Case study 1 Martyna Learning goals Martyna After

Case study 1: Martyna

Learning goals: Martyna After completing this case study, you should have greater insights into: Managing the needs and expectations of an adolescent woman who is ambivalent about contraception and risk of pregnancy Supporting mother-daughter communication during a consultation with an adolescent Addressing the fears and misperceptions around use of some contraceptive methods The relevance of STI risk and need for screening

Your patient: Martyna 15 years old Arrives with her mother, who is very insistent that her daughter uses a reliable method of contraception on a regular basis

Interactive question Is it appropriate to continue the consultation with Martyna alone?

Interactive question Is it appropriate to continue the consultation with Martyna alone? If yes, at what point would you ask her mother to leave? If no, how would you use the joint consultation to obtain an accurate picture of Martyna’s needs and expectations?

Managing parental presence in an adolescent consultation Carrying out the consultation alone could provide an opportunity to gather useful additional information 1 However, where it is permissible, it may be appropriate to start the consultation with the parent present 1 Potential benefits of parental presence include: 1 Increasing the speed at which medical and family history can be gathered Identify opportunities to support communication between adolescent and parent Parents can be an important source of information regarding contraception and should be included in discussions where possible and appropriate 2 Mothers in particular feel a strong responsibility to be involved and support their teenage daughters’ decisions regarding contraception 2 1. Sacks D, Westwood M. Paediatr Child Health 2003; 8(No 9): 554 -556; 2. O'Rourke-Suchoff DK et al. Int J Adolesc Med Health. 2017 Jun 9. [Epub ahead of print].

Effective communication between mothers and daughters can shape long-term sexual behaviour 1 -4 It can also have a positive impact on adolescent sexual decision-making and use of contraception 1, 2 Use of contraception and rate of unintended pregnancy amongst daughters who did or did not communicate with their mothers (n=299)1 70 60 50 40 30 20 10 0 Daughters who communicated with their mothers Contraceptive use OC use Vaginal ring Condom Dermal patch Unint. pregnancy / elective abortion Daughters who did not communicate with their mothers 1. Palatnik A, Seidman DS. Int J Women Health 2012; 4: 265 -270; 2. Karofsky PS, et al. Fam Plann Perspect 1996; 28: 159 -165; 3. Hutchinson MK, et al. J Adolesc Health 2003; 33: 98 -107; 4. O'Rourke-Suchoff DK et al. Int J Adolesc Med Health. 2017 Jun 9. [Epub ahead of print].

When asked, Martyna says she is happy for her mother to stay Using the Counselling Checklist, you ask key questions including: her medical and sexual history her use of contraception her needs and expectations from a contraceptive method You reassure Martyna that you ask all your patients these questions irrespective of their age

Martyna tells you… There are no problems with her periods or known medical issues but there is a family history of breast cancer She has been sexually active for almost a year during which time she has had three different partners She uses condoms most of the time but her current partner doesn’t like them so sometimes she doesn’t bother She isn’t particularly worried about contraception or getting pregnant as her friend’s sister (aged 17) is going to have a baby soon She is only here because her mother insisted - her mother is divorced and does not want Martyna to be a single mother Her mother tells you that Martyna does well at school and higher education is a definite possibility

Interactive question How does Martyna’s sexual history affect the way you counsel her about contraception?

Interactive question How does Martyna’s sexual history affect the way you counsel her about contraception? What would your focus be? Her high risk of STI? Her attitudes towards contraception? Her ambivalence towards pregnancy?

A contraceptive consultation provides an opportunity to discuss STI risk Prevalence rates of many sexually transmitted infections (STIs) are highest among adolescents 1, 2 Women aged <25 years have the highest rates of chlamydia 1 Men Rate (per 1000, 000 population) 4000 3200 2400 1600 800 14. 7 715. 2 1325. 6 757. 9 390. 9 207. 5 116. 6 55. 9 17. 0 4. 0 262. 6 0 Age 10 -14 15 -19 20 -24 25 -29 30 -34 35 -39 40 -44 45 -54 55 -64 65+ Total 0 Women 800 1600 2400 3200 4000 108. 9 599. 2 273. 4 118. 3 41. 4 11. 3 2. 5 623. 1 1428. 3 3043. 3 3621. 1 Rates of reported cases of chlamydia by age and sex, United States, 2013 1. Murray PJ, et al. Pediatrics 2014; 134: e 302–e 311; 2. Centers for Disease Control and Prevention. (2014, December). Accessed at: http: //www. cdc. gov/std/stats 13/surv 2013 -print. pdf.

Martyna’s multiple sexual partners and inconsistent use of a condom places her at risk of STI Screening for chlamydia and gonorrhoea can be performed by nucleic acid amplification test (NAATs) of urine or cervical/vaginal swabs 1 It is reasonable and possible to screen for an STI and initiate contraception on the same day and then administer treatment if the test results are positive 2, 3 Irrespective of method of contraception, a condom is recommended at all times for protection against STIs in women at risk 4, 5 1. Murray PJ and Committee on Adolescence. Pediatrics 2014; 134: e 302–e 311. 2. Ott MA, Sucato GS and Committee on Adolescence. Pediatrics 2014; 134(4): e 1257– 1281; 3. Hoopes AJ et al. J Pediatr Adolesc Gynecol. 2017 Apr; 30(2): 149 -155; 4. Centers for Disease Control and Prevention. 2015. Accessed at: http: //www. cdc. gov/condomeffectiveness/docs/condoms_and_stds. pdf; 5. Committee on Adolescent Health Care. Obstet Gynecol. 2017 May; 129(5): e 142 -e 149.

Table discussion How could you use the fact that someone Martyna knows is having a baby to motivate her regarding use of contraception? • • • Please discuss this question together for five minutes Identify areas where you agree and areas where you had different opinions Nominate one group member to provide feedback on your discussions

Table discussion How could you use the fact that someone Martyna knows is having a baby to motivate her regarding use of contraception? Could you explore Martyna’s thoughts about: The impact of the impending pregnancy on the girl concerned and/or her family? How such an event might impact on Martyna and her family – in terms of attitudes, practical aspects of living at home, and her aspirations? • • • Please discuss this question together for five minutes Identify areas where you agree and areas where you had different opinions Nominate one group member to provide feedback on your discussions

Asking the right questions, in the right way Motivational interviewing (MI) techniques can be useful to: 1 -3 Explore and manage ambivalence towards pregnancy and contraception Identify inconsistencies between life goals and sexual behaviour Anticipate potential compliance or adherence issues Assist in the selection of the most appropriate method 1. Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. 1991; New York: Guilford Press; 2. Ott MA, Sucato GS. Pediatrics 2014; 134(4): e 1257– 81; 3. ACOG Committee Opinion No. 423. Obstet Gynecol 2009; 113(1): 243– 6.

Motivational Interviewing techniques can be used successfully in a contraceptive counselling situation 1 Four guiding principles in motivational interviewing 2 Express empathy – seek to understand feelings and perspectives without judging Develop discrepancy – create or amplify the discrepancy between current behaviour and broader goals and values Roll with resistance – new perspectives are invited but not imposed and resistance is reframed to create a new momentum toward change Support self-efficacy – use belief in the possibility of change as a motivator Using OARS 2 Open-ended questions Affirmations Reflective listening Summaries 1. Lopez LM et al. Theory-based interventions for contraception. Cochrane Database Syst Rev. 2016 Nov 23; 11: CD 007249; 2. Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. 1991; New York: Guilford Press.

Martyna’s attitudes towards pregnancy can be explored using the following types of question What does the friend’s family think about their daughter having a baby so young? Will having a baby affect this woman’s opportunity to stay in school and/or her future employment? How important to Martyna is doing well at school and going to college? If important, how would having a baby affect her ability to do that? What else would she miss out on if she had a baby at this point?

Martyna agrees that contraception would avoid the negative consequences of pregnancy You move on to check: Martyna’s awareness, knowledge, needs and expectations The accuracy of her knowledge of methods, including her fears and concerns The acceptability and affordability of her preferred option. For example, is she good at taking medicines regularly if needed

Your discussion reveals: Martyna’s knowledge about contraceptive methods is minimal and mostly incorrect She is concerned about the effects of the pill on her weight and risk of breast cancer When you ask her if she has had any recent illness or is on any medication, she tells you that she recently had to take some antibiotics but unfortunately she missed some doses because she kept forgetting to take the tablets

Martyna’s poor knowledge of contraceptive methods is common amongst adolescents 1 Proportion of women surveyed demonstrating correct knowledge about contraceptive methods Measure Young adults (aged 20 -29) (%) Teenagers (aged 18 -19) (%) a. OR (95% CI) If a woman stops taking ‘the pill’, she cannot get pregnant for more than 2 months 80 64 0. 56 (0. 33 -0. 94) P<0. 05 To get ‘the pill’, a women must have a pelvic exam 22 35 1. 98 (1. 14 -3. 44) P<0. 05 To obtain an IUD, a woman must undergo an operation 57 37 0. 41 (0. 25 -0. 57) P<0. 001 IUDs/implants cannot be removed early if a woman changes her mind 74 59 0. 64 (0. 38 -1. 07) P=0. 01 Negative effects from the ‘shot’* can last the rest of a woman’s life 52 29 0. 41 (0. 24 -0. 69) P<0. 001 Selected examples of statistically significant differences in correct knowledge of contraceptive methods by age group: Percentages and Adjusted Odds Ratios (a. OR; n = 897) 1. Craig AD, et al. Women Health Issues 2014; 24(3): e 281– 9. * Depot contraception

Interactive questions What method(s) would you discuss with Martyna at this point?

Interactive questions What method(s) would you discuss with Martyna at this point? • Is there any method you think would be most suitable for Martyna and why? • Any method you think would not be suitable for Martyna and why? How would you improve Martyna’s knowledge and understanding of her choice(s)?

In principle, all methods of contraception are an option for Martyna as an adolescent The WHO Medical Eligible Criteria 1 say that ‘no medical reason currently exists to deny any method based on young age alone’ Method Combined oral contraceptive pill (COCP), patch, ring, progestogen only pill (POP), hormonal implant Intrauterine contraception Age MEC* Menarche to 40 years of age 1 Menarche to 20 years of age 2 > 20 years 1 * The Medical Eligibility Criteria *MEC) state: 1 = No restriction to use; 2 = Advantages generally outweigh the risks; 3 = Risks generally outweigh the advantages; 4 = Unacceptable health risk 1. World Health Organization. Medical eligibility criteria for contraceptive use. 5 th ed. Geneva: WHO; 2015

A consultation provides an ideal opportunity to address some myths or misperceptions that may artificially limit choice of method 1 Method Combined oral contraceptives Intrauterine contraception Hormone injections Condoms Vaginal ring Myths or misperceptions amongst women that are not evidence-based 1, 2 They can cause weight gain They require a pelvic examination prior to initiation They are no more effective than a condom They require you to take a ‘pill’ break every two years They affect future fertility It can only be used in women who have had children previously It requires a major operation for placement It means you cannot use tampons They have long-term negative effects that can last the rest of a woman’s life They can cause infertility They can be used with any lubricant, including petroleum jelly It has to be inserted by a healthcare provider every month 1. Bitzer J, et al. Eur J Contracept Reprod Health Care 2016; 21: 6, 417 -430; 2. Craig AD, et al. Womens Health Issues 2014; 24(3): e 281– 9.

A consultation provides an ideal opportunity to address some myths or misperceptions that may artificially limit choice of method Method Combined oral contraceptives Intrauterine contraception Hormone injections Condoms Vaginal ring Myths or misperceptions amongst women that are not evidence-based 1, 2 They can cause weight gain They require a pelvic examination prior to initiation They are no more effective than a condom They require you to take a ‘pill’ break every two years They affect future fertility It can only be used in women who have had children previously It requires a major operation for placement It means you cannot use tampons They have long-term negative effects that can last the rest of a woman’s life They can cause infertility They can be used with any lubricant, including petroleum jelly It has to be inserted by a healthcare provider every month 1. Bitzer J, et al. Eur J Contracept Reprod Health Care 2016; 21: 6, 417 -430; 2. Craig AD, et al. Womens Health Issues 2014; 24(3): e 281– 9.

Addressing Martyna’s concerns about risk of breast cancer can help with her choice of method Studies on breast cancer and oral contraceptive (OC) use suggest either modest 1 -5 or no 6 -11 effects of OC use on the breast cancer risk Case-control studies provide conflicting results, but most cohort studies including long-term observation data, have found no increase in risk When the relative risk was shown to be increased, this effect disappeared gradually during the course of 10 years after cessation of OC use 2, 12 1. Kahlenborn et al. Mayo Clin Proc 2006; 81(10): 1290 -302; 2. Collaborative Group. Lancet 1996; 347(9017): 1713 -27; 3. Hunter et al. Cancer Epidemiol Biomarkers Prev 2010; 19(10): 2496 -2502; 4. Kumle et al. Cancer Epidemiol Biomarkers Prev 2002; 11(11): 1375 -81; 5. Rosenberg et al. Am J Epidemiol 2009; 169(4): 473 -9; 6. Marchbanks et al. N Engl J Med 2002; 346(26): 202532; 7. Heinemann et al. Geburtshilfe Frauenheilkd 2002; 62: 750 -7; 8. Vessey et al. Br J Cancer 2006; 95(3): 385 -9; 9. Colditz GA. Ann Intern Med 1994; 120(10): 821 -6; 10. Hannaford et al. BMJ 2007; 335(7621): 651; 11. Vessey et al. Contraception 2013; 88(6): 678 -83; 12. Gierisch et al. Cancer Epidemiol Biomarkers Prev 2013; 22(11): 1931 -43.

COC use does not have an appreciable longterm effect on body weight Many women believe that COCs increase body weight, 1 despite the fact that studies do not support this belief 2, 3 Concerns about weight gain may Deter women from starting COCs Be a reason for early discontinuation 4 One study showed that COC use was not a predictor for weight gain 5 There was no correlation between weight increase and duration of COC use in these women 1. Vogt C, Schaefer M. Eur J Contracept Reprod Health Care 2011; 16(3): 183– 93; 2. Gallo MF, et al. Cochrane Database Syst Rev 2014; 1: CD 003987; 3. Beksinska M, et al. Expert Rev Obstet Gynecol. 2011; 6(1): 45 -56; 4. Rosenberg MJ, Waugh MS. Am J Obstet Gynecol 1998; 179(3 Pt 1): 577– 82; 5. Lindh I, et al. Hum Reprod 2011; 26(7): 1917– 24.

You can use the reverse of the Counselling Checklist to further discuss Martyna’s choice of contraceptive method

Table discussion Do you now feel that Martyna is able to make an informed choice about a contraceptive method? • • • Please discuss this question together for five minutes Identify areas where you agree and areas where you had different opinions Nominate one group member to provide feedback on your discussions

Table discussion Do you now feel that Martyna is able to make an informed choice about a contraceptive method? Are any other tests or investigations appropriate? When would you arrange to see her next? • • • Please discuss this question together for five minutes Identify areas where you agree and areas where you had different opinions Nominate one group member to provide feedback on your discussions

Maintaining consistency of use with userdependent methods Managing expectations or concerns regarding side effects of contraception may help prevent discontinuation 1 Other tips that may aid compliance include: Quick start and extended regimens for oral contraceptives 2 Using smartphone technology to issue reminders and provide help and support if needed 3 1. Moreau C, et al. Contraception 2007; 76(4): 267– 72; 2. Westhoff C, et al. Contraception 2002; 66(3): 141– 5; 3. Society of Obstetricians and Gynaecologists of Canada (SOGC). Available at www. sexandu. ca. Accessed 30 April 2015.

Regular follow-up can help address any issues with compliance Regardless of the method chosen, scheduling followup appointments: 1, 2 Creates an opportunity to discuss satisfaction with method and change if needed 1 Provides reassurance around potential short-term side effects 2 Improves contraceptive compliance 1 Allows screening for STIs 1 1. Yoost JL et al. J Adolesc Health. 2014; 55(2): 222– 7; 2. Grossman N. Am Fam Physician. 2010; 82(12): 1499 -1506

Review of learning goals: Martyna After completing this case study, you should have greater insights into: Managing the needs and expectations of an adolescent woman who is ambivalent about contraception and risk of pregnancy Supporting mother-daughter communication during a consultation with an adolescent Addressing the fears and misperceptions around use of some contraceptive methods The relevance of STI risk and need for screening

CARE materials are available to download from www. your-life. com Checklist Publication 4 x patient cases 2 animated videos 3 x slide modules