Case study 3: Nadia Learning goals: Nadia - PowerPoint Presentation

Slide1

Case study 3: Nadia

Slide2

Learning goals: Nadia

After completing this case study, you should have greater insights into:

Managing

the needs and expectations of an adolescent

woman who has poor

understanding of the importance of consistent use of contraception to protect against unintended pregnancy

Communicating the importance of the need for protection against STIs

Exploring how non-contraceptive benefits of some methods may be of interest to some women

Communicating the side effects and risks associated with use of COCs

Communicating the impact of

‘pill breaks’ with COCs on

cardiovascular risk

Wider discussion: Recognising

situations where confidentiality does not prevent the asking of questions about consent or

coercion

Slide3

Your patient: Nadia

16

years

old and

she is new

to the areaHer period is two weeks lateand she thinks she is pregnantShe thinks she might finish with her current boyfriend of three months because he is ‘an idiot’She is unaccompanied

Slide4

A pregnancy test shows that she is not pregnant

You use Nadia’s attendance for a pregnancy test as an opportunity to talk about her medical and sexual history

Using

the Counselling Checklist, you ask

her key

questions including:her medical and family historyher use of contraceptionher needs and expectations from a contraceptive methodher views on different methods and her ability and motivation to use them

Slide5

What the discussion reveals:

Nadia’s

periods have been fairly normal since menarche (at 12 years)

There are no medical issues or family history of note but you notice that she suffers quite badly with acne

This is her first boyfriend; he is

25 years old and her mother doesn’t like him because he has a ‘bit of reputation’ Nadia tells you that she borrowed some pills from a friend, and ‘took when she had sex’ Nadia tells you that the friend’s mother has found out about the pills and now her friend is in trouble

She asks you to promise not to tell her parents, particularly her mother about the pregnancy scare and her visit to you

Slide6

Table discussion

What do you see as the key issues for

Nadia?

Please discuss this

question together

for five minutesIdentify areas where you agree and areas where you had different opinions

Nominate one group member to

provide feedback

on your discussions

Slide7

Table discussion

What do you see as the key issues for

Nadia?

Her lack of knowledge about how contraception works?

Please discuss this

question together for five minutesIdentify areas where you agree and

areas where you had different opinions

Nominate one group member to

provide feedback

on your discussions

Her inconsistent use of contraception?

The dynamics of her current relationship?

Her risk of STIs?

What is your biggest concern at this point?

Slide8

There are a number of important aspects to address

Nadia is

seeking

reassurance regarding confidentiality

Her knowledge of how oral contraception works is poor and has led to risk of unintended pregnancy

Although Nadia says she may finish with her boyfriend she still needs to be counseled about correct and continuous use of contraception and the need to protect herself from the risk of STIsNadia’s negative attitude towards her boyfriend and the comment she shares about her mother not liking him hint at Nadia’s lack of control over her own sexual and reproductive health in this relationship

Slide9

You acknowledge Nadia’s request for confidentiality

Defining confidentiality and its limits up front

:

1,2

increases the likelihood that adolescents will discuss sensitive issues about sexuality, substance use and mental health increases the number of adolescents willing to return for a future visit

1. Advocates

for Youth. Best practice for youth-friendly clinical services,

2009; 2. Reddy

DM, et al.

JAMA

. 2002;288(6):710–

714; 3. Ford

CA, et al.

JAMA

. 1997;278(12):1029–

34; 4. Gordon

CM, Pitts SA.

J

Clin Endocrinol Metab. 2012;97(1):9–

15; 5.Slater

C, Robinson AJ.

Clin

Dermatol 2014;32(2):189–95.

Provision of confidentiality should:

3-5

not compromise access be balanced with the support of a parent where possible and appropriateClinics should be willing to:1treat unaccompanied minorsoffer some counselling time alone with an adolescent when attending with a parent

Slide10

CONFIDENTIALITY is key to the continuing participation

of

adolescents in sexual healthcare services

1

In a US state-wide survey, almost half of adolescent girls would stop using all services if parents had to be notified that they were seeking prescribed

contraception11. Reddy DM,

et al. JAMA

2002;288(6):710–4.

60

50

40

30

20

10

0

Girls

(%)

Discontinue use of all services

Change their use of services

Delay/discontinue testing or treatment for HIV/other STDs

Effect of

mandatory parental

n

otification

on

adolescent girls

'

use

of

sexual health care services

by

age (n = 814) (adapted from Reddy et al

1

)

47%

12%

11%

Slide11

You reassure Nadia about confidentiality and move on to discuss her past and current use of contraception in more detail

You ask her:

Why she only took the contraceptive pill when she had sex

Whether she has used condoms

Whether she has been tested for an STI

Slide12

Your discussion reveals:

Nadia knows

she should probably use contraception but is reluctant to discuss different methods in detail because of the need to keep it a secret from her mother

She has never used a

condom

because when she suggested it to her boyfriend he said he didn’t like them She has never been tested for an STI

Slide13

A contraceptive consultation provides an opportunity to discuss STI risk

Nadia’s lack of condom use places

her at

risk of STI and you

advise her that

she will need to be testedScreening for chlamydia and gonorrhoea can be performed by nucleic acid amplification test (NAATs) of urine or cervical/vaginal swabs1It is reasonable and possible to screen for an STI and place IUC on the same day and then administer treatment if the test results are positive2

1. Murray

PJ, et al.

Pediatrics

2014;134:e302–

e311; 2.

Ott MA, Sucato GS and Committee on Adolescence. Technical Report: Contraception for adolescence. Pediatrics 2014;134(4):e1257–1281.

Slide14

Table discussion

How might you address Nadia’s ambivalence towards 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

Slide15

Table discussion

How might you address Nadia’s ambivalence towards contraception?

Are there any aspects of her medical history that you could discuss further at this point?

How might you use the non-contraceptive benefits of some methods?

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

Slide16

Many women are unaware of the therapeutic uses of oral contraceptives

COCs are

known to exert beneficial effects on

many aspects

related

to menstruation1-4Lighter bleeding, more regular and stable menstrual cyclesReduction in dysmenorrhea (painful menstruation)Use of oral contraceptives decreases the risk of ovarian and endometrial cancer5Depending on the composition, some COCs have been shown to improve symptoms of acne6,7

1. Lakehomer H, et al. Contraception 2013;88(3):426-430; 2. Burkman R, et al. Am J Obstet Gynecol 2004;190(4 Suppl):S5-22; 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, Yeates D

.

Contraception 2013;88(6):678-

683; 6.

Pitashny

M, et

al.

Skinmed

2005; 4(2):101-6.

Arowojolu

AO et al.

Cochrane Database Syst Review 2012;7:CD004425.

Slide17

Acne is a common problem for adolescents1

Androgen-stimulated sebum production (seborrhea) is one of the main causes of acne

1

Other

androgen-related disorders include hirsutism

and androgen-related alopecia2Estro-progestin compounds decrease androgen

secretion by the

ovary

via

inhibition

of gonadotropin

secretion

3

Ethinylestradiol stimulates

secretion of sex hormone-binding globulin (SHBG), thereby decreasing androgen

bioavailability

3

1. NAIAMS

. Available from:

http://www.niams.nih.gov/health_info/acne/#acne_d

;

2.

Pitashny

et al. Skinmed 2005;4(2):101–

6; 3. Melis

et al. Open Access J Contracept. 2011;2(151-59).

Slide18

Further skin-related effects of COCs

1-4

The properties of the progestin may further modulate the hypo-androgenic effect of COCs

1,2

COCs

with progestins with no intrinsic androgenic activity (such as cyproterone

acetate, chlormadinone acetate, drospirenone)

may improve symptoms of acne to a greater extent than

those with intrinsic androgenic activity

(levonorgestrel

and

norgestimate)

3

Acne can also be an undesirable side effect following COC

initia

tion

4

1. Melis

et al. Open Access J Contracept.

2011;2(151-59

);

2. Darney

. Am J Med. 1995;98(1A):

104S-10S

.

3. Arowojolu

et al. Cochrane Database Syst Rev 2012;7:CD004425;

4. Lopez et al. Cochrane Database Syst Rev. 2010(3):CD003552

Slide19

You ask Nadia whether she is willing to discuss the use of regular contraception and suggest options that may also help her acne if she is interested

Nadia agrees to consider using regular contraception but she tells you that she is worried about side effects of COCs

She asks you to explain the potential side effects

You

also emphasise the need for dual protection to reduce risk of STI

Slide20

You describe the common adverse effects of combined oral contraceptives (COCs)

Commonly occurring adverse effects with COC use are well documented, and include:

1

nausea, breast tenderness, and headache

Less common adverse effects of COC use can include:

1acne; decreased libido; dizziness; fluid retention; increased cervical ectopia; melasma;

mood changes and depression; ocular effects; including decreased tolerability to contact lenses

;

vaginal candidiasis; vomiting and other gastrointestinal symptoms (e.g., bloating); weight changes; and unscheduled bleeding

For the most part, the common adverse effects of COCs are mild in intensity, are transient in nature, and resolve within a few months of starting COCs

1-3

1. US

FDA, 2004;

2. Barr

NG. Am Fam

Physician

2010;82(12):

1499-506

;

3. Sabbatini R,

et al. J Reproduktionsmed

Endokrinol

2011;8(Special Issue

1):

130-56

Slide21

There is the potential for serious cardiovascular events with COC use

1,2

Of the potential serious adverse reactions that might occur in COC users, cardiovascular events, including VTE and ATE, which may be life-threatening or may have a fatal outcome, are among the most relevant

These events

rarely

occur1,2 Many women are unaware of these potential

complications

3

ATE: Arterial

thromboembolism;

COC: Combined

oral contraceptive;

VTE: Venous

thromboembolism

1. Dinger JC, et

al.

Contraception

2007;75(5):

344-54

;

2. Dinger J, et

al.

Contraception

2014;89

(4):

253-63; 3. Vogt C, et

al. Eur J Contracept Reprod Health Care 2011;16(3):183-93.

Slide22

Symptoms of VTE (DVT and PE)

In the event of symptoms women should be advised to seek urgent medical attention and to inform the healthcare professional that she is taking a COC

Symptoms of DVT can include:

Symptoms

of

PE can include:

Unilateral swelling of the leg

and/or foot or along

a vein in the

leg

Pain or tenderness in the leg which may be felt only when standing or walking

Increased warmth in the affected leg; red or discolored skin on leg

Sudden onset of unexplained shortness of breath or rapid

breathing

Sudden coughing, which may be associated

with hemoptysis

Sharp chest pain

Severe light headedness or dizziness

Rapid or irregular heartbeat

DVT: Deep

vein thrombosis;

PE: Pulmonary

embolism;

VTE: Venous thromboembolism

Slide23

Once Nadia has chosen a method, you agree a follow-up appointment to help address any issues or concerns she may have

Regardless

of

the method chosen, scheduling follow

-up

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

Slide24

Nadia returns three months later

She is still with the same boyfriend but the relationship has been on and off over the last month

Nadia tells you that he still refuses to wear a condom but it will be OK now because she

is about to end the relationship

once

and for allShe tells you that she’s interested in starting another relationship but wants to know when would be the best time for the ‘pill break’ her friend told her she would need while using COCs

Slide25

Communicating the impact of a ‘pill break’ on cardiovascular risk

The risk of VTE is highest during the first months of COC declining thereafter to relatively stable levels

1,2

Switching between COCs without a break is not associated with an initial excess risk of VTE

2

However, the VTE risk is increased in women re-starting the same COC or switching to another COC following a pill break of 4 weeks or more2

1. Dinger JC, et al.

Contraception 2007;75(5):

344–54

; 2.

Dinger

et al. Pharmacoepidemiol Drug Saf 2010;19(S1):

S214–5.

Slide26

After building up a rapport with Nadia,

you explore her relationship with her family and her boyfriend a little further

Is

the age and ‘reputation’ of the boyfriend

an issue for Nadia?

Slide27

After building up a rapport with Nadia,

you explore her relationship with her family and her boyfriend a little further

Is

the age and ‘reputation’ of the boyfriend

an issue for Nadia?

What would you do if you found out that Nadia was regularly being coerced into sex against her will?

Slide28

Relationships play a major role in

adolescent

life but

they may not always be healthy

1

Relationship factors can impact contraceptive use2E.g. Increased age difference between a woman and her partner increases the risk of contraceptive non-useA consultation for contraception creates an opportunity to discuss an adolescent’s relationship and emphasise that:1Everyone

deserves to have control over their own sexual and reproductive

health

Making

anyone do anything that they don’t want to do sexually is sexual

control

Interfering with

someone’s birth control is one form of reproductive

control

1. Planned Parenthood Federation of America Inc. Sexual and Reproductive Control,

2014;

Guleria S et

al.

Acta

Obstet

Gynecol

Scand.

2017;96(3

):286-294.

Slide29

Learning goals: Nadia

After completing this case study, you should have greater insights into:

Managing the needs and expectations of an adolescent women who has poor

understanding of the importance of consistent use of contraception to protect against unintended pregnancy

Communicating the importance of the need for protection against STIsExploring non-contraceptive benefits of some methods may be of interest to some womenCommunicating the side effects and risks associated with use of COCs

Communicating the impact of ‘pill breaks’ with COCs on cardiovascular risk

Wider discussion: Recognising situations where confidentiality does not prevent the asking of questions about consent or coercion

Slide30

Additional slides

Slide31

The gap between typical and perfect use of user-dependent methods needs to be considered, especially for adolescents

1,2

1. Trussell

J. Contraceptive efficacy. Contraceptive Technology 2011; Twentieth Revised

Edition; 2.

Apter D.

Gynaecol Forum 2013;18(3):3.

Slide32

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