sexual and Reproductive Health, and fits coils and implants.

Here, she discusses some of the challenges for perimenopausal and menopausal women when it comes to contraception, and the importance of individualisation. She gives an insight into the hormones used in the contraceptive pill and HRT and shares how the Mirena coil can be transformative for some women.

Finally, Dr Clair suggests three things to consider about contraception:

1. Spend some time gathering information, talking to other women about their experiences with contraception and considering what your priorities are. Your healthcare professional can also help you make your decision.
2. Remember that side effects of contraception are quite unusual but that if something doesn’t work for you, you can change your mind. It’s OK to take time to find the best contraception for you. 
3. Some forms of contraception may mask perimenopausal symptoms so if you’re not sure if this is happening to you, track your symptoms and how you are feeling so you can get guidance from your healthcare professional.

Click here to find out more about coil fitting services at Newson Health

Transcript

Dr Louise Newson: [00:00:11] Hello, I’m Dr louise Newson. I’m a GP and menopause specialist and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So on the podcast today, I’ve got somebody who’s been on the podcast before actually, and somebody who works incredibly closely with me, is very highly regarded as a clinician and menopause specialist and full of enthusiasm for the work that we’re doing. So Dr clair Crockett has worked with us for a little while, and like all of us actually, who work in the clinic, really keen for individualised choice and working closely with patients to understand their needs and what they want out of their consultation, but also treatment choices as well. So welcome again Clair for coming today. [00:01:34][83.8]

Dr Clair Crockett: [00:01:35] Thanks, Louise. Thanks for inviting me. Pleasure to be here. [00:01:38][2.5]

Dr Louise Newson: [00:01:38] So we thought today, actually we will talk about menopause and perimenopause, of course, because it’s you know, that’s all I think about. But actually, we wanted to talk about contraception. And that might feel a bit strange for some people because a lot of people think menopause is loss of fertility. And indeed, for many years it’s been defined as loss of periods. And some specialists will say it’s loss of fertility as well. Now, of course, our ovaries stop working or don’t work as well during the perimenopause and stop working in the menopause but our ovaries don’t just switch off overnight unless we have them removed in an operation. And so if our ovaries are still functioning, they’re still producing some hormones – not enough for our body’s requirements often – but if our ovaries are still working, there is a chance still of women becoming pregnant. So we see women, especially younger women, who are, have premature ovarian insufficiency (POI) under the age of 40. And we know these women can sometimes, depending on the cause of their early menopause, but they can sometimes still become pregnant, can’t they Clair? [00:02:42][64.0]

Dr Clair Crockett: [00:02:43] Yes, they can, absolutely. So it’s really important that even if we’re giving them HRT that we think about whether contraception is required as well and include that in their regime. [00:02:53][10.9]

Dr Louise Newson: [00:02:54] Yeah, and it’s important actually because for two reasons for some women absolutely don’t want to have a family or they don’t want to have another pregnancy or whatever, so contraception is really important for them. But there are other women who have really tried to conceive and for one reason or another haven’t. And I remember about four years ago we got a phone call from one of our patients who was in her 30s, and one of the admin person took the call and said, Oh, Louise this woman’s phoned up and she’s pregnant. I’m really worried. And I said oh but is she pleased, she said well, actually, she was delighted. And so for some women, actually, we know that taking the right dose and type of hormone replacement therapy, especially when it’s body identical, can improve fertility. And it’s probably because it almost relaxes the ovaries. So then they can do what they need to do and the lining of the womb can build up. And so the type of HRT is quite important if we want people to have contraception or not have contraception. And so this is where this individualisation is really important actually. We always ask, or I certainly always ask people how their thoughts are about their periods, because a lot of us really don’t want periods. But I have had some women, even in their fifties, mid-late fifties, who say, No, I want to carry on having my periods. And that’s fine because there are different ways that we can prescribe HRT aren’t there? [00:04:14][79.8]

Dr Clair Crockett: [00:04:15] Yeah, there are and everyone will exactly as you said, individualisation is so important and asking women what they want, what their priorities are. [00:04:22][7.8]

Dr Louise Newson: [00:04:23] Yes. Yeah, absolutely. So just to really sort of talk about the basics, really, there are different types of contraception and we’ve now got a lot more choice even than when I graduated many years ago. A lot of contraception is about stopping our ovaries working, actually, because if our ovaries don’t work, we’re not producing an egg. And as many of you know, it’s the egg that becomes fertilised and then it becomes implanted in the lining of the womb and then a pregnancy starts. And so a lot of contraceptive pills, we have the combined contraceptive and the progestogen-only contraceptive and they usually stop egg production, don’t they Clair. [00:05:01][38.1]

Dr Clair Crockett: [00:05:02] Yeah, they do, amongst other things as well. So they some will thicken the mucus in the cervix so that semen then can’t get through into the womb. Or they might stop the lining of the womb from thickening. But essentially yes, we’re stopping ovulation. [00:05:15][13.7]

Dr Louise Newson: [00:05:16] Yes. And there are different types. If we look at the combined oral contraceptive pill, combined means that it’s more than one hormone, it’s got oestrogen and progesterone in it, but they’re all synthetic. So they’re not the body identical hormones, the same as the HRT we prescribe are they. So can you just explain the differences with the combined oral contraceptive pill to HRT? [00:05:39][22.1]

Dr Clair Crockett: [00:05:40] Yeah. So as you’ve alluded to, the combined oral contraceptive pill’s got synthetic hormones in and the HRT, the gold standard that we would aim to use, is body identical, which means that it’s safer for one, but also almost gentler I think on our bodies and suits us much better because we’re replacing it in the form our body’s used to. So we don’t have any of those sort of toxic byproducts in the sense that we get with the combined oral contraceptive pill that can increase our risk of things like blood clots or breast cancer, for example. [00:06:13][33.1]

Dr Louise Newson: [00:06:14] Yeah, you’re absolutely right. So when we’ve got hormones, oestrogen, progesterone and testosterone actually that work all over our body, they’re biologically active hormones and obviously oestrogen and progesterone work very closely together to regulate our periods, to change the way everything works so we can produce this egg every month, and that’s why we have our periods. But we have cells that respond to these hormones. We have these things called receptors where the hormones go on. They fit into the receptor, if you like, which is like very simplistic, like a key and lock really isn’t it. Then, what they do is they activate a whole load of cascade of responses within the cells, and this is where the hormones, when they’re biologically active, are really important, actually, because they work with other parts of the cell, not just the sort of cell membrane where the receptor is. So once they have this chain and sequence of events, then even the mitochondria, which is a powerhouse of our cell that can be kickstarted into working in a different way, and also it can actually change the way our genes work as well so they can have longer term effects, the way our hormones work. Now the synthetic hormones in the contraceptive pills are similar, but not the same. It’s like having a key that’s almost right. You put it in the lock, but you can’t turn it the same way so it doesn’t unlock the door. So it doesn’t always unlock and have this sort of cascade of events in the same way. So they will have an effect on egg production, but they won’t have the same biological effects in the body. Now, so many of you that hopefully have listened to podcasts before, you know that I’m very interested in the biological effects of our hormones and the disease preventative effects. Now, with contraceptive pills, they don’t all have the same disease preventative effects, because they don’t have the same sort of cascade of events, really this sort of chain reaction that occurs in our cells because they’re synthetic, they don’t work the same way. And as you’ve said, they also can be associated with some risks. And you mentioned about risk of clot, didn’t you with some types of – do you want to just explain a bit more about that? [00:08:21][127.3]

Dr Clair Crockett: [00:08:22] Yeah. So the synthetic hormones in the combined contraceptive pill as they’re metabolised in the liver and as part of that, they affect then the clotting cascade and that’s then how they can increase our risk of blood clotting. So it would be really important that women that had had a clot before don’t use that form of contraception. But equally we do, it might be rare, but we do see that women will develop a clot and it will be caused by them being on the combined oral contraceptive pill, even if they’ve not known to have an increased risk of blood clot. [00:08:53][31.5]

Dr Louise Newson: [00:08:54] Yeah, and it is important. I mean, the risk is small, but actually we don’t want to have any risk if we can in medicine. And it’s the oestrogen can have that effect but also the synthetic progestogens as well can have this risk. And it’s very interesting. I was reading Unwell Women again, amazing book by Elinor Cleghorn, and she was talking about the history of contraceptive pills. And when they were first brought out, the doses were a lot higher than we prescribe now. And a lot of women were complaining of feeling sick, having headaches, feeling really quite unwell. And there was this increased risk of clot. And like in the history of medicine, people weren’t believed. They just said, Oh, this is ridiculous, this is all hysterical women. And it was only when they had more numbers and they were testing the pill in different populations because initially they started in a very small population of women and then they obviously the pill became more generic and easier to prescribe, but women were still complaining. So then finally people started listening and realised actually that we could prescribe a lower dose to still have a contraceptive effect. And lo and behold, side effects were reduced. And with any type of hormone, it’s the balance is really important. So it’s not just the dose of one hormone, it’s how they interact with other hormones as well in the body, isn’t it? [00:10:14][79.6]

Dr Clair Crockett: [00:10:14] Yeah. Yeah, it is. And we had some great teaching yesterday even, didn’t we, about the how it interacts with the thyroid. And so it’s really important that we think of all of those things. It’s not just… [00:10:26][11.9]

Dr Louise Newson: [00:10:27] In isolation. Yeah. Absolutely, and with progestogens, a synthetic progesterone, there are many, many different types actually and as part of my GP training, and I’m sure yours as well Clair, is that you learn about the different types of progestogen. And so some, they all have side effects actually because they’re not the natural hormones. Some people don’t have the side effects or if they are, they’re very small and they don’t affect them. But if people are going to have side effects, some of them will cause fluid retention, some of them will cause skin changes, so acne or skin to be slightly greasier. Some can actually cause mood changes and people can become lower in their mood, they can become feeling more flat and can affect sleep as well. But the different progestogens can all have slightly different side effects so often in general practice, and when we’re doing a lot of contraception, we spend a lot of time if someone did have a side effect, working out what that was and then changing the type of contraceptive pill and it could be quite common for people to try two or three contraceptive pills can’t it until they find one that’s right for them. [00:11:33][65.9]

Dr Clair Crockett: [00:11:34] Yeah, it can and it can be really helpful part of the perimenopause assessment as well to ask them, have you ever used a contraceptive pill? Because they might quite clearly say, Well, I tried the progesterone only pill and I felt dreadful. And that might make them nervous about trying HRT as well so it can be helpful then to reassure them that, no, we’re going to be using a body identical progesterone, a micronised progesterone, and that it’s unlikely you’ll have the same side effects with that. [00:12:00][26.1]

Dr Louise Newson: [00:12:00] Yeah, it’s really important because a lot of people say, I don’t want hormones, they don’t suit me at all. And the progestogen-only pill is what it says. It’s just pure progestogen as well. And it works in different ways, as you say, it can prevent or reduce the sperm actually penetrating through into the womb, but a lot of them will stop ovulation as well. But they are highish dose, not not high, but they often are higher than the dose that we would prescribe in HRT, because as I’ve already said, HRT isn’t a contraception, but also they are synthetic so a lot of people that don’t tolerate contraceptive hormones actually will still tolerate body identical hormones, won’t they? And it’s very important for people to know that there is this difference and it can be difficult, so when people are on the contraceptive pill, they won’t necessarily know when they’re menopausal either, will they? Because a lot of women now are taking contraception for longer so into their forties. And there’s now, quite rightly, this change in the way we prescribe it. So we used to do a three weeks and then have a week break and then three weeks and a week break but actually we know that it’s better for the lining of the womb actually to be thin the whole time, it’s better for the body to have hormones as level as possible, really. So a lot of people now change the way that they advise to take the contraceptive pill, the combined oral contraceptive. So you have it for the whole time. And then often people then after maybe three or four months will have a little breakthrough bleed and then they have a pause for 4 to 7 days and then carry on. And so if you’re not having periods and you’re not having a week where you’re not having hormones because that’s the giveaway, often if people are only having it for three out of four weeks, they’ll say, Oh, in that week I started to feel tired and had some sweats and I had joint pains or headaches or whatever. But if they’re not having that time, they’re having some hormones, often it’s very difficult to know if you’re perimenopausal, isn’t it? [00:13:55][114.6]

Dr Clair Crockett: [00:13:55] Yeah, it can be really hard, I think. And also there’s a sort of the misconception that I’m sure you’ve well, I know that you’ve talked about a lot on your podcast before is that if you’re still having regular periods that you can’t be perimenopausal or you’re too young to be perimenopausal, then just being on some form of contraception can often make that even harder to distinguish. [00:14:15][20.2]

Dr Louise Newson: [00:14:17] Yeah, absolutely. And it’s interesting, I’ve just come back from Australia and in Australia a lot of clinicians actually are recommending to go on the contraceptive pill for this perimenopause. And I don’t always think that’s the right thing. And the reason being is, well, there’s a few reasons really. I think firstly, a lot of women don’t need contraception, so why give them contraceptive that they don’t need? Secondly, that you’re giving them synthetic hormones that we’ve already said have small risks. They’re only small but our risk of clot increases as we age. Thirdly, part of when we see people who are perimenopausal is trying to set them up for life, really, and thinking ahead. And I always think it’s better in medicine to try something that you’re more likely to continue because of compliance and concordance everything will be better. So it’s always better to start something that you want to continue. So we usually start body identical hormones and then we can change the dose and type as well. And also something, we want to start something that has the lowest risk of problems, but also the lowest risk of side effects as well. And also about choice, if I said to you, if you were my patient, said, Oh, we can give you something that’s synthetic, that is similar to your hormones, but not quite the same, or we can give you a body identical hormone that’s the same as you’re producing already, you probably would say the latter, wouldn’t you? [00:15:39][82.1]

Dr Clair Crockett: [00:15:39] Yeah, for all those reasons that you’ve just mentioned. And I think it because the body identical preparations are so adaptable as well, it’s often it can work so well to just sort of, the dose might evolve and change as you come up to a time where you do reach your menopause and your periods would stop and we can just evolve that as we go along and that can work really well and really empower women, I think, to feel like they’re in control of what’s happening. [00:16:07][27.8]

Dr Louise Newson: [00:16:08] Yeah, for sure. And it’s interesting. So in the perimenopause, it can often be, I think quite a hard time to start HRT, in that getting the right dose can be difficult. So sometimes we start as a low dose because people are still producing their own hormones and that can be fine for some people. But then what happens is obviously their own hormones are declining, so they’re starting on a low dose. Six months later, it might, they often come back and say, Well it’s not working for me, and it was working initially, but that’s because their deficit has increased. So they actually need a higher dose. But there are also a lot of women who really have worse symptoms in the perimenopause and that’s because in the perimenopause our hormones fluctuate so much, and our bodies, especially our brains, do not like fluctuations of anything at all. And so that can be a harder time for people. And if we’re just topping up a little bit that they’re missing, they still get these fluctuations. So sometimes with patients, I actually give a higher dose to try and stop that hormonal fluctuation. And so it will suppress their own ovaries because the dose is higher and they feel so much smoother and then less sort of chaos in their brain. Do you find that as well? [00:17:20][71.9]

Dr Clair Crockett: [00:17:20] Yeah, definitely, I find that you almost need a higher dose to buffer out the fluctuation that they’re getting. And then often you find then that you can decrease it almost once they get to a point where those fluctuations aren’t happening anymore and they’ve got more of a plateau and more stability in their own hormone levels in the background. Definitely. [00:17:40][19.9]

Dr Louise Newson: [00:17:42] Which is interesting because there’s some people who think, well, we shouldn’t be giving higher doses and we’ve talked before about the absorption being really important because we can absorb in different ways, but actually this fluctuation as well that can occur often we do need higher doses, but it’s very hard to compare the dose of oestrogen in a patch or gel compared to the dose of oestrogen in a combination oral contraceptive because they’re different and they get metabolised differently as well, like we’ve already said. But the general feeling is when you try and work it out is that the dose of oestrogen is actually quite a lot higher in the combined oral contraceptive pill than we prescribe. Even if we prescribe off label slightly higher doses, it’s still lower than the contraceptive pill, isn’t it? [00:18:29][47.9]

Dr Clair Crockett: [00:18:30] Yeah, yeah, it is, because you need those higher doses to suppress the ovulation, as you said. Whereas with HRT we’re just wanting to replace the levels to help manage symptoms and protect health and things. And we’re giving it in a much safer way as well if we’re using the body. Identical preparations too. [00:18:47][17.2]

Dr Louise Newson: [00:18:48] Yeah. So it’s interesting actually and I spend quite a lot of time thinking about should we really be calling it HRT? I think we should be just calling it natural hormones because the HRT three letters, immediately people think about breast cancer. That’s all they’re thinking about. And we know we’ve spoken about it a lot before, that stems from this WHI study using older types of hormones, and actually this risk of breast cancer wasn’t statistically significant. And what’s really interesting, I think, is I was looking recently the Faculty of Sexual Reproductive Health in the UK have guidelines for contraception in women over the age of 40, as you know, and they’ve recently updated them. But when they look at the synthetic progestogens, which we’ve been talking about, have this small risk of clot and heart disease and have been sort of pointed towards breast cancer, although like I say, it wasn’t statistically significant. The guidelines for contraception are very clear that synthetic progestogen do not have a clot risk, do not have a heart disease risk, do not have a breast cancer risk. But if you look at some of the guidelines for HRT, they would still talk about risk of clot, risk of stroke, risk of heart attack, risk of breast cancer. So what is it about the hormones that are different when we use them for contraception compared to for HRT and there isn’t any difference is there? [00:20:05][77.8]

Dr Clair Crockett: [00:20:06] No, no, there isn’t. The patient perhaps is just different in that they might be at a different stage in their life. And and it’s probably due to other factors, not the hormone that we’re giving, which I think is is not spoken about is it, it’s all focused on the hormones rather than other lifestyle factors that we know impacts all of these risks. [00:20:25][18.6]

Dr Louise Newson: [00:20:25] Absolutely and I think if we look at clot risk, there’s a lot of women I’ve spoken before on podcasts about a lot of women who have had a history of clot or a family history of clot who are incorrectly told they can’t have HRT, and of course we can still prescribe body identical hormones with oestrogen through the skin. But then when they’re younger and they got an earlier menopause or they younger and want contraception, they’re often told, oh you can have the progestogen only pill or you can have the implant because there’s no risk of clot. Now as a purist, when you look at the science, I wouldn’t be happy for my patients having that because there is some pointing to say that there is a small increased risk of clot with synthetic progestogens. So it’s again, I’ve spoken before about not having this joined-up thinking in medicine. There’s too many silos, really. And I think sometimes we do have to challenge the guidelines or challenge where these statements have come from. Because then it can become very confusing for us as doctors, but also for the patients as well, can’t it? [00:21:26][60.4]

Dr Clair Crockett: [00:21:26] Yeah, I always think if it’s confusing for us as doctors, then as a patient it must just be, yes, so difficult. We want to be able to get the right information across to patients to help them make a decision about what they want and what’s best for them. [00:21:39][13.6]

Dr Louise Newson: [00:21:40] Absolutely. And I think more and more, actually, as a patient myself, I really want to have the hormones that are lowest risk to me, that when I take for many years, probably forever, then I know that my risks are low but my benefits are high. And as many of you might have heard before, I’m very worried about osteoporosis and I want to reduce my risk of osteoporosis. And I know that taking body identical hormones, the evidence has shown the risk of osteoporosis is lower than if I was taking synthetic hormones. There might be some protection, there might be some cardiovascular protection with synthetic oral contraceptives, a combination, but it’s more established evidence for body identical hormones. But if I needed contraception as well, and if I was a perimenopausal woman, we’ve already said a few times now that HRT isn’t a contraception. So one of the ways that we often advise women is to carry on with the body identical oestrogen and testosterone, if they need that as well, but not have the natural progesterone which isn’t licensed as a contraceptive. And to think about a Mirena coil. [00:22:44][64.0]

Dr Clair Crockett: [00:22:45] Yeah, it can be really effective. Well, it offers contraception, obviously, and then it’s licensed to also protect the womb lining to provide the endometrial protection that we need for when we’re taking HRT. So in ladies that need both contraception and are taking HRT, it can be really, really good and a lot of women as well then will get on so well with it that even once they don’t need contraception anymore, will prefer to continue to have a Mirena coil for that. [00:23:15][30.3]

Dr Louise Newson: [00:23:16] So can you just explain what a Mirena coil is. [00:23:18][2.1]

Dr Clair Crockett: [00:23:19] Yes. So it’s a small, we say coil, but it actually doesn’t resemble anything like a coil. So it’s quite… I think a coil sounds quite disconcerting as a patient, thinking oh someone’s going to put a coil inside my womb. But actually it’s just a very small, about the size of a matchstick, probably even less really, just with a wing on either side at the top and we insert it inside the womb. So the wings just help it sit inside so it doesn’t come out. And then that sort of matchstick size little plastic, it will release the progesterone over five years it’s licensed for contraception and for endometrial protection. [00:23:54][35.4]

Dr Louise Newson: [00:23:55] And it’s really incredible because it works really just locally. Some people have some leaching out of the progestogen for the first few months, but because its aim is to thin the lining of the womb and work where it’s needed, it means that people don’t have periods, which for a lot of women actually in the perimenopause, obviously menopause is defined as not having periods, so everyone thinks in the perimenopause, you’re not going to have many periods, they’ll peter away. But a lot of women, we don’t know the exact figures, but different surveys have even shown as many as 30% or 50% of women, have very heavy periods that are closer together. And they’re just coping with it because they think, well, that’s just what happens. But to have a Mirena, even if they don’t need contraception, but just for their heavy periods, can be transformational, can’t it. [00:24:42][47.7]

Dr Clair Crockett: [00:24:43] Yeah, it really can because it can have, we see ladies they don’t like to go out even when they’re having a period because it’s so heavy and they’re embarrassed by leaking and flooding, which is it’s really sad, I think, that women are having to experience that and not thinking about other things that they can do to help manage it. [00:25:04][20.9]

Dr Louise Newson: [00:25:05] Yeah, and there’s a lot of women who aren’t going to work for three or four days a month. And just say, well, that’s just the way it is. Well, that’s awful. And we see a lot of women in the clinic who obviously are perimenopausal and when I ask them specifically about their periods, they say, yes, they’re incredibly heavy and they’ve gone back and forth to various healthcare professionals, asking for help for their perimenopause and haven’t received the right help and advice, obviously that’s why they come to us. But then no one’s also looked at their heavy periods as well. So even if the specialist or doctor or nurse that they see doesn’t know anything about HRT, they’re still not looking at these really heavy periods. And obviously they can cause symptoms, but they can cause iron deficiency as well. And it’s really important actually, that we think about the Mirena not just as a contraceptive or not just as part of HRT, but also as a treatment for heavy periods, don’t you think? [00:25:58][53.6]

Dr Clair Crockett: [00:25:58] Yeah, absolutely. Because it can just be so debilitating, having that dreadful bleeding. And as you said about iron deficiency, then not only are you perhaps experiencing perimenopausal symptoms because of hormone deficiency, but then if you are becoming a little bit anaemic because you’re bleeding so heavily, that’s going to be exacerbating how you’re feeling more tired and things as well. It’s just frustrating, isn’t it, when there’s things we can do about it and women are struggling. [00:26:26][27.6]

Dr Louise Newson: [00:26:27] Yeah, absolutely. So a lot of people actually really struggle to get a Mirena coil because of the way the NHS services in the UK are, that you can have it for contraception, but you can’t have it as part of HRT. And as you say, some women start having it for contraception, but get on so well with it that every five years they want it replaced as their HRT continues. So we do see women in their sixties, even seventies, who want to have their Mirena coil replaced, and that’s absolutely fine. But it’s not always easy to get in the NHS, is it? [00:26:58][30.7]

Dr Clair Crockett: [00:26:58] No, no, it’s not. It can be, I don’t know if it’s localised to certain areas, I’m not sure of the details, but I think a lot of the patients that we see in the clinics are Mirena coil fittings are coming because the GPs, for example, aren’t funded to fit coils for HRT, only for contraception. And so then quite understandably, with this pressure that the NHS is under at the moment and GPs, it’s not something that they can offer. And so then women are left trying to find other ways to get the coil that they need. [00:27:28][30.0]

Dr Louise Newson: [00:27:30] And certainly people travel for many miles actually to come and have the Mirena coil fitted and we’re very fortunate because you fit them and we’ve got other clinicians who fit them as well. And I personally don’t fit them because I’ve not done the training and I now feel too old to do the training. But it’s really important that you see someone who’s really experienced. It’s a bit like any procedure. The more that you do it, the more confident you are, the easier it is to do. And I do hear some horror stories from some women about how difficult or uncomfortable or whatever it’s been. And so it’s really important, if any of you thinking of having a Mirena to find somebody who is very experienced and obviously using local anesthetic is good, but it’s not just about it not being painful, it’s being an easy experience as well and not a traumatising experience. And so spending time, I know you spend time and the other clinicians do, talking to the patients before, explaining everything, going through, making sure they’re very comfortable. And actually, I think, I presume you’ll say the same, but I know from speaking to some of my patients, who’ve had Mirena coils in our clinic, they actually sort of say, well, what was the fuss about? That was so incredibly easy and straightforward. [00:28:40][70.4]

Dr Clair Crockett: [00:28:41] Yeah often women will say that because it’s one of those things that you hear a lot about. Everyone’s got a story about, well, not everyone, but if you’ve had a coil, some people will have found it fine, there’ll always be people that haven’t had such a nice experience and then it can be really worrying, I think then if you’re asking, you’re saying, oh, I’m going for a coil, and then you’re hearing all of these dreadful things about what can happen. But I think we obviously have the luxury of additional time in the clinic, and I think that makes a really big difference because as you say, we can have a good chat before, answer any questions and then we can take our time during the procedure as well. And we have some excellent healthcare assistants that support us, which they’re invaluable because they’re really experienced as well at what we’re doing and so they can support the patient and talk them through what we’re doing and reassure them as well. So yeah, we create the best environment we can and I think that really helps. Really helps. [00:29:39][57.2]

Dr Louise Newson: [00:29:39] Absolutely. Yeah, absolutely. And just before we finish really talking about there are other types of coils as well. So there’s the Mirena, which is the traditional one that sort of started. And there is an alternative to Mirena that’s the same dose and type of progestogen and then there’s these smaller lower dose ones as well, which can be really useful for people that haven’t had children because certainly there are increase in number of young women who want to have contraception in this form. They don’t necessarily want to have systemic hormones and they usually last three years rather than five years, don’t they? [00:30:12][32.6]

Dr Clair Crockett: [00:30:12] Yeah, that’s right. So there’s the Mirena coil and then you mentioned there’s another one that is the same dose of progesterone, that’s the Levosert, which both of those are licensed to use for HRT. The Kyleena then is a lower dose of progesterone and then the Jaydess as well. So neither of those are licensed for HRT, but they’re licensed for contraception. So sometimes we could if we’re looking from a contraception perspective, we might use those and then still use some body identical HRT, the micronised progesterone capsules alongside it, so that then we’re giving enough progesterone to protect the womb lining, but also using a coil that might be more suitable to you from a contraception perspective. [00:30:56][43.7]

Dr Louise Newson: [00:30:58] So lots of choice and really important. Obviously, there’s lots of information about contraception on our websites and it’s really important. And also knowing that people can change their choices about contraception, circumstances might change or they might want to explore different options. And that’s really important as well. I’m very grateful for your time, Clair. I think we need to come back and talk a bit more. And I’m very keen if people leave comments or suggestions of other details about contraception that they want to hear, because we can certainly talk again. There’s lots to talk about. [00:31:29][31.6]

Dr Clair Crockett: [00:31:30] Yes, it’s a huge topic. [00:31:30][0.7]

Dr Louise Newson: [00:31:31] It is. But really, really important because we need to think about contraception, not just about stopping fertility, but about how we need to make sure that women using contraception have as few side effects as possible. And if they can, they can improve their future health with the type of contraception that they’re using, too. So before we finish, just for three take-home tips. So three things, if you don’t mind, that people should think about when they’re thinking about contraception, especially during the perimenopause or the three things that you’d say that people should consider doing. [00:32:04][33.2]

Dr Clair Crockett: [00:32:05] I think spending some time talking to other women can be really helpful to understand, particularly if you’re thinking about a Mirena coil. Just bear in mind that everyone experiences it very differently. But just spending some time gathering information and thinking about what your priorities are and to help you make a decision. And I think bearing in mind that everyone is very different, as I said, and that then taking that information to perhaps discuss with your healthcare professionals so you get a different viewpoint on things from a healthcare professional’s perspective to help you make that decision. I think another important thing as well is that just knowing the side effects and complications of the coil, perhaps any contraception, are quite unusual and quite rare, and particularly with the coil. Yes, you might make a decision to have a coil, but it doesn’t mean that you have to stick with that. So if it didn’t suit you for any reason or you wanted to change your mind, then the coil can be removed. Or if you were using a different form of contraception, we can change it. So it’s quite a fluid thing in a way, and it is fine to take our time to find out what’s best for you. And then three, I think just taking some time to… We talked initially at the beginning about how difficult it can be if you’re already on contraception and your hormones might be changing and you’re not sure about whether you’re in the perimenopause, should you be changing your contraception to incorporate the HRT like we talked about. So I think just thinking about using the balance app and tracking your symptoms and recording how you’re feeling can be just really helpful in understanding what’s happening so that then you can look at that and take that to your healthcare professional and say, Oh, I’m not sure. Am I getting some perimenopausal symptoms now? Is this contraception still the right thing for me and not being afraid to sort of have that discussion. [00:34:10][125.5]

Dr Louise Newson: [00:34:11] Absolutely. Really good advice as per usual. So thanks ever so much for your time today, Clair. I look forward to you coming about so we can talk some more. Thank you. [00:34:19][7.6]

Dr Clair Crockett: [00:34:19] Thank you very much, Louise. Thank you. [00:34:21][1.7]

Dr Louise Newson: [00:34:25] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk and you can download the free balance app on the App Store or Google Play. [00:34:25][0.0]

ENDS