Thinking outside the box: meeting the sexual health needs of women presenting for emergency contraception

INTRODUCTION

Unprotected sexual intercourse poses a risk of pregnancy and sexually transmitted infection (STI) including blood-borne viral infection (BBVI). Women in the UK are able to access emergency hormonal contraception (EHC) from a range of providers, including genitourinary (GU) medicine clinics and contraceptive services (CS).

The Faculty of Sexual and Reproductive Health-care guideline ¹ recommend that women presenting for EHC (1) have a sexual history taken to assess STI risk with screening considered for high-risk women; and (2) are offered the emergency intrauterine device and discuss future contraception. National guidelines for HIV testing ² recommend universal testing at sexual health clinics and in populations where diagnosed HIV prevalence exceeds two in 1000. The audit is conducted against these standards. ^1,2

The audit was prompted by the authors’ concern that less sexual health screening was carried out in women receiving EHC (either at presentation or by failure to return for deferred screening) than expected, and over adequacy of advice for long-term contraception.

METHODS

This was a retrospective review of case-notes of women requesting emergency contraception at Leicester Royal Infirmary GU medicine clinic and St Peter's contraceptive services clinic, University Hospitals of Leicester NHS Trust, over a 21-month period (April 2007–September 2008). Screening at CS included self-testing for chlamydia; screening at GU medicine was always quadruple swabs. Data were entered on an Excel spreadsheet and analysed using SPSS software (SPSS Inc, Chicago, IL, USA) and Fisher's exact tests from Graphpad Quick Calcs (www.graphpad.com/quickcalcs; GraphPad Software Inc, La Jolla, CA, USA).

RESULTS

During the period, 174 and 993 patients attended the GU medicine and CS clinics, respectively, for emergency contraception. Fifty case-notes at CS and 18 at GU medicine were not found. The results are summarized in Table 1.

The proportion of women offered an STI screen at CS was significantly higher (P < 0.0001) in those aged <25 years than in those >25 years (21% versus 8%). There was no difference by age in those offered screening at GU medicine. Outright refusal for screening on the day was documented in 15% of GU medicine attendees. A common reason in both settings for not advising screening (23%) was a ‘regular’ relationship. Attendance at GU medicine was recommended to 9% of CS patients. Two women at GU medicine were at risk of HIV exposure following sexual assault and required postexposure prophylaxis. ³ In addition to the recommended follow-up, 187 of 943 (20%) reattended CS (mainly for pregnancy testing or contraceptive advice) and 18 of 156 (11%) reattended GU medicine (mainly for STI testing) within three months.

DISCUSSION

Unsurprisingly, STI and BBVI assessment and screening were more comprehensive at GU medicine while contraceptive management was more complete at CS. Follow-up was seldom recommended or attended. The low rate of return could reflect the practice of informal referral by clinicians to other services (CS, GU medicine and general practice) but it was not within the scope of our audit to assess this. Deferring sexual health screening following an episode of high-risk exposure has been shown to be of little benefit. ⁴ Chlamydia prevalence overall is lower than the national screening programme, ⁵ which suggests that those most at risk are not being screened. Reluctance to screen for STI, on the part of clients or medical staff, may be due to time constraints or embarrassment. Self-testing for chlamydia via the national screening programme was offered at CS, and, since this audit, was made available at GU medicine. Wider availability of self-test dual nucleic acid amplification tests (NAATs) testing for gonorrhoea and chlamydia could increase uptake.

The study is limited by dependence on written records, which may underestimate the advice given to clients. There is also a lack of knowledge of services accessed by the client group from other providers, including general practice, chlamydia screening programme and joint CS/GU medicine attendance.

Local HIV prevalence (2.83/1000 in 2007) ⁶ necessitates a more pro-active approach to HIV testing at presentation. Women requesting EHC present to a variety of clinical settings, each with their own areas of expertise. In an age of integrated sexual and reproductive health, these women deserve a holistic approach to care, and a common protocol for management agreed between departments, implemented and re-audited.