Long-Acting Reversible Contraception Methods, Prenatal and First Trimester Screening and Early Medical Abortion in Rural Setting
Dmitri
Good evening everyone. Welcome. My name is Dmitri and I will be hosting tonight's webinar. Apologies that we are running a couple of minutes late this evening. We ran into some last minute technical issues, but we are all good to go. this instalment of the Rural Health webinar series will summarise key updates on long-acting reversible contraception methods, discuss options for prenatal and first trimester screening, and outline the role of early medical abortion in a rural setting. Our presenter this evening is Dr Izzy Gebler Hughes. Dr Gebler Hughes is a rural generalist working in Murray Bridge, South Australia. Dr Izzy works in both inpatient hospital and in general practice. She has a special interest in antenatal and postnatal care having completed an Advanced Obstetrics Diploma during her training. Dr Izzy enjoys the flexibility of rural generalism and is a partner of the clinic she works at.
I would like to begin tonight's webinar by acknowledging the traditional owners of the lands on which we are coming together from and the land on which this event is being broadcast. I would like to pay our respects to the elders, past and present, and would also like to acknowledge any Aboriginal or Torres Strait Islander people who have joined us this evening.
Before we begin, a few housekeeping things to cover. Participants are all set on mute to ensure that the webinar is not disrupted by any background noise, but of course, we do encourage you to use the chat function or Q&A function to ask questions. When using the Q&A function, we do ask that you address your questions and comments to all panellists and attendees rather than just the panellists, so that everyone can see your questions and comments. Finally, the webinar has been accredited for one hour educational activities CPD. To be eligible, you must be present for the duration of the webinar. We also kindly ask that you complete the short evaluation at the end of the webinar. This should only take a few minutes to complete and will help us improve the format and content of future webinars.
We have just got a couple of learning outcomes on this slide. The first one is to provide up-to-date recommendations for GPs in regards to reproductive carrier screening, first trimester screening, intrauterine devices, menopause and hormone replacement therapy and medical termination of pregnancy, but for now I will hand over to Dr Izzy.
Dr Izzy Gebler Hughes
Hi, everyone. As Dimitri said, I am Izzy. Sorry about the late start. That is my fault. I am not very technologically savvy with Zoom, so apologies in advance, if I am having a bit of trouble with this. I thought I would start just by introducing myself and where I work so that you have got a bit of perspective on where I am coming from. As Dimitri said, I am work in Murray Bridge in South Australia with a population of about 20,000. We are about 100 km from Adelaide. I work in a 40 bed hospital. We have got two delivery suites and we do about 200 births a year. I work between general practice at a clinic called Bridge Clinic and our local hospital. My clinic work includes, I do a lot of women's health. I do contraception, Pap smears, preconception care, postnatal care and then my inpatient work involves both emergency and obstetric care, including labour and delivery. Because my talk is broken up into little sections, I might ask for questions at the end of each section. As Dimitri said, at the end of the talk, we will cover medical termination of pregnancy. If that is not something that you want to hear about, you can just leave the talk then.
I am going to start in the preconception space looking at reproductive carrier screening. All the topics I have chosen tonight to talk about areas where there have been changes in the last few years, and I have tried to pick areas where all GPs, whether or not they are involved in much women's health, would have exposure. Reproductive carrier screening. This is a test that occurs prenatally before someone is pregnant, and it aims to identify couples who are at increased risk of having a child with a specific heritable disorder. We do not use this sort of screening for people with a known or suspected genetic disorder. They need to go to a specialist genetic service. One of the important things to think about in reproductive carrier screening is a positive result does not guarantee they will have an affected child. If everyone can remember back to medical school, the old Punnett square. Even if you and your partner are both carriers of a certain genetic disorder, there is still only a 25% chance of having an affected child. Probably, we are all carriers for a lot of stuff that we do not even realise. If you are in the situation where you end up with both people in the couple being carriers for the same gene that is when you consider referral on to further services.
They might look at IVF and those sort of things. As with most genetic screening, there is a lot of potential ethical issues here. RANZCOG says that in order to do this test, you need to have well-defined clinical pathways for pre and post test genetic counselling. It is a little bit more complicated than someone just wandering in and saying "Oh, I heard my neighbour did this test. I want to do it too." You get a lot of people that have heard about it, but then are not particularly educated on the implications. Before ordering these tests, you need to do some good counselling and ensure they understand the implications of any potential results. Some of the implications can even include things like life insurance or identifying stuff that might be a problem for them in the future. If you do decide to go ahead with this testing, there are two main options. There is one that has just become available through Medicare which tests for three common genes, and then there is the expanded reproductive carrier screening which is just done privately, and that tests at least 350 genes up to 1000 depending on which one you do. I will talk about those two options in a little bit more detail.
In 2023, Medicare introduced a funded reproductive carrier screening for three common genetic abnormalities. These abnormalities are cystic fibrosis, spinal muscular atrophy and fragile X syndrome. It is available to all Medicare eligible individuals who are pregnant or planning a pregnancy and their reproductive partners. Everyone is eligible for one test in a lifetime. If you are going to do this, you first order the test for the person who is pregnant or potentially pregnant. Then if they come up as positive, then you can go ahead and test their reproductive partner. If they are both positive, that is when they are going to need further referral onto a genetic service. Looking at the expanded carrier screening, as I said, they are privately funded. There are a few different labs doing it, Sonic Genetics, Repromed, VCGS and there are others as well. They are just some of the more common ones. They cost around $1,000 a couple. It is quite a big financial investment. They test anywhere from 350 up to 1,000 different genes.
Again, before you are going ahead with this testing, it is important to point out to the individuals that most people are going to be positive for at least one gene. Depending on what source you look at, it is quoted up to 1 in 30 to 1 in 45 Australian couples will be positive for being carriers of the same gene, so it is actually quite high. Again, this needs to be an area where the pre-test counselling and clear pathways of what you are going to do if it is positive. The labs that offer it actually have some quite good counselling resources available online. I would often give the patients some of the handouts and tell them to go away, have a think about it, have a read and come back with any questions before we proceed. Some of them even have consent forms that you can use. There are some quite good resources available through the companies that are offering it. That is the reproductive carrier screening. Does anyone have any questions on this topic before I go on to talking about first trimester screening? I do not actually know how to look if anyone does have any questions. If there are no questions, then I will move on to the next topic.
The next topic is about first trimester screening. If I had to pick one area as a GP OBS where I see things go astray the most often with pregnant patients, it is actually in the first trimester screening. It can be quite a complicated area for GPs that do not do a lot of antenatal care. It is also quite complicated for patients. It is not uncommon that things get missed here. That is why I thought it would be worth covering it tonight.
I will talk about the traditional combined first trimester screening, which has been around for a while, but as I said, I thought it was probably worth covering because it is a little bit complicated. I think for people that do not see a lot of pregnant patients, it can be an area that we struggle with. It is also relevant to note that there is some state to state variation in the protocols for the first trimester screening. It is important to know at your local area what you need to do. The combined first trimester screening, also known as the maternal serum screening, uses a combination of maternal factors. These include weight, age, ethnicity, smoking status, previous affected pregnancies. It also incorporates an ultrasound measurement of the nuchal thickness and two biochemical markers. It takes all of these factors and puts them into a computer algorithm which spits out a number. You get a result that looks something like what you can see on this side here. It is really important when you are doing this that on the form where it has got the weight, age, ethnicity boxes, it is really important that you fill them out accurately because even just the weight changing could be shifts from what we consider a low risk pregnancy to a high risk pregnancy. The thing to take away from this is it is just a computer algorithm. It is just putting in all these numbers and just spitting out your combined risk odds, which is sort of usually about half way down. Different states actually use a different number to say what is considered high risk. In South Australia, we consider high risk or increased risk 1 in 250, but in some states, they actually use 1 in 300. One of the really important things about ordering this test is making sure that it is done at the correct timeframes with the ultrasound and the blood tests.
As I have got listed here, the ultrasound has to be done between 11 weeks and 13 weeks and six days. If you do it at 14 weeks, they will not run it. The biochemical markers, you have a bigger window that is got to be between nine weeks and 13 weeks and six days. If you do miss this window, there is a second trimester screening which just uses the biochemical markers, but that gives a different set of results. Because of these timeframes, it can be more difficult for patients in rural areas to coordinate getting an ultrasound, getting the blood tests and how it is got to all be done. It is important when you have got that patient in front of you to talk about how are you going to get this ultrasound where we live? It is a long wait for ultrasound. Sometimes that involves me actually picking up the phone and telling the radiology we really need to do this because they are already 13 weeks and four days. It is great if you as the person ordering the test can help to coordinate that. Most of its cost is covered by Medicare. Some states have some private providers that do charge a small fee, in the realm of $30 to $40. There is also the cost of the ultrasound, which can vary from location to location, but some places can be quite expensive. One final thing about this test is that the biochemical markers in themselves also provide some really important information. The reason I have picked this is a real life example, this one here. There is an abnormality in this. At least in South Australia, when you get the results, it is not highlighted. The PAPP=A and the beta-hCG are reported in mums and I am not particularly mathematically and scientifically inclined, but from a basic perspective, the further away you are from one means the more abnormal it is. This level here of 0.28, although it is not highlighted by the lab as being abnormal, that is actually around the third centile and would be warranting further screening and ultrasound down the track. That is something that definitely gets missed quite frequently. Even though the Down syndrome and the trisomy 18 have come back at not at increased risk, it is worth still just having a glance at those numbers. If they are far away from 1, there are lots of resources where you can look up of from state to state what they consider needs further Investigation. That is the combined first trimester screening.
Moving on now into the non-invasive prenatal testing or the NIPT, which has become more and more popular over the last 5 to 10 years. NIPT or also known as the cfDNA or cell-free DNA screening is a blood test where they can extract foetal DNA from the maternal serum. Mum goes in for a blood test anywhere from 10 weeks' gestation, and they use that blood, extract foetal DNA from it and from that can test for aneuploidy in chromosomes 13, 18 and 21. At the same time, you can also test for sex chromosome abnormalities like Klinefelter's or Turner's, and because you are looking at the sex chromosomes, you can also determine the sex of the baby. This testing is much more sensitive and specific than the combined first trimester screening, but it is important to note it is still a screening test, so it is not a diagnostic test like amniocentesis or chorionic villus sampling. There are significant out-of-pocket costs. It is around $450 to $500 depending again on which brand you use. There are different brands of the non-invasive prenatal testing. There is the Harmony test, the Nest test, the Generation test are just some of the more common ones. Down the track, this may become a funded test and in New Zealand, recently, it is now funded by the government if you come up with an increased risk on the combined first trimester screening, but now just the individuals have to pay for it. With that depending on which brand you use, some of them will also report the PAPP-A levels and another biochemical marker called placental growth factor which, if you have got the option of doing, then they are definitely worth doing because abnormal levels of those can be associated with increased risk of preeclampsia, stillbirth, IUGR and can have further implications. Some of them just offer them as free add-ons to the tests. Definitely, if you have got that option, it is good to do. A few further points on the NIPT. One potential benefit in a remote area is that there is more flexibility with timing. It can just be done any time from 10 weeks and it also does not require ultrasound. That said, although the NIPT does not require ultrasound, we would still recommend people to have an ultrasound, if they can, because there can be morphological abnormalities outside of the chromosomal issues. Definitely while that is a benefit and you have got a bit more flexibility with the ultrasound, it is definitely worth still doing the ultrasound before the 20 week scan. Logistically, a lot of places require you to book this test in and pay online beforehand and not all labs are available.
Another really important thing to counsel people about before ordering the test is that there is a risk of getting no result, and that risk sort ranges from anywhere to 1-6% depending on where you ask? If you get a no result, the lab usually will do a redraw at no cost to the individual. They go back, have another set of blood taken. If you still get no result, and about half the people still end up with no result after that, the RANZCOG recommendations are now that there should be further evaluation with an earlier morphological scan, as they are having no result. There is some increased risk of aneuploidy and issues down the track. It is important to discuss that with people beforehand. There are now also expanded NIPTs being offered that can look at aneuploidies in other chromosomes. That is beyond the 21, 13 and 18 that we traditionally look at. They are more expensive. They have a lot more implications that they can even identify some maternal conditions. RANZCOG actually says that expanded NIPT for rare autosomal trisomies and copy number variants is not sufficiently accurate to be routinely offered to all women. RANZCOG has got a really good freely available resource about all the ins and outs of the screening and diagnosis of the foetal structural abnormalities and chromosome conditions. You can just pop that into Google. It is a really good document that talks about the pros and cons of all the different options. In the early antenatal space, this is another area where I think input from a GP who will often be the first person seeing the pregnant woman can actually have a very significant input. The two things for this is the aspirin and calcium for the use of hypertension prevention. Low dose aspirin is indicated for women with at least moderate to high risk of preeclampsia.
The low dose aspirin, it varies from study to study, but it is recommended between 50 to 150 mg a day. We want to start that definitely by 16 weeks, ideally by 12 weeks, so that is when the first and second waves of placentation occur. Now the recommendation is that we should be starting it as soon as there is a heartbeat. By starting it early and before the placentation occurs, so you make a healthier placenta. It has been shown that this statistically reduces your risk of stillbirth, of IUGR and pre-eclampsia, which are all very beneficial if you can reduce that and often the GP will be the one seeing the people at this gestation. It can make a big difference starting that. There are no safety concerns associated with the aspirin. You have got the same risk of the antenatal bleeding, PPH, abruption risk compared to placebo. Calcium has also been shown to significantly reduce the risk of pre-eclampsia, particularly in high risk women and those with low dietary calcium. Similar to aspirin, that has been shown to reduce pre-eclampsia and reduce pre-term birth. The recommended dose is 1.5 g a day. When you are thinking about aspirin and calcium, you need to be assessing who is the increased risk patients. Some of the big ones to think about is people that have had pre-eclampsia before, patients that have underlying hypertension, underlying diabetes, chronic kidney disease, multifoetal gestation. More and more indications are now being added to the list of recommendations, and there are some variations from state to state, but other factors, some guidelines would say indicate aspirin and calcium, are surrogate pregnancies, women with increased BMI or very low PAP-A levels from the biochemical markers that we spoke about earlier. I will just pause there again for questions.
Dmitri
Doing well Izzy? If anyone has got any questions, just feel free to pop them in the chat box there.
Dr Izzy Gebler Hughes
Omega-3 testing. In South Australia, they are doing a big study on Omega-3 levels. On the first trimester screening form, there is a box that you can tick to get Omega-3 levels tested as well. There is good evidence now that low Omega-3 is actually associated with increased risk of preterm birth and that if we can identify it in the first trimester and then put people on supplementation that they can reduce their risk of preterm birth. To my understanding, that is just something offered in South Australia at this stage, and it is being funded as part of a study.
The next question was where do you do it, and time overlap with usual bloods. I assume they are talking about the NIPT here. I would often say to people to do the NIPT as soon as within that 10 weeks. It takes a week to get the results back. If they were thinking that they would not continue with it, if they had a pregnancy with an abnormal result, it is easier to know sooner, and then if we need to refer for amniocentesis or anything, the sooner the better. Next question was about low PAPP-A being a marker for preeclampsia. Yes. That is correct. Associated with preeclampsia, IUGR, stillbirth. NIPT can be done, to my knowledge, to any gestation. There is no cutoff, but you do not really see it being done outside of the second trimester. No. The PAPP-A does not have to be done 35 days before the nuchal. It can be done on the same day or you could do your PAPP-A blood test at 9 and 0 and you could do the nuchal at 13 and 6. Calcium supplement, again, start as soon as you have got a heartbeat. Got a couple more questions. Can you guys see the questions? I have just been told I should be reading out the question. The next question is "Should we be asking all newly pregnant patients about dietary calcium intake?" Yes, I think that is a great idea, but it can be hard for a range of reasons logistically actually to get the patients to have 1.5 g of calcium a day, and for a lot of people, just taking the supplement is going to be easier and more reliable. It is just over-the-counter plain old calcium like you would give someone with osteoporosis. The next question was "If you had someone with increased risk of preeclampsia, would you start aspirin or is there still a role for testing the placental growth factor?" I would say yes. You would start them on aspirin. It is still good to know. I still do the test for the placental growth factor and the PAPP-A because if they are abnormal, then it varies from state to state, but you will do things like uterine artery Dopplers, growth scans.
I will move on to talking about intrauterine devices now. Intrauterine devices are becoming more and more common. This is a really good graph. It is a little bit old now, but the trends in the long-acting reversible contraceptives in the last 10 years, and it has gone up from IUD use from 6% all the way to 12%, so doubling. More and more women are coming into general practice wanting to look at getting a long-acting reversible contraceptive. This is also reflected with the MBS billing that it is being done more in general practice. In the last few months, the TGA has changed the indication for contraception for the Mirena. It has been extended from five years to eight years. This is on the back of multiple studies. The ACCESS IUS study and the Mirena extension trial where they have tested thousands of women and found that the efficacy remains greater than 99% from years five to eight. There is no evidence of worsening safety or adverse reactions. The amenorrhoea rates in years seven and eight remain stable compared to previous years. The rate for removal for concerning bleeding is also stable. No downsides, but the benefit of just not having to change it as often. I anticipate over the next few years, we will be getting a lot of women that are coming back for their five years, and then having to have the conversation. Well, actually it is good for another three years. There is some a population of women who think that they get more side effects as time goes on and they request to have it changed early, which is fine, but they have just got to know there are those slight risks with the insertion procedure, but most women will be very happy that they can leave it for eight years. This is something we have already been doing in the perimenopausal population, so just expanding it now to everyone. It is worth noting, though that according to the TGA, if you are using it as uterine protection in combination with oestrogen for HRT, it is still only a five-year indication.
The other big new thing in the long acting reversible contraception space is the Kyleena, and I suspect most of you have had drug reps coming and talking about this. Kyleena is a new type of IUD. It is the exact same hormone as the Marina, but it is at a lower dose. It has been on the PBS for a few years now, but it is not approved on the PBS for heavy menstrual bleeding or endometrial protection, so it is just for contraception. It is being sold as that it is easier, less painful to insert. The insertion tube for the Marina is 4.4 mm. The insertion tube for the Kyleena is 3.8 mm. I am personally not completely convinced that you can feel that much of a difference in 0.5 mm, but there are certainly some studies to suggest that it is more comfortable to have it put in, but personally I have not really seen that reflected in practice, but there could be an element there if we tell someone, oh, this is going to be less painful than they experience less pain. I guess for women that are wanting that the lowest possible hormone dose, the Kyleena could be a good option and particularly if they are worried about side effects related to the progesterone. The biggest downside that I find with the with the Marina is the irregular bleeding and that with certainly all the studies suggest that the Kyleena are actually has higher rates of irregular bleeding. It is reflected here the amenorrhea rates with the Kyleena. At five years, who is not getting a period at all 20% to 30% to 40%, so it is significantly more bleeding, and depending on what study you look at, the Kyleena is slightly less effective for pregnancy. Some studies say there is a 2% difference and some are quoting a much lower 0.2% difference. The Kyleena, because it is slightly smaller, also has a slightly higher expulsion risk, but it exists and it is worth knowing about it and being able to talk to the patients about potential pros and cons. Overseas, there are a lot of other different brands of hormonal IUDs, and I suspect that over the next few years, we might see more in our market as well.
I am just reading through the questions now. About the marinas. Can Marina cause weight gain? And if yes, what should be done in women with this BMI or metabolic syndrome?
I think a lot of the talk about marinas causing weight gain is more anecdotal. We use a lot of marinas in the perimenopausal population, and a lot of the another thing that we see a lot of in this population of people that do not have marinas in is they also struggle with the weight gain associated with going through menopause. I think there are not really a lot of evidence that marinas do cause significant weight gain in looking at the women that do have a higher BMI or a metabolic syndrome. The Marina is certainly a safer form of contraception because it does not have any oestrogen in it, and so it does not have that increased stroke blood clot risk. We actually would recommend that over something like the pill for women with metabolic syndrome or increased BMI.
The next question was how long can the Marina be left if it is inserted for heavy periods? And that is eight years as well. So it is just when you are just when you are using it for HRT purposes that you do not that they are saying it is still five years. I suspect that is more that we do not have the evidence to say it is safe rather than there being an actual issue. Did anyone have any other questions about before we move on.
We just touched on menopause briefly and I will talk about this a little bit more because I think this is another space where sometimes GPs that do not do a lot of women's health are a little bit more nervous about. The most I guess before we talk about HRT specifically, it is important to note that there are lots of different menopause treatments and a lot of them are not related to hormone replacement therapy, but I will not be talking about those today. Today I am just going to focus on hormone replacement therapy. It is also worth saying that, you know, when you do have the women coming in to discuss HRT, it is a really good opportunity to look at their other screening things, cardiovascular osteoporosis, bowel cancer screening and mammograms. The general principle is the HRT, the most up to date guidelines from RANZCOG recommends that HRT should be given to women for troublesome vasomotor symptoms impacting on quality of life. I think it is important to ask the woman, well, how much trouble are the symptoms that you are, is it just that you are aware of it and you need reassurance that it is normal or is this impacting on your sleep and your day to day activities? When thinking about HRT, I think it can get a little bit overwhelming, but the first step you have got to think about is it going to be combined, oestrogen and progesterone or oestrogen only. The simple way for this is if you require progesterone, if you have got a uterus. The woman has had a hysterectomy. You can do oestrogen only, everyone else requires some form of progesterone as the unopposed oestrogen has an unacceptable risk of endometrial cancer. Then you have got to think about whether what route is it going to be. The traditional tablets, there is topical.
As we touched on earlier, the Marina can be used for the progesterone for HRT. It can be intra uterine, and then you have also got to think about whether it is going to be cyclical or continuous. I will come back to this in another slide, but I guess just talking about the general principles you know, RANZCOG recommends that we start low and then titrate up, so using the lowest possible hormone dose to start with. Generally, the recommendation is that we do not start people on HRT over 60 years or around the ten years post menopause as when you get to this stage, the risks are starting to outweigh the benefits. Again, it is on a case by case basis, so that is just a general rule of thumb, and that we do not just put people on it when they are 50 and still have them on it when they are 80 without reassessing. RANZCOG is recommending by around the 5 to 7-year mark, we really should be talking with them about their individual risk versus benefits. There certainly is some people that try to stop it and have just intolerable symptoms and say, well, I would rather die of breast cancer than come off my HRT, and I guess that is just an individual discussion that you need to have.
Risks and benefits of HRT, and again this is an area where there is a lot of different studies that all say different things. I have tried to just summarise the main points that the studies agree on, establish risk, we know that oral oestrogen, whether it is in the combined form or on its own, roughly doubles your VTE risk, but that is not the case for the transdermal preparation, so that is the patches and the gels. Personally, I would try to get everyone to start on a transdermal preparation just to mitigate that. Then there is an increased risk of breast cancer. The longer you are on HRT, the more the risk increases. If you are only on it for that 5 to 7-year window, we think that the risk probably returns to baseline. We know that having the combined, so the progesterone and oestrogen is at greater risk than just oestrogen alone, and we think there's probably less risk when using one of the micro-ionised forms. One other established risk that we have got like lots of evidence for is that liver disease again, may be worsened with oral therapy, so really looking at the transdermal preparations is going to be the way to go. Possible risks with it might slightly increase your risk of cholecystitis and ovarian cancer, and then we have got some definite benefits of obviously the main reason we are prescribing it symptom relief. There is also some evidence that it reduces your cardiovascular risk and can improve bone density, but the recommendations are that it is not enough of a benefit to prescribe it purely for these things. There is a lot of different resources about how do you pick what you are going to do, which I am not going to go into huge detail with them, but for health professionals, this here is taken from the Practitioner's toolkit for the management of menopause, which is a really good resource that is from Monash University, and there is also managing menopause symptoms and the RANZCOG published and the Australian Menopause Society has really good information for health professionals, but almost as important as that is, I think there is a lot of misinformation about menopause online, and so I think being able to point patients in the direction of some good information is really, really important. For those who are not aware of it, the Jean Hailes website has some great patient resources about all the different options of treatment for menopause, as does the Australian Menopause Society. My own practice before prescribing any form of HRT is to talk through their individual risks, so personal history of stroke, family history, breast cancer risk and then make sure we have done baseline bloods to make sure they do not have some liver disease.
We do not know about it. Check their blood pressure, and I also make sure that everyone has a mammogram prior to starting just to make sure they do not have or that they have had one in the recent past to ensure they are not having a breast cancer that we are unaware of that we could be potentially making worse by prescribing hormones, and I have had a couple of women that have then come up positive and we have been very grateful that we did not start on HRT. Just one other really good resource when you are thinking about what to prescribe is I have this printed out in my office and look at it at least once a week. It is produced by the Australian Menopause Society and it has got the cyclical hormone therapy. It is got the continuous. Then it goes through all the doses, the products that are available. It is got little stars for things that are on the PBS or not on the PBS which can have significant price implications, and then it is got all your options just for the oestrogen and just for progesterone. Anyone that has not seen that resource, it is really good because it is hard keeping track of all the different brand names as well. One final thing on HRT is just to note there is the product tibolone which is a synthetic steroid. It is got estrogenic and weak androgenic effects. It is just one tablet a day. It is effective, as is the traditional HRT for vasomotor and urogenital symptoms, but it also can have with the androgenic effect, it can assist with sexual function which some women do struggle with. The main side effect is again irregular bleeding, and so you need to make sure that women are 12 months post menopause before starting on that. Similar to the traditional HRT, we think it probably does overall increase your breast cancer risk, and increased stroke risk if you are taking it well into your 60s.
Just pausing again for any questions. Going back to someone has got another IED question. That is fine. With the Marina, if inserted after 45, can it be left till 55 then removed without needing to check FSH levels i.e. no longer need for contraception after the age of 55? Yes. You could. I always check the FSH levels just because you might have the odd person who has not gone through menopause at 55 and then gets really troublesome bleeding and is then very cross that they have got heavy periods again, by 55, that is probably unlikely, but I always just check them just to be sure. How to manage bleeding after starting hormone replacement therapies is The next question and that is usually going to require a dose adjustment. I guess first you want to make sure that the bleeding is related to the HRT and not that they have got an underlying uterine or cervical cancer that you are missing. Unless it is within the week or two after starting, I would usually be saying, well, you need to make sure their pap smear is up to date, do the pelvic ultrasound. Then if it really does look like the bleeding is related to the HRT then you usually looking at going up in dose. Can we start HRT in the perimenopausal age? Yes, you can. If they are still in that perimenopausal or going six months between periods, you need to use a cyclical form. That gives you the withdrawal bleed because otherwise they will continue to, they will have all irregular bleeding. If the patient reaches 60 years and still needs hormone replacement, will you continue? I would give them the strong talk about the increased risks, but if they say, I have tried coming off of it, my life is miserable, I just cannot handle it, I do not sleep then yeah, there are people I have continued it for and they had tried to come off of it a few times, got intolerable symptoms, and so for them their increased risk was worth it. Next question is about LARCs again. So any update or comments on non-hormonal long acting reversible contraceptives such as the copper T? No, there are no changes in that space because you could they are all off patent and there is not really a lot of research being done about them. I put in a few copper T every year. They are more expensive, so they are usually a couple hundred dollars and some pharmacies do not stock them, so you often have to order them in, but they are effective, and some women are really keen to avoid any form of hormone, and it is just about counselling them beforehand that a lot of women will have heavier periods or more painful periods with the with the copper IUDs, but they work. They are effective for stopping pregnancy.
The next question was person with the menopausal symptoms. Will you go for hormone first or non-hormone, what is my preference? I talk through all the options with the individual, and so I will say you know your options are do nothing. Your symptoms are normal. That is fine if they are happy to do nothing. Some people find great benefit in some of the more natural herbal supplements and there is some evidence for some of them. Again, the Jean Hailes website has some really good information on that. I would say that that is an option. Then there is the non-hormonal such I tend to use the SNRI first and some people will find that very effective for the vasomotor symptoms, and some people say, look, I really just I am happy just to go straight to HRT and that is fine too. It is I do a shared decision making with the patient. I guess one other question that people have asked and I am just conscious that we are getting towards the end of our time, but is how long to continue with the cyclical HRT, and that is for a year, and after you have done a year of that, then you can go on to continuous.
I am going to go on to the just some updates on the medical termination of pregnancy now. For anyone that does not want to hear about that you feel free to switch off now. Termination of pregnancy again varies from from state to state. These are the most, currently it is legal in every state, but when it is legal until vary, so the gestation varies, but certainly it is very common. 20% of Australian women will have a termination in their lifetime, and we know it is higher for women living in rural areas. I guess another factor to note all states have within the law something stating that people who are conscientious objectors have a legal requirement to refer to someone who can help the individual in a timely manner. That is a legal requirement in every state and territory at the moment. Medical termination of pregnancy, for those who are not familiar with the protocol, it is two tablets, mifepristone and Misoprostol, that are taken 36 to 48 hours apart. In Australia, there is only one brand available, which is MS-2 Step and MS-2 Step is indicated for termination of intrauterine pregnancy up to 63 days, which is nine weeks. Previously, there were quite specific training requirements that you had to be an authorised prescriber and do a specific course to be able to prescribe MS-2 Step and pharmacies also needed to do specific training to dispense it. However, in the TGI made changes in mid 2023 to the prescribing regulations and now any GP can prescribe it and any pharmacist can dispense it. It is actually now does not even have to be a doctor, but it can be prescribed by a health professional or with appropriate qualifications. There is some scope for like nurse practitioners to be prescribing which is much more in line with what they do in other countries. In some places, it is like 95% of abortions before nine weeks are done by medical termination, and they have nurse and midwife led clinics. Other than the requirements lessening the big game changer in the medical termination space has been the increase in telehealth, and we are seeing more and more medical terminations being provided remotely. The MBS item numbers, the 92718 and the 92721 for services related to blood-borne viruses, viruses, sexual and reproductive health by general practitioner. They do not have to have the established clinical relationship. You do not have to be near that doctor. You do not have to know them, and you can still get the Medicare benefit for it. There are also several larger private organisations providing Tele MTOPS or abortion online services. These include the MSI clinic 66 abortion online.
There are obviously some potential benefits there for rural patients as they can have improved access, and it is traditionally rural patients that have reduced access and tend to have terminations later at later gestations. However, from my perspective there are some possible downsides as well. Safety concerns that they say the general guideline is that you should be within two hours drive of emergency services if you are having one of these tele MTOPS, but I think there are a lot of you do not really know where the patient is if you are just talking to them over the phone. There is also then no continuity or follow up with their own GP, and the GP might be in a better position to sort out things like contraception moving forwards, provide mental health support or even doing things like screening for domestic violence and coercive control, which is certainly something that I is not infrequently discussed in when I do these terminations. It is also worth noting a lot of these services do charge significant out of pocket costs. It is around $300 for Medicare patients, and they may also then need to pay a gap for the ultrasound as well. I think there is a lot more scope for GPs to be providing medical terminations of pregnancy, and we have had a service in our clinic for eight years now that we have been doing this. It is a little bit of work establishing the service, but I think once it is established certainly our patients locally are very grateful. If you are looking at establishing it, it is worth thinking about what are your inclusion exclusion criteria? Like for us, we are a hospital that will be providing the emergency service. We have a cut off BMI of 40. We do not provide the medical terminations for people with a BMI above 40 because we could not safely take them to theatre if they did haemorrhage. It is also important to have a system to see people in a timely manner, so they are not waiting six weeks for the appointment to consider how are you going to get access to ultrasound and pathology. I just do a bedside ultrasound, which is great because then it can all be done in one appointment. Thinking about access to medications, some pharmacies still do not stock MS-2 Step. Thinking about what is your emergency services access. Instead of I guess if you were looking at establishing it in a rural area, it is probably worth giving the whoever is working in the emergency services a heads up that that is something you are doing, and thinking about what is your follow up strategy? How are you going to capture these patients down the track to make sure they do their follow up bloods? And then another question of what to bill because there is no item number for it. Lots of places do charge a bit more than a standard consult. It is all stuff to think about. Did anyone have any questions about the medical terminations or otherwise I think we are approaching time. If anyone did want to talk, anyone wanted some advice on setting up, an MTOP service in their clinic, I would certainly be happy to talk down the track as well.
Dmitri
Great. Thank you so much, Izzy, and well done for catching up on the lost time there. We did really well. Just a few things before I let everyone log off to enjoy the rest of their evening. A reminder to please complete the evaluation that will pop up in a moment when the webinar session closes. It really only takes a couple of minutes to complete or no more than a minute, actually. Certificates of attendance will become available on your CPD statements within the next few days. For any non-RACGP members who have joined us this evening, if you would like a certificate, please email rural@racgp.org.au. I would also like to invite you all to attend next month's free webinar, a slightly different topic on medical emergencies, upskilling your practice team. It is co-presented by Dr John Eadie, and the webinar will explore ways to upskill your practice team and how to manage common emergency presentation presentations. For those of you who are interested, I will just pop in the registration link in the chat now and again that is free for everyone. Fantastic, and on that note, I will end the webinar. Have a wonderful evening and thank you again, Dr Izzie, for your knowledge and sharing such great insights. Thank you and good night.