Ottawa Family Planning Clinic: experience with 3862 registrants J.C. WHYTE,* MD, FRCS[C], FRCOG, FACOG; S.J. CORBER,t MD, DPH; C.H. KEYS,* REQ N, B SC N, PHN
Many attempts have been made to bring family planning information to the public.14 In 1970 the Ottawa-Carleton Regional Health Unit took over the operation of the Ottawa Family Planning Clinic from Planned Parenthood Ottawa (a voluntary organization supporting family planning, funded by the federal government). The clinic is located in central Ottawa in a small building unidentified except by the procession of women entering and leaving three afternoons and three evenings each week. It is advertised only by a listing in the telephone directory and by word of mouth. Nevertheless, attendance has increased rapidly over the past 5 years, from 2000 to more than 11 000 visits annually, and 95% of visits are by appointment. Included in this number are visits made by persons from rural areas and from the Ottawa Valley, who frequently return to their local physician for continuing supervision after one or two visits. Others transfer to one or other of the local university clinics. Many are transients from distant parts of Canada or from the United States who are not seen after the first visit. The high attendance at the clinic has encouraged us to describe its operation and the characteristics of the people who attend, and to review the medical effects of various contraceptive methods on a large population. The following report is based on observations concerning 3862 persons under treatment at the clinic as of June 30, 1974, this num-
ber representing less than half the visits in the period reviewed.
and the complete physical examination are repeated.
Clinic procedure
Findings
Each new patient is fiist interviewed by a nurse, who records the medical and social history, weight, blood pressure and urinalysis results. A general physical examination, including breast and pelvic assessment, is carried out by a physician, and cervical cytology, smear and culture are done. If no contraindication exists, the method of contraception of the patient's choice is prescribed and instruction in its use given. The patient is requested to return in 6 to 8 weeks to discuss any problems that may have arisen. Until recently most women chose oral contraceptives; our usual procedure is to prescribe a year's supply. These may be purchased at the clinic at just above cost. Usually the patient is given a combination pill containing not more than 50 ,.tg of ethinyl estradiol or mestranol and 1 mg of a progestational agent; change in dosage may be made at subsequent visits. All patients are instructed to return at intervals of 1 year. At the annual visit the interview
The age distribution of the clinic population is presented in Table I. Less than 5% were under age 17 years. The distribution of patients according to marital status is shown in Table II and the pregnancy history in Table III. Of the group 3017 (78.1%) came for contraceptive advice, 617 (16.0%) because of suspected pregnancy, 49 (1.3%) for postabortion examination and 179 (4.6%) for other gynecologic complaints. In more than 90% oral contraceptive
*Medical director, Ottawa Family Planning Clinic tDeputy medical officer of health, OttawaCarleton Regional Health Unit tAssistant director of nursing, Ottawa-Carleton Regional Health Unit Reprint requests to: Dr. S.J. Corber, Deputy medical officer of health. Ottawa-Carleton Regional Health Unit, 1827 Woodward Dr., Ottawa, Ont. K2C 0R5
CMA JOURNAL/FEBRUARY 18, 1978/VOL. 118
401
therapy was started or continued. About 6% began or continued the use of an intrauterine device as a method of birth control and about 3% were instructed in the use of barrier methods. The 444 women who discontinued oral contraceptives (14.3% of those who used this method of contraception at some time) had a variety of reasons for doing so (table IV). There were 10 pregnancies in the group studied. In two instances the woman had taken oral contraceptives irregularly and in eight instances the woman became pregnant while "on a break" from an oral contraceptive. In addition to these 10 women 445 women attending the clinic were referred to other agencies because of pregnancy. Discussion The experience and problems with oral contraceptives have been summarized in a number of publications. . Between 1970 and 1974, 65.1% of our patients were under the age of 21 years at the time of their first visit. This proportion has been changing slowly and at the time of submission of this paper about half of our new patients were over 21 years old. The women came from all walks of life. Some were mentally retarded and attending special schools; others were university students, nurses and other "average.. Canadians who might otherwise visit a private physician. Severe mental depression is uncommon among women taking oral contraceptives. Usually it occurs in those with a history of mental illness or depression;8 therefore oral contraceptives are unsuitable for this small group of women. Secondary amenorrhea is often preceded by increasing oligomenorrhea. This can usually be corrected by inThM. IV-4aasoos for dicoatlnolug oral citfteaptlrn Ne (and .) of patista
-
or varicosltiw lbl.matiwam,t
Is a 5
4am.
4
1E .*sfr#1tbmnptnetlioi
Ne MfM).Ialibft
I. I.
5* (117)
444(30,5)
creasing the proportion of estrogen in rate in our series was 14.3 %. We bethe oral contraceptive. Although with lieve that we were able to achieve this the exception of pregnancy there is good result by following a few basic not a real contraindication to the use principles: of oral contraceptives in the presence 1. The patient must be accepted as of amenorrhea, it is rarely possible a participant in decision-making. to convince the patient of this and 2. Physicians should avoid making it is preferable to substitute another value judgements; their role is to help, method of birth control and await the not to dictate. resumption of menstruation, which 3. Physicians doing this kind of work occurs spontaneously in at least 80% should develop good counselling techof cases. niques or work with nurses, social workAsymptomatic modest elevation of ers or other trained paramedical people blood pressure may be transient but with this expertise. 4. Any contraceptive device is better should serve as a warning of the need to monitor the blood pressure frequent- than no contraceptive, and the method ly. If it continues to rise the oral con- the couple uses is the best for them. traceptive must be discontinued and are indebted to Mrs. Maxine Cohrs another method substituted. The re- We and her assistants for their weeks of painsponse is usually prompt and use of the staking coding from the charts, to Mr. oral contraceptive should not be re- George Lynch and Mr. Gilles Mousseau, sumed. programmer-analysts of the department of In our group of women taking oral epidemiology of the University of Ottawa, contraceptives two were found to have and to the dedicated and sympathetic abnormal Papanicolaou smears and nurse-counsellors, to whom much of the two had suspicious breast tumours; the credit for the success of our operation former were free of cervical cancer belongs. and the latter had benign lesions. References Minor side effects with oral contra1. COLES R: A retrospective study of patients ceptives such as weight gain, breakseeking pregnancy advice, January 1971 to through bleeding, mood changes, June 1974. .1 Biosoc Sd 7: 357, 1975 2. Porrs DM: Family planning. Community change in libido and skin pigmentation Health (Bristol) 4: 185, 1973 Contraception: An Exploration of the Limitacan account for a large proportion of 3. tions of Contraception. Proceedings of a Condiscontinuances unless these women are ference, Ontario Science Centre, November, 1975, Don Mills, Ont, Ortho Pharm (Can), seen frequently and counselled with the 1975 4. CommunicatIon In Family Planning, family purpose of reinforcing their motivation. planning division, Health and Welfare CanSuch counselling should be sympathetic ada, Ottawa, 1975 Report of the special committee appointed and must come from people with ex- 5. by the minister of National Health and Welfare to advise the food and drug direcpertise in the field gained through edutorate on all aspects of the safety and cation and experience. efficacy of oral contraceptives marketed in Canada, October, 1970. Rx Bull 1 (10): DeNot infrequently social reasons are cember 1970 Oral contraceptives. Rx Bull 5 (3): summer given as a reason for discontinuing oral 6. 1974 contraceptives. At times the reasons are 7. Oral contraceptives. Rx Bull 6 (suppi 1): unclear, and vague statements such as 8. 1975 Lawis A, Hoossuosu M: An evaluation of depression as a side effect of oral contra"I wanted a break", "My partner left, ceptives. Br I Psychiatry 115: 697, 1969 so I didn't need contraception", "I was 9. Royal College of General Practitioners: Oral Contraceptives and Health, New York, Pitafraid of the effect of these chemicals man, 1974 BIGGERS JD: General principles of contraon my body" and "My boyfriend (or 10. ceptive technology, In Regulation of Human Fertility, MoGHISsI KS, EvANs TN (eds), husband) objects" are not uncommon. Detroit, Wayne St U Pr, 1976, p 31 The two patients who became pregnant while taking oral contraceptives admitted taking the pills irregularly and BOOKS not taking them for at least 2 days during the cycle in which the pregnancy continued from page 400 began. Some of those in our series who IDIOPATHIC URINARY BLADDER STONE DISEASE. became pregnant during a "break" from Fogarty international center Proceedings No. 37. Edited by Robert Van Roan. Sponsored by the oral contraceptive therapy claimed they John E. Fogarty international center, The Eastern Mediterranean Regional OffIce of the World Health had been advised by a physician to OrganIzation, and. the National Institute of Arhave such a break every 2 years. There thritis, Metabolism, and Digestive Diseases. 1977. 370 pp. lIlust. U.S. Department of Health, Educais no indication that a break does any tion, and Welfare, NatIonal institutes of Health. good,0 and too frequently it leads to Bethesda, 1977. DHEW publ no (NIH) 77-1063 an unwanted pregnancy. IFIP WORLD CONFERENCE SERIES ON MEDICAL Conclusions The average time for which oral contraceptives are taken by our clinic patients is just over 3 years, a duration better than is reported from most other published series.1 The discontinuance
402 CMA JOURNAL/FEBRUARY 18, 1978/VOL. 118
INFORMATICS. Vol. 2. MedInfo 77. Proceedings of the Second World Conference on MedIcal Informatics, Toronto, August 8-12, 1977. EdIted by DavId B. ShIres and Hermann Wolf. 1090 pp. liust. North-Holland Publishing Company, Amsterdam, 1977. 895. ISBN 0-7204-0754 THE MEDIASTINUM. Radlolo Ic CorrelatIons with Anatomy and Pathology. E. .Iobert Heitzman. 341 pp. lilust. The CV. Mosby Company, Saint Louis, 1977. 639.40. ISBN 0-8016-2132-1
continued on page 412
Many attempts have been made to bring family planning information to the public.14 In 1970 the Ottawa-Carleton Regional Health Unit took over the operation of the Ottawa Family Planning Clinic from Planned Parenthood Ottawa (a voluntary organization supporting family planning, funded by the federal government). The clinic is located in central Ottawa in a small building unidentified except by the procession of women entering and leaving three afternoons and three evenings each week. It is advertised only by a listing in the telephone directory and by word of mouth. Nevertheless, attendance has increased rapidly over the past 5 years, from 2000 to more than 11 000 visits annually, and 95% of visits are by appointment. Included in this number are visits made by persons from rural areas and from the Ottawa Valley, who frequently return to their local physician for continuing supervision after one or two visits. Others transfer to one or other of the local university clinics. Many are transients from distant parts of Canada or from the United States who are not seen after the first visit. The high attendance at the clinic has encouraged us to describe its operation and the characteristics of the people who attend, and to review the medical effects of various contraceptive methods on a large population. The following report is based on observations concerning 3862 persons under treatment at the clinic as of June 30, 1974, this num-
ber representing less than half the visits in the period reviewed.
and the complete physical examination are repeated.
Clinic procedure
Findings
Each new patient is fiist interviewed by a nurse, who records the medical and social history, weight, blood pressure and urinalysis results. A general physical examination, including breast and pelvic assessment, is carried out by a physician, and cervical cytology, smear and culture are done. If no contraindication exists, the method of contraception of the patient's choice is prescribed and instruction in its use given. The patient is requested to return in 6 to 8 weeks to discuss any problems that may have arisen. Until recently most women chose oral contraceptives; our usual procedure is to prescribe a year's supply. These may be purchased at the clinic at just above cost. Usually the patient is given a combination pill containing not more than 50 ,.tg of ethinyl estradiol or mestranol and 1 mg of a progestational agent; change in dosage may be made at subsequent visits. All patients are instructed to return at intervals of 1 year. At the annual visit the interview
The age distribution of the clinic population is presented in Table I. Less than 5% were under age 17 years. The distribution of patients according to marital status is shown in Table II and the pregnancy history in Table III. Of the group 3017 (78.1%) came for contraceptive advice, 617 (16.0%) because of suspected pregnancy, 49 (1.3%) for postabortion examination and 179 (4.6%) for other gynecologic complaints. In more than 90% oral contraceptive
*Medical director, Ottawa Family Planning Clinic tDeputy medical officer of health, OttawaCarleton Regional Health Unit tAssistant director of nursing, Ottawa-Carleton Regional Health Unit Reprint requests to: Dr. S.J. Corber, Deputy medical officer of health. Ottawa-Carleton Regional Health Unit, 1827 Woodward Dr., Ottawa, Ont. K2C 0R5
CMA JOURNAL/FEBRUARY 18, 1978/VOL. 118
401
therapy was started or continued. About 6% began or continued the use of an intrauterine device as a method of birth control and about 3% were instructed in the use of barrier methods. The 444 women who discontinued oral contraceptives (14.3% of those who used this method of contraception at some time) had a variety of reasons for doing so (table IV). There were 10 pregnancies in the group studied. In two instances the woman had taken oral contraceptives irregularly and in eight instances the woman became pregnant while "on a break" from an oral contraceptive. In addition to these 10 women 445 women attending the clinic were referred to other agencies because of pregnancy. Discussion The experience and problems with oral contraceptives have been summarized in a number of publications. . Between 1970 and 1974, 65.1% of our patients were under the age of 21 years at the time of their first visit. This proportion has been changing slowly and at the time of submission of this paper about half of our new patients were over 21 years old. The women came from all walks of life. Some were mentally retarded and attending special schools; others were university students, nurses and other "average.. Canadians who might otherwise visit a private physician. Severe mental depression is uncommon among women taking oral contraceptives. Usually it occurs in those with a history of mental illness or depression;8 therefore oral contraceptives are unsuitable for this small group of women. Secondary amenorrhea is often preceded by increasing oligomenorrhea. This can usually be corrected by inThM. IV-4aasoos for dicoatlnolug oral citfteaptlrn Ne (and .) of patista
-
or varicosltiw lbl.matiwam,t
Is a 5
4am.
4
1E .*sfr#1tbmnptnetlioi
Ne MfM).Ialibft
I. I.
5* (117)
444(30,5)
creasing the proportion of estrogen in rate in our series was 14.3 %. We bethe oral contraceptive. Although with lieve that we were able to achieve this the exception of pregnancy there is good result by following a few basic not a real contraindication to the use principles: of oral contraceptives in the presence 1. The patient must be accepted as of amenorrhea, it is rarely possible a participant in decision-making. to convince the patient of this and 2. Physicians should avoid making it is preferable to substitute another value judgements; their role is to help, method of birth control and await the not to dictate. resumption of menstruation, which 3. Physicians doing this kind of work occurs spontaneously in at least 80% should develop good counselling techof cases. niques or work with nurses, social workAsymptomatic modest elevation of ers or other trained paramedical people blood pressure may be transient but with this expertise. 4. Any contraceptive device is better should serve as a warning of the need to monitor the blood pressure frequent- than no contraceptive, and the method ly. If it continues to rise the oral con- the couple uses is the best for them. traceptive must be discontinued and are indebted to Mrs. Maxine Cohrs another method substituted. The re- We and her assistants for their weeks of painsponse is usually prompt and use of the staking coding from the charts, to Mr. oral contraceptive should not be re- George Lynch and Mr. Gilles Mousseau, sumed. programmer-analysts of the department of In our group of women taking oral epidemiology of the University of Ottawa, contraceptives two were found to have and to the dedicated and sympathetic abnormal Papanicolaou smears and nurse-counsellors, to whom much of the two had suspicious breast tumours; the credit for the success of our operation former were free of cervical cancer belongs. and the latter had benign lesions. References Minor side effects with oral contra1. COLES R: A retrospective study of patients ceptives such as weight gain, breakseeking pregnancy advice, January 1971 to through bleeding, mood changes, June 1974. .1 Biosoc Sd 7: 357, 1975 2. Porrs DM: Family planning. Community change in libido and skin pigmentation Health (Bristol) 4: 185, 1973 Contraception: An Exploration of the Limitacan account for a large proportion of 3. tions of Contraception. Proceedings of a Condiscontinuances unless these women are ference, Ontario Science Centre, November, 1975, Don Mills, Ont, Ortho Pharm (Can), seen frequently and counselled with the 1975 4. CommunicatIon In Family Planning, family purpose of reinforcing their motivation. planning division, Health and Welfare CanSuch counselling should be sympathetic ada, Ottawa, 1975 Report of the special committee appointed and must come from people with ex- 5. by the minister of National Health and Welfare to advise the food and drug direcpertise in the field gained through edutorate on all aspects of the safety and cation and experience. efficacy of oral contraceptives marketed in Canada, October, 1970. Rx Bull 1 (10): DeNot infrequently social reasons are cember 1970 Oral contraceptives. Rx Bull 5 (3): summer given as a reason for discontinuing oral 6. 1974 contraceptives. At times the reasons are 7. Oral contraceptives. Rx Bull 6 (suppi 1): unclear, and vague statements such as 8. 1975 Lawis A, Hoossuosu M: An evaluation of depression as a side effect of oral contra"I wanted a break", "My partner left, ceptives. Br I Psychiatry 115: 697, 1969 so I didn't need contraception", "I was 9. Royal College of General Practitioners: Oral Contraceptives and Health, New York, Pitafraid of the effect of these chemicals man, 1974 BIGGERS JD: General principles of contraon my body" and "My boyfriend (or 10. ceptive technology, In Regulation of Human Fertility, MoGHISsI KS, EvANs TN (eds), husband) objects" are not uncommon. Detroit, Wayne St U Pr, 1976, p 31 The two patients who became pregnant while taking oral contraceptives admitted taking the pills irregularly and BOOKS not taking them for at least 2 days during the cycle in which the pregnancy continued from page 400 began. Some of those in our series who IDIOPATHIC URINARY BLADDER STONE DISEASE. became pregnant during a "break" from Fogarty international center Proceedings No. 37. Edited by Robert Van Roan. Sponsored by the oral contraceptive therapy claimed they John E. Fogarty international center, The Eastern Mediterranean Regional OffIce of the World Health had been advised by a physician to OrganIzation, and. the National Institute of Arhave such a break every 2 years. There thritis, Metabolism, and Digestive Diseases. 1977. 370 pp. lIlust. U.S. Department of Health, Educais no indication that a break does any tion, and Welfare, NatIonal institutes of Health. good,0 and too frequently it leads to Bethesda, 1977. DHEW publ no (NIH) 77-1063 an unwanted pregnancy. IFIP WORLD CONFERENCE SERIES ON MEDICAL Conclusions The average time for which oral contraceptives are taken by our clinic patients is just over 3 years, a duration better than is reported from most other published series.1 The discontinuance
402 CMA JOURNAL/FEBRUARY 18, 1978/VOL. 118
INFORMATICS. Vol. 2. MedInfo 77. Proceedings of the Second World Conference on MedIcal Informatics, Toronto, August 8-12, 1977. EdIted by DavId B. ShIres and Hermann Wolf. 1090 pp. liust. North-Holland Publishing Company, Amsterdam, 1977. 895. ISBN 0-7204-0754 THE MEDIASTINUM. Radlolo Ic CorrelatIons with Anatomy and Pathology. E. .Iobert Heitzman. 341 pp. lilust. The CV. Mosby Company, Saint Louis, 1977. 639.40. ISBN 0-8016-2132-1
continued on page 412
