Advising on family planning
The menstrual cycle2
To understand methods of preventing and promoting pregnancy, it is useful to have a good understanding of the menstrual cycle. Understanding this cycle will make it easier for you to explain how different contraception methods work and how they can be used effectively.
The menstrual cycle is controlled by hormones and consists of four main phases:
Menstruation/period is the elimination of the thickened lining of the uterus (endometrium) from the body through the vagina. The average length of a period is between three days and one week.
The follicular phase starts on the first day of menstruation and ends with ovulation. The pituitary gland releases follicle stimulating hormone (FSH) which stimulates the ovary to produce follicles (tiny nodules or cysts). Each follicle contains an immature egg. Usually, only one follicle will mature into an egg, while the others die. This can occur around day 10 of a 28-day cycle. The follicles release oestrogen, which stimulates the lining of the uterus to thicken in preparation for possible pregnancy.
Ovulation is the release of a mature egg from the surface of the ovary. This usually occurs mid-cycle, around two weeks or so before menstruation starts. Ovulation is triggered by a surge of luteinising hormone (LH). The egg travels down the fallopian tube toward the uterus and has a life span of around 24 hours. Unless it meets a sperm during this time, it will disintegrate.
Luteal phase: During ovulation, the egg bursts from its follicle, but the ruptured follicle stays on the surface of the ovary. For the next two weeks or so, the follicle transforms into a structure known as the corpus luteum. This structure starts releasing progesterone, along with small amounts of oestrogen. This combination of hormones maintains the thickened lining of the uterus, waiting for a fertilised egg to stick (implant).
If a fertilised egg implants in the lining of the uterus, it produces hormones such as human chorionic gonadotrophin (hCG) which are necessary to maintain the corpus luteum. The corpus luteum keeps producing the raised levels of progesterone that are needed to maintain the thickened lining of the uterus.
If pregnancy does not occur, the corpus luteum withers and dies, usually around day 22 in a 28-day cycle. The drop in progesterone levels causes the lining of the uterus to fall away, beginning menstruation. The cycle then repeats.
Trying for a baby3
Most couples who are having regular sex without contraception fall pregnant within a year. However, it can sometimes take longer. Factors affecting fertility include age, general health, reproductive health and frequency of sexual intercourse. You should refer couples who have been trying to conceive for over a year to their GP.
There are a number of things you can advise to increase the chances of getting pregnant:
- Have sex every two to three days without using contraception – make sure sperm enters the vagina
- Try to have sex around the time of ovulation – this is usually 12 to 16 days before the period starts. Some customers may want to use ovulation tests, which predict ovulation by measuring the surge of luteinising hormone in the urine
- Try to maintain a healthy weight, cut down or stop drinking alcohol and do not smoke – this is important for both partners as these factors also affect sperm quality
- Men should be advised that keeping their testicles cool can improve sperm quality. They can take steps such as wearing loose fitting underwear and taking breaks outside if they work in a hot environment.4
You should advise female customers who fall into the following categories to see their GP before trying to get pregnant:3
- They have a long-term condition such as diabetes
- There is a risk of them or their partner passing on a genetic condition, such as sickle cell disease
- They regularly take medicines – some medicines can affect a pregnancy, e.g. certain acne and epilepsy medicines
- They are aged 36 and over.
Methods of contraception
There are a variety of methods of contraception. These include:
Hormonal methods5,6
These contain hormones, such as oestrogen or progestogen, and they work primarily by preventing ovulation.
- Long-acting reversible contraception (LARC) includes hormones that are given as an implant, intrauterine device (IUD), intrauterine system (IUS) or injection. They can last from four months to 10 years depending on the form used.
- Tablets, such as combined oral contraceptives or the progesterone-only pill (also known as the mini-pill), need to be taken regularly. Missing pills can make it a less effective form of contraception. Contraceptive vaginal rings are used every three weeks and contraceptive patches are reapplied each week.
While the majority of hormonal methods are only available on prescription, progesterone-only pills containing desogestrel have recently become available over the counter. Make sure you have completed your training and are competent to sell these products.
Barrier methods7
These are often single-use and work by preventing the sperm from reaching the egg. Examples include condoms and diaphragms (diaphragms should be used with spermicides). These aren’t as effective as hormonal methods but can be used together to improve efficacy. Condoms have the added benefit of helping to protect from sexually transmitted infections.
Natural family planning (or fertility awareness method)8
This involves identifying the signs of fertility, such as cycle length, body temperature and cervical excretions, and avoiding intercourse (or using a barrier form of contraception) when fertility is at its highest. This method involves commitment and practice and can be less effective than other methods of contraception if not followed accurately. These same measures can be useful when trying to increase the chances of conception.
Permanent methods6
These methods of contraception are surgical operations which are very difficult to reverse. In women, this involves sealing, cutting or blocking the fallopian tube to prevent the egg reaching the sperm and becoming fertilised. In men, a vasectomy involves cutting, tying or sealing the tubes that carry sperm from a man's testicles to the penis.
Emergency contraception9
This can be used to prevent pregnancy after unprotected sex or if the contraception used has failed – for example, if a condom has split. There are two types:
- Emergency contraceptive pill, e.g. levonorgestrel or ulipristal acetate
- Emergency intrauterine device (IUD).
Consider what emergency contraceptive services you offer in your store and where else you might signpost customers to.
Did you know?
Sperm can live for up to five days in the female reproductive system.
Pregnancy testing kits10
It’s important to remember that a customer could be using a pregnancy testing kit in hopes of either a positive or negative result. Remain factual and unbiased in your comments unless the customer has been clear on the result they are hoping for.
Pregnancy tests work by checking urine for the presence of a hormone called human chorionic gonadotrophin (hCG), which is released shortly after a fertilised egg attaches to the lining of the uterus. Most tests are accurate from the first day of the missed period, but some claim to give results up to a week before that. hCG is most concentrated first thing in the morning, so performing the test at this time is most likely to give an accurate result, particularly if testing early.
If the test is negative but a menstrual period does not come after a week, the customer should be advised to test again. If a positive test is received, the customer should be advised to visit their GP to arrange their antenatal care or explore other options.