Case study 2 Emma Learning goals Emma After

Case study 2: Emma

Learning goals: Emma After completing this case study, you should have greater insights into: Managing the needs and expectations of an adolescent woman who is preparing to embark on a sexual relationship Addressing the fears and misperceptions around initiation of contraceptive methods as well as their impact on future fertility Opportunities to communicate non-contraceptive benefits of some methods Wider discussion: Impact of smoking on contraceptive choice in adolescent women

Your patient: Emma 17 years old She is unaccompanied She tells you she thinks she will begin a sexual relationship soon and so needs contraception

You welcome Emma and reassure her about the positive step she is taking regarding contraception 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

Emma tells you… She is nervous because she is under the impression that everyone has to have a pelvic examination when they go for advice about contraception There are no known medical issues, although she does sometimes have heavy and painful periods There is no other family history of note She has been with her boyfriend for two months She is hoping to study at university so is very keen to avoid an unplanned pregnancy

Table discussion What do you see as the key issues, if any, in providing contraception for Emma? • • • 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 What do you see as the key issues, if any, in providing contraception for Emma? Is fear of a pelvic exam common amongst adolescent women you see in your practice? What is the policy in your practice? How would you reassure Emma about a pelvic exam? • • • 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

Fear of a pelvic exam can be a barrier to adolescents when seeking contraception 1, 2 One third of ob-gyns and family physicians require a pelvic exam prior to initiation of contraception despite being aware of guidelines indicating they are unnecessary 2 Neither pelvic exam nor cervical cancer screening are needed to start or continue most methods of contraception 3 -5 Those patients requesting intrauterine contraception (IUC) should be counselled regarding the requirement for a pelvic examination 5, 6 1. Harper C , et al. Fam Plann Perspect 2001; 33: 13– 8; 2. Henderson JT, et al. Obstet Gynecol 2010; 116(6): 1257– 64; 3. World Health Organization. Selected practice recommendations for contraceptive use. 2 nd ed. Geneva: WHO; 2004; 4. ACOG Practice Bulletin No. 140, Obstet Gynecol 2013; 122(6): 1338 -67; 5. Committee on Adolescent Health Care. Obstet Gynecol. 2017 May; 129(5): e 142 -e 149. ; 6. World Health Organization. Medical eligibility criteria for contraceptive use. 5 th ed. Geneva: WHO; 2015.

Interactive question When you ask Emma about her periods in more detail, she tells you that they can sometimes be heavy and painful but that hasn’t always been the case

Interactive question When you ask Emma about her periods in more detail, she tells you that they can sometimes be heavy and painful but that hasn’t always been the case How far would you investigate Emma’s heavy menstrual bleeding at this stage? Is there anything relevant in her family history?

Heavy menstrual bleeding is common in adolescent women 1, 2 Up to one in three adolescent women are affected 1, 2 Symptoms can be due to: Immature hypothalamicpituitary-ovarian (HPO) axis 3 Polycystic ovary disease 4 Bleeding/coagulations disorders 4, 5 Thyroid dysfunction 4 Adrenal disorders 4 1. Barr F, et al. Public Health Nutr 1998; 1: 249– 7; 2. Friberg B, et al. Acta Obstet Gynecol Scand 2006; 85: 200 – 6; 3. Vo K, et al. Haemophilia 2013; 19(1): 71– 75; 4. Sokkary N, et al. Curr Opin Obstet Gynecol 2012; 24: 275– 80; 5. NICE Heavy Menstrual Bleeding Clinical Guideline 44; 2007.

Asking key questions can determine both the extent of bleeding and its impact 1 -5 Does Emma’s monthly bleeding affect her daily life? Does she have to organise her social activities around her menstrual bleeding or worry about having accidents related to her bleeding? Does it affect her physically? Does she pass large blood clots or has she ever felt faint or breathless during her period? How much does she bleed? Does she have to change her sanitary protection during the night or, on her heavy days, does she bleed through a tampon or sanitary pad in under 2 hours? 1. Philipp CS, et al. Am J Obstet Gynecol 2008; 198: 163. e 1– 163. e 8; 2. Bushnell DM, et al. Curr Med Res Opin 2010; 26(12): 2745– 55; 3. Matteson KA, Clark MA. Women Health 2010; 50(2): 195– 211; 4. Acuna J, et al. On The Clinical and Global Burden of Chronic Heavy Menstrual Bleeding: The HELP* Group Statement. [In preparation]. 5. National Collaborating Centre for Women's and Children's Health. Heavy Menstrual Bleeding Clinical Guideline 44. London: RCOG Press for NICE; 2007.

When asked these questions, Emma tells you that… Her periods don’t impact too much on her social life as she doesn’t go out that much When they are painful, she usually takes some pain relief on the first or second day On the occasions where they are particularly heavy, she wears double protection and changes every 2 or 3 hours She is also careful about what she wears on those days

Recommendations regarding investigation of heavy menstrual bleeding where an organic cause is suspected Additional laboratory tests are indicated in the following situations: 1 -3 The possibility of pregnancy A history of menstrual bleeding since menarche or a personal or family history of abnormal bleeding Clinical findings suggestive of thyroid disease 1. Singh S, et al. SOGC Clinical Practice Guideline. J Obstet Gynaecol Can 2013; 35(5 e. Suppl): S 1 -S 28; 2. Marret H, et al, on behalf of CNGOF. Eur J Obstet Gynecol Reprod Biol 2010; 152: 133 -137; 3. NICE Heavy Menstrual Bleeding Clinical Guideline 44; 2007.

Indications for imaging and endometrial assessment and biopsy 1 -5 Physical examination suggests a structural cause of the bleeding 1, 2 Pharmaceutical treatment has failed 1, 2 A risk of malignancy has been identified 1, 5 Presence of intermenstrual bleeding, post-coital bleeding, pelvic pressure or pain are also risk factors for endometrial cancer or other pathology in women of reproductive age 1 -5 1. NICE Heavy Menstrual Bleeding Clinical Guideline 44; 2007; 2. SOGC Clinical Practice Guideline. J Obstet Gynaecol Can 2013; 35(5 e. Suppl): S 1 -S 28; 3. Marret H, et al, on behalf of CNGOF. Eur J Obstet Gynecol Reprod Biol 101(152): 133 -137; 4. ACOG Committee on Practice Bulletins – Gynecology, Bulletin 136. Obstet Gynecol 2013; 122: 176– 85; 5. Spanish Society of Gynecology and Obstetrics 2013, pro. SEGO. com.

You decide not to investigate further at this stage but highlight that some hormonal methods have noncontraceptive benefits that may help 1 Some combined hormonal methods are known to exert beneficial effects on aspects related to menstruation 1 -4 Lighter bleeding, more regular and stable menstrual cycles Reduction in dysmenorrhea (painful menstruation) They can also reduce the risk of endometrial and ovarian cancer 5 and improve acne symptoms 6 You also advise Emma of the importance of condom use to protect her from STIs 1. Lakehomer H, et al. Contraception 2013; 88(3): 426 -430; 2. Burkman R, et al. Am J Obstet Gynecol 2004; 190(4 Suppl): S 5 -22; 3. ESHRE Capri Workshop Group. Hum Reprod Update 2005; 11(5): 513 -525; 4. Schindler AE. Int J Endocrinol Metab 2013; 11(1): 41 -47; 5. Vessey M, et al. Contraception 2013; 88(6): 678 -683; 6. ACOG. Obstet Gynecol 2010; 115(1): 20.

Emma tells you she is keen to use a method that may reduce the impact of her monthly bleeding You move on to check: Emma’s awareness and knowledge of different contraceptive methods The acceptability and affordability of her preferred option

Your discussion reveals: Emma is aware of some of the contraceptive options but she has some questions and concerns Her biggest concern is the effect of hormonal methods on her future fertility; although pregnancy now would be a disaster, she does want children in the future

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.

You can reassure Emma that most reversible methods of contraception offer a prompt return to fertility 1 Most reversible methods of contraception offer a prompt return of fertility after discontinuation, with the exception of the injectable contraceptive methods 1 Cumulative conception rates for a pregnant population by the contraception method used before pregnancy (%) Effect of contraceptive use on subsequent cumulative conception rates, within 1 year, in a pregnant population (P<0. 001) (adapted from Hassan and Killick [2004])1 100% 75 - 50 - 25 94. 7% 91. 3% 87. 8% 83. 8% IUS Progesterone only pill Condom Intrauterine contraceptive device Combined oral contraceptive pill 51. 6% - Three Six Nine Time to pregnancy (months) 1. Hassan MAM, Killick SR. Human Reprod 2004; 19(2): 344 -51 Twelve Injectable

Advising adolescent women about the return to fertility Resumption of ovulation and the ability to conceive after cessation of COC use is important to women Women may believe that oral contraception impairs future fertility, and prevents them from conceiving after discontinuing use 1, 2 Some women take ‘pill breaks’ in the erroneous belief that these are necessary to preserve their future fertility 1 Cessation of modern-day, low-dose OCs is not associated with a delay in conception 3, 4, 5 Women should be advised that breaks in COC use in order to ‘preserve’ fertility are not necessary particularly in view of the fact that re-starting COCs after a pill break of four weeks or more is associated with an increased risk of venous thromboembolism 6 1. Shulman & Westhoff. Dialogues in Contraception 2006; 10: 1– 32; 2. Vogt & Schaefer. Eur J Contracept Reprod Health Care 2011; 16(3): 183 -93. 3. Barnhart et al. Fertil Steril 2009; 91(5): 1654– 6; 4. Cronin et al. Obstet Gynecol 2009; 114(3): 616– 22; 5. Mansour et al. Contraception 2011; 84(5): 465 -77; 6. Dinger et al. Pharmacoepidemiol Drug Saf 2010; 19(S 1): S 214 -15. 22

Rate of pregnancy (%) COC use does not have a negative effect on shortand long-term fertility 1 -3 100 90 80 70 60 50 40 30 20 10 0 88. 3% 79. 4% 45. 7% 21. 1% 1 3 13 26 Cycles after stopping COC use 2 1. Barnhart et al. Fertil Steril 2009; 91(5): 1654– 6. 2. Cronin et al. Obstet Gynecol 2009; 114(3): 616– 22. 3. Mansour et al. Contraception. 2011; 84(5): 465 -477.

Interactive question Do you now feel that Emma is able to make an informed choice about a contraceptive method?

Interactive question Do you now feel that Emma is able to make an informed choice about a contraceptive method? If not, what other information does she need? If yes, and if relevant, what do you need to tell her? What about screening for an STI?

In principle, all methods of contraception are an option for Emma 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 WHO 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

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

Wider discussion: You find out towards the end of the consultation that Emma smokes 10 cigarettes a day Does this impact on Emma’s choice of 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

Wider discussion: You find out towards the end of the consultation that Emma smokes 10 cigarettes a day Does this impact on Emma’s choice of contraceptive method? What about if she smoked 1520 cigarettes a day – would that have an impact? What other risk factors might need to be considered? • • • 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

Being a smoker changes the MEC for combined hormonal contraception from 1 to 21 A condition where the advantages of using the method generally outweigh theoretical or proven risks Method Combined oral contraceptive pill (COCP) Patch Ring Progestogen only pill (POP) Hormonal implant Age MEC* Menarche to 40 years of age 1 Smoker aged <35 years 2 Smoker aged ≥ 35 years (i) < 15 cigarettes/day (ii) ≥ 15 cigarettes/day 3 4 * The WHO 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 Even if Emma smoked 15 -20 cigarettes per day, she could still be prescribed CHC; however, counselling about general health risks of smoking would be appropriate 1. World Health Organization Medical Eligibility Criteria for Contraceptive Use. 5 th Edition, 2015.

Review of learning goals: Emma After completing this case study, you should have greater insights into: Managing the needs and expectations of an adolescent woman who is preparing to embark on a sexual relationship Addressing the fears and misperceptions around initiation of contraceptive methods as well as their impact on future fertility Opportunities to communicate non-contraceptive benefits of some methods Wider discussion: Impact of smoking on contraceptive choice in adolescent women

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