contraception - teenager
Doctor Information
Lacey Clark, age 14
Previous consultation:
Jan 2012
Seen with mum, has spots on cheeks and chin, feels quite self conscious around school friends.
Currently using clearasil wash but doesn't work very well.
O/E multiple small comedomes on cheeks and chin, mild inflammation, no scarring.
Discussed options, wants to try Duac gel. Review if not settling.
No other PMH
No known allergies or current medication
Previous consultation:
Jan 2012
Seen with mum, has spots on cheeks and chin, feels quite self conscious around school friends.
Currently using clearasil wash but doesn't work very well.
O/E multiple small comedomes on cheeks and chin, mild inflammation, no scarring.
Discussed options, wants to try Duac gel. Review if not settling.
No other PMH
No known allergies or current medication
Patient Information
Lacey Clark, age 14
Opening line: I want to go on the pill please.
History:
You have come alone to the doctors. You have heavy periods and want to try the pill because your best friend is on it and says it works really well. You started your periods at 13 and they are not very regular. You tend to go through a sanitary towel every hour for the first few days, and on your last period you leaked through your skirt which was really embarrassing. No bleeding between periods.
If asked only:
You have had a boyfriend, Jake, for 4 months, he is a childhood friend who is 15. You haven’t had sex yet but you talked about with him and you are going to next week. He is not forcing you, you feel ready. Your mum knows about Jake, but she would be furious if you told her you were going to have sex. You won't be persuaded to tell her, and if you were refused the pill you would still use condoms and have sex. This is the real reason you wanted the pill.
You have 2 older brothers at home, and your family is generally quite close. You don't smoke and have only tried wine once.
No PMH or DH
Ideas: you think that going on the pill is a good idea for your periods and your relationship
Concerns: that the doctor will tell your mum about your plans with Jake
Expectations: you might be able to get away with not telling the doctor about Jake and would only tell him/her if they are nice to you
Opening line: I want to go on the pill please.
History:
You have come alone to the doctors. You have heavy periods and want to try the pill because your best friend is on it and says it works really well. You started your periods at 13 and they are not very regular. You tend to go through a sanitary towel every hour for the first few days, and on your last period you leaked through your skirt which was really embarrassing. No bleeding between periods.
If asked only:
You have had a boyfriend, Jake, for 4 months, he is a childhood friend who is 15. You haven’t had sex yet but you talked about with him and you are going to next week. He is not forcing you, you feel ready. Your mum knows about Jake, but she would be furious if you told her you were going to have sex. You won't be persuaded to tell her, and if you were refused the pill you would still use condoms and have sex. This is the real reason you wanted the pill.
You have 2 older brothers at home, and your family is generally quite close. You don't smoke and have only tried wine once.
No PMH or DH
Ideas: you think that going on the pill is a good idea for your periods and your relationship
Concerns: that the doctor will tell your mum about your plans with Jake
Expectations: you might be able to get away with not telling the doctor about Jake and would only tell him/her if they are nice to you
Examination Findings
Pulse 87 reg
Blood Pressure 117/65
BMI 22
Blood Pressure 117/65
BMI 22
Mark scheme
Data Gathering
|
Positive Indicators
Takes menstrual and sexual history Uses Fraser guidelines Checks blood pressure and BMI |
Negative indicators
Omits important details in menstrual/sexual history Does not use Fraser guidelines Fails to examine patient |
Clinical Management Skills
|
Positive Indicators
Makes appropriate decision regarding contraception Shares treatment options and provides relevant information each including risks Arranges follow-up |
Negative Indicators
Makes assumptions about contraception or refuses to prescribe Makes decisions without involving patient Does not arrange follow-up |
Inter Personal Skills
|
Positive indicators
Identifies health beliefs and agendas Builds up rapport with patient and encourages discussion Explains treatments in lay terms |
Negative indicators
Does not enquire about health beliefs and agendas Poor rapport Uses jargon when explaining |
Management
Although this case is focussed around a basic ‘pill consultation’, there is the added level of complexity because the patient is a minor. It is important to take an accurate menstrual history, particularly in terms of dysmenorrhoea, menorrhagia, and whether any measures have been tried previously, as this will guide your management options. It is also important to assess whether the patient has any contraindications to any of the options (see below). It is wise to take a sexual history in a sensitive manner.
In anyone under 16 years old, you need to apply the Fraser Guidelines to decide whether it is appropriate to prescribe a contraceptive:
"...a doctor could proceed to give advice and treatment provided he is satisfied in the following criteria:
1) that the girl (although under the age of 16 years of age) will understand his advice;
2) that he cannot persuade her to inform her parents or to allow him to inform the parents that she is seeking contraceptive advice;
3) that she is very likely to continue having sexual intercourse with or without contraceptive treatment;
4) that unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer;
5) that her best interests require him to give her contraceptive advice, treatment or both without the parental consent."
As she should be deemed competent, a few options are available to her. She could use either the combined or the mini pill, but arguably the combined may be more suitable in controlling her heavy periods and help with acne as well. There is also a reduced risk of ovarian, uterine and colon cancer. Lets say you start a combined pill e.g. Micrognynon. She needs to know the following:
The pill is taken every day for three weeks, and then there is a pill-free break for one week. During the break she should get a ‘withdrawal’ bleed, which is usually lighter and less painful than a regular period. Normal fertility returns when the pill is stopped. It works by stopping egg release, and also affects the lining of the womb and cervical mucus.
Disadvantages: some people get temporary adverse side effects e.g. headaches, breast tenderness, nausea, mood changes. You have to remember to take it, and it is less effective than long acting methods. There is no protection against sexually transmitted infections, so condoms should be used as well.
Risks: small increased risk of DVT, breast cancer (worse in smokers/diabetics/older age/high BP/overweight)
Missed Pills - if one is missed anywhere in the cycle, take when remembered and take the next one as usual. If 2 pills or more are missed, the actions depend on where in the cycle she is: week 1 (take emergency contraception if UPSI occurred during pill free week) and continue the pack as normal; week 2 (consider emergency contraception is UPSI in pill free week or week 1); week 3 (omit pill free interval, no emergency contraception needed).
Arrange follow-up - 3 month review.
For information about other forms of contraception, visit cks.nice.org.uk/contraception
In anyone under 16 years old, you need to apply the Fraser Guidelines to decide whether it is appropriate to prescribe a contraceptive:
"...a doctor could proceed to give advice and treatment provided he is satisfied in the following criteria:
1) that the girl (although under the age of 16 years of age) will understand his advice;
2) that he cannot persuade her to inform her parents or to allow him to inform the parents that she is seeking contraceptive advice;
3) that she is very likely to continue having sexual intercourse with or without contraceptive treatment;
4) that unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer;
5) that her best interests require him to give her contraceptive advice, treatment or both without the parental consent."
As she should be deemed competent, a few options are available to her. She could use either the combined or the mini pill, but arguably the combined may be more suitable in controlling her heavy periods and help with acne as well. There is also a reduced risk of ovarian, uterine and colon cancer. Lets say you start a combined pill e.g. Micrognynon. She needs to know the following:
The pill is taken every day for three weeks, and then there is a pill-free break for one week. During the break she should get a ‘withdrawal’ bleed, which is usually lighter and less painful than a regular period. Normal fertility returns when the pill is stopped. It works by stopping egg release, and also affects the lining of the womb and cervical mucus.
Disadvantages: some people get temporary adverse side effects e.g. headaches, breast tenderness, nausea, mood changes. You have to remember to take it, and it is less effective than long acting methods. There is no protection against sexually transmitted infections, so condoms should be used as well.
Risks: small increased risk of DVT, breast cancer (worse in smokers/diabetics/older age/high BP/overweight)
Missed Pills - if one is missed anywhere in the cycle, take when remembered and take the next one as usual. If 2 pills or more are missed, the actions depend on where in the cycle she is: week 1 (take emergency contraception if UPSI occurred during pill free week) and continue the pack as normal; week 2 (consider emergency contraception is UPSI in pill free week or week 1); week 3 (omit pill free interval, no emergency contraception needed).
Arrange follow-up - 3 month review.
For information about other forms of contraception, visit cks.nice.org.uk/contraception