THE FEMALE HEALTHCARE GENERATION GAP
Some middle-aged women are waiting a year to have a coil fitted thanks to cutbacks in contraceptive services, yet younger women are seen more quickly. Now experts warn it’s even led to a rise in abortions
DIANE FRENCH-FINLAY’S periods used to be so heavy and painful that for two to three days a month she was effectively housebound. ‘I was in agony,’ says Diane, 50, a mother of three from leicester. ‘I took ibuprofen but it never really got rid of the pain. so I would lie on the bed or sofa with a hot-water bottle on my tummy to try and soothe it.’
And if she had to leave the house to pick up her children from school, she would have to wear several sanitary towels as well as her usual protection to avoid the risk of any embarrassing leaks before she returned home, less than an hour later. ‘It made my life a misery,’ she says. But Diane, then in her late 40s, was confident she knew how to fix the problem.
‘Both my older sisters had also suffered with heavy periods that virtually disappeared when they were each fitted with a coil,’ says Diane.
The coil, or intrauterine device (IUD), is a T-shaped plastic or metal contraceptive placed inside the womb by a doctor or specially trained nurse.
hormone-based IUDs prevent pregnancy by gradually releasing progestin to thicken mucus around the entrance to the womb, stopping sperm entering, while non-hormonal ones are made with copper, which acts as a spermicide.
As well as providing long-acting contraception (the implants need replacing after five to ten years), the hormonal coil is also often recommended for women who, like Diane, suffer with excessively heavy periods, as the gradual release of hormones reduces the thickness of the lining of the womb, thereby lessening bleeding every month when the lining breaks down.
But what Diane assumed would be a straightforward process — accessing Nhs contraceptive services — proved anything but. After all, every woman in the UK is entitled to free contraception, whether it’s the Pill or long-acting implants.
In fact, it took almost a year from first requesting it from her GP to having an implant fitted in October 2019 at another practice. During that time Diane was shunted between GP practices and local authority-run sexual health clinics. Each time, the answer was they either did not provide the service, had no funding to do it, or lacked trained staff to fit the implant.
‘It was incredibly frustrating,’ says Diane, a former recruitment worker. ‘I had assumed I would be able to get the coil more or less straight away.’
In fact, it’s thought thousands more older women are in a similar position because of changes in the way they are funded that led to clinic closures and a shortage of the trained staff needed to fit coils and implants.
Among those Good health spoke to who have faced similar obstacles, one urgently needed her coil removed after it caused excessive bleeding — which can happen in the first few weeks and months after being fitted (thought to be as a result of the body adjusting to its presence).
she said: ‘I couldn’t get in anywhere and was bleeding horribly every day for nine weeks. In the end I had to pay privately to have it removed.’
Another told Good health: ‘I’ve been waiting 15 months to have one fitted. Every time I ring the surgery or clinic they don’t have any appointments or have stopped doing them.’ And according to some experts, such as Dr Anne connolly, a GP in Bradford and a leading member of the Primary care Women’s health Forum, the lack of access is almost certainly to blame for a rise in abortions in older women (defined as 35 and over) who ‘take second place’ to younger women when it comes to access to contraceptives such as the coil.
RECENT Department of health figures for England show terminations in those aged 35 to 39 have risen 27 per cent since 2015, while those in the over-50s are up 65 per cent, although the actual numbers are small.
This coincides with a significant drop in the number of women of all ages in England and Wales being fitted with longacting contraception such as coils or implants (a flexible plastic rod placed under the skin in the upper arm to gradually release the hormone progestogen). These have declined by about 8 per cent, to around 300,000, since 2015.
This is despite long-acting contraception being regarded as the most effective form of birth control; while one in 100 women on the Pill will accidentally become pregnant, with long-acting arm implants it’s just one in 2,000.
‘Women are being bounced around the system and it’s having a big impact on their health,’ says Dr connolly. ‘Abortion rates are going up and the contraception service is not working.’
But why are things in such a dire state? The finger of blame is being pointed at the 2012 health and social care Act.
Previously, budgets for Nhs contraception-fitting services were mostly in the hands of primary care groups — GPs — who decided how services in their area were funded.
GP surgeries were paid a fixed fee, usually around £100, every time they would fit, replace or remove an IUD or implant. This covered their time and cost of the equipment and gave
practices an incentive to pay for one or two staff members to keep up-to-date with the training needed to be a qualified ‘fitter’. But the 2012 Act split funding so that fitting coils and implants prescribed primarily for contraception — rather than for heavy periods — was carried out by community sexual health clinics, funded by councils. GPs would instead just be paid to do them when there was an underlying clinical need, such as excessive bleeding. But they are under no obligation to do so if it is not financially viable. In addition, out went the national fee of around £100 per patient, in favour of local authorities negotiating their own deals with GP practices. Some now get just £35 for each patient they treat, despite each coil alone costing up to £80 for the hormone versions. This huge disincentive for GPs has been compounded by long-term
cuts in local authority budgets, which have forced many councils to reduce contraception services.
Since reducing unwanted pregnancies in young women was a priority under the Act, this had led to reports that some local authority-run clinics even refuse to see women over 25 wanting coils or implants.
‘The Health and Social Care Act has been a big issue in this,’ says Dr Connolly. ‘It was focused on prevention of health problems [such as unwanted pregnancies] and so took contraception out of women’s health and made it a sexual health issue.
‘This was great for younger women and teenage pregnancy rates have fallen. But not so great for mature women who are
just as concerned about gynaecological problems such as very heavy periods.’
And not so great either for the thousands of middle-aged women encouraged by the nHS to switch to coils and implants, instead of the widely-used ‘combined’ Pill, before they hit 50.
The combined Pill, which contains the hormones oestrogen and progesterone, has been linked to a raised risk of breast cancer.
‘The Act was flawed and I fear women are paying the price for it now,’ says Dr Connolly.
A damning report in 2020 by the All-Party Parliamentary Group on Sexual and Reproductive Health found almost one in two cash-strapped councils had
reduced the number of clinics providing contraceptive services in the last five years.
Those that remained saw staff cuts and shorter opening hours to try and save money. More than one in ten councils also slashed the number of contracts agreed
with GPs to fit coils and implants.
One exeter GP told the MPs’ inquiry people were travelling nearly 200 miles from London for their contraception services. ‘It’s easier for them to come for a long weekend to Devon and have their needs met here rather than try and find a service in London.’
Dr Connolly says what frustrates many women is that they get passed from pillar to post.
‘If a woman goes to a community sexual health clinic because she has heavy periods, it won’t provide a coil or implant.
‘She will probably be told to go back to her GP. And if they don’t
do it, she may get referred to another practice or to hospital.’
The Primary Care Women’s Health Forum wants a revamp of services, with a network of ‘hubs’ across the UK, each based at a GP surgery, providing coils and implants for both contraceptive and clinical reasons. And GPs
across the country would all get the same fee.
Dr Connolly says: ‘The service needs to be built around the needs of women — not the needs
of whoever is controlling the purse strings.’
Diane’s heavy periods were well controlled by the Pill until she stopped taking it to have her
family. But after the birth of her last child in 2014, her GP was reluctant to put her back on the Pill at 43.
She used condoms for contraception but recalls: ‘I was having heavy and agonising periods.
‘When I asked my GP about it, he said heavy bleeding was to be expected at my age and there wasn’t much I could do.’
Dogged by persistently painful periods, Diane went back to her GP to ask again about the coil in
november 2018. But the practice had stopped doing them and she was referred to a sexual health
clinic in Leicester city centre. After months of calling them, she was told they didn’t fit coils for heavy bleeding and Diane would have to go back to her GP.
In spring 2019, her doctor managed to locate another practice in Leicester that provided longacting contraception but it had a six-month waiting list.
After Diane finally received a hormonal coil, in October 2019, it made a real difference.
‘I felt so much better and I’ve not had a proper heavy period since,’ she says. ‘But nobody should have to face delays like that.’