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Case 4.7 – Contraception (Adolescence)

Category: Endocrine & Reproductive Systems | Discipline: Obstetrics & Gynaecology | Setting: General Practice

Case

Monica Wentworth aged 15 years presents requesting the oral contraceptive pill. She has been in a relationship with her boyfriend for 4 months and in the past two weeks she has commenced sexual relations. She has not used a condom and is worried she may be pregnant. She wants a reliable contraceptive so she doesn't become pregnant. She has told her mother and states that her mother supports her request for contraception and to access the oral contraceptive pill.

Questions

1. What further history, examination and investigations would you undertake in this situation?

History

A full history should be conducted but focusing upon:

  • The relationship - Is it mutual and caring?
  • Past medical and family history - If known, hereditary thrombophilia, breast cancer
  • Previous sexual encounters (if any)
  • Partner's risk of STI - Including HIV, Hep B, etc.
  • Childhood vaccinations - Has HPV vaccination been given?
  • Menstrual history - Menarche, cycle length, menstrual flow, irregular bleeding, vaginal discharge
  • Other relevant symptoms - Any headaches, migraines
  • Smoking history

Discussion Should Include

  • Safe sexual practices
  • STIs and HIV
  • "Double Dutch" - condoms and OCP together
  • Instructions on OCP usage, side effects, "golden rules"
  • Emergency contraception (morning after pill)
  • Follow up

Examination

Requires STI screening but does not require PV or speculum examination. Patient will usually NOT want you to do anything invasive at this visit.

Investigations

  • Pregnancy test - Serum bHCG or early morning urine
  • STI screening - First pass urine for Chlamydia and gonococcus (PCR) or self-collected vaginal swab
  • Baseline HIV (offered) and Hep B
2. What screening for disease is warranted?

Investigations

  • Pregnancy test - Serum bHCG or early morning urine
  • STI screening - First pass urine for Chlamydia and gonococcus (PCR) or self-collected vaginal swab
  • Baseline HIV (offered) and Hepatitis B

Vaccinations

  • HPV vaccination should be offered (not as effective after intercourse but does have some reduction in abnormalities)

Cervical Screening

Cervical Screening test - from age 25. In current recommendations, routine cervical screening is not recommended in young women, except for women who experience first sexual activity at a young age <14 years, and who had not received the HPV vaccine before sexual debut, to consider a single HPV test between age 20-24 on an individual basis.

3. List the contraceptive options available for Monica and in a table list their respective mechanism of action, Pearl Index, advantages and disadvantages.

Contraceptive Options for Teenagers:

Type of Contraception Mode of Action Pearl Index Advantages Disadvantages
Condoms Barrier 3
  • Available
  • No health risks
  • Protects against STI
  • Relatively easy to use but need practice and training
  • Requires motivation
  • Rare rubber allergies
  • Can fall off
  • Need to be used for every sexual event
Combined Oral Contraceptive Pill (OCP) Hormonal control - prevents ovulation in majority of women, changes cervical mucous, develops hostile endometrium for implantation 0.1
  • Convenient
  • Allows spontaneity
  • May reduce acne
  • Reduces menstrual flow and pain to point of amenorrhoea
  • Requires daily taking of OCP
  • Long term health issues with smoking and DVT
  • Reduction in effectiveness with NVD
  • Warn of breakthrough bleeding
Sub-dermal Progesterone Implant Progesterone effects - hostile endometrium and cervical mucous 0.1
  • Provides contraception for 3 years
  • No motivation required after insertion
  • Immediate return to previous fertility state on removal
  • Requires procedure to insert
  • Requires procedure to withdraw
Depo-Provera Progesterone effects - hostile endometrium and cervical mucous, may stop ovulation 0.3
  • No pills
  • Reliable
  • Minimal motivation required
  • May induce amenorrhoea
  • Injection 3 monthly
  • May cause irregular cycle
  • 3 kg weight gain maximum
  • Not immediately reversible

Note: The Pearl Index is the number of contraceptive failures per 100 woman-years of use. Lower numbers indicate greater effectiveness.

4. What does Australian law state about prescribing contraceptives to teenagers?

Legal Capacity to Consent

The age that a young person acquires the legal capacity to give consent has been considered by the High Court of Australia and gave the following précis:

"Achieves a sufficient understanding and IQ to enable him or her to understand fully what is proposed"

14 years and above.

Practitioner Considerations

This then leaves the practitioner to balance IQ, knowledge, maturity and nature and seriousness of the treatment. The law is unclear on contraceptive advice and prescribing but the following applies:

  • Patient is capable of understanding advice
  • Unable to be persuaded to talk to parents/guardians
  • Likely to engage in sexual activity regardless of contraception
  • The treatment is required for their wellbeing (physical and mental) and is clearly in their best interests
5. How should a medical practitioner behave, and remain true to their duty of care to a patient, if they do not wish to prescribe contraception to Monica for religious or other reasons?

Key Points

Doctor's obligations: A doctor has a duty to care for this patient, however that does not mean that they must prescribe the OCP. However if Monica is to remain sexually active - highly likely - she needs reliable contraception. If she is likely to forget pills the implant would be the most appropriate.

Duty of Care Includes

  • To diagnose
  • To treat appropriately
  • To follow-up
  • To attend when called
  • To disclose relevant facts
  • To provide information to make decisions
  • To maintain confidentiality

Essential Actions

  • Explore the nature of the relationship - Age of the partner to ensure that there is no sexual abuse or any issues that require mandatory reporting
  • Explain all options - Should explain the indications, contraindications and risks of all forms of contraception
  • Discuss risks of sexual intercourse - Especially infection, use of condoms, etc.
  • Provide information on screening - STI screening if required, cervical screening tests, etc.

If Unwilling to Prescribe

If a practitioner has religious or other objections to prescribing contraception, they must:

  • Inform the patient of their objection
  • Not abandon the patient
  • Refer the patient to another practitioner who can provide the service
  • Ensure continuity of care
  • Still provide advice on safe sexual practices and STI prevention