• hormonal contraception
• contraceptives
• oral
• counseling
• long-acting reversible contraception

Our service, a fully integrated sexual health service, took part in the combined hormonal contraception (CHC) benchmarking audit, whose final report was published on 9 March 2020.1 Participation provided some positive affirmation for areas in which our service was doing well but also highlighted how poor we, and others, are at taking the opportunity to discuss long-acting reversible contraception (LARC) and explain the fundamental ‘pros and cons’ of CHC to clients.

I was particularly distressed by one comment I read in the final report which said: “We do not think that for every single CHC check patients should be informed of the risks. Those who have come to us for years understand the score well and we feel they would be ‘put off’ the service if we lectured them at every pill check”.

I believe this statement demonstrates a lack of understanding about how much information clients probably retain about the product they are using and an underlying disinclination to check clients’ awareness not only about the ‘pros and cons’ of the method they are using, but also of the alternatives available.

Clients forget immediately 40%–80% of the information given to them;2 and of the information they retain, about half is likely to be incorrect.2 This suggests to me that the clients of the colleague quoted above who “understand the score very well” may have a totally different understanding to that which the clinicians imagine. If sharing with clients the ‘cons’ of CHC “put them off” then I would venture to suggest that they didn’t understand the ‘cons’ in the first place. I do not believe mentioning that more effective methods are available in a conversational style is “pushing LARC” – rather it is checking that clients are aware of all their options and this is positively encouraged by the General Medical Council in their shared decision-making guidance.3 It is beholden on us as medical professionals to make sure clients understand what medication they are taking, and the good and bad things about this so that they can make an informed decision. No one should be setting out to lecture their patients; genuine shared decision-making is the way to avoid that and inform patients about the options (each time).

The informed decision should also involve awareness of other available methods, which includes a discussion about LARC. In this audit an average of 55% (median 62%) of services recorded sharing information with clients about LARC. This might include quoting figures or using visual aids. I would like to encourage colleagues to use visual information (we use a chart based on the Trussell efficacy rates4) to communicate the increased efficacy of LARC to clients. As a trainer I encourage my students to use this chart in their consultations and they are often quite resistant initially, viewing it as “something else that takes time”, but very quickly they experience clients having ‘light bulb’ moments such as “Oh my goodness, is that really how often condoms/pills fail?”, and subsequently become converts. This chart would be suitable to use during video conference calls or televisual consultations or, if a telephone consultation is being used, the Contraception Choices website5 has excellent infographics about failure rates which clients can access. Following our own rather disappointing scores on how often we discuss LARC with clients we have made the importance of this aspect of service provision apparent to staff via emails and department meetings and moved to having a rather prescriptive mandatory section on our history-taking sheet that says “LARC discussed and efficacy chart shown to clients”. I hope this will remind and encourage staff to discuss LARC and not just tick the box to keep me quiet!