Embedded Files
In module Family Medicine and Public Health
17 years old school student in last grade ( grade 12) married of 2 months. She came to your clinic to discuss her contraceptive choices.
MAIN CASE
Guidance and Resources – Contraception MED 35
Case Introduction – Contraception MED 35
Further Case Information – Contraception MED 35
Background Science – Contraception MED 35
Case Conclusion – Contraception MED 35
Formative Assessment – Contraception MED 35
CASE COMPONENT
Guidance and Resources – Contraception MED 35
In case FM&PH – Contraception
Recommended essential Reading and Resources
Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.
You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.
Overview of Contraceptive Methods: NHS Choices (there is a link to this also within the case)
Chapter of family planning (99) in MURTGH
Resources for Additional Information/Reference
· FSRH Guidance: Combined Oral Contraceptive
· FSRH Guidance: Emergency Contraception
· You can revise previous ethics and law work on shared decision making with young people on OneMedLearn
· You can revise some BSS work on teenagers and their psychology
You may also want to review your ‘Prescribing Handbook’ which you can download on your iPads.
CASE COMPONENT
Case Introduction – Contraception MED 35
In case FM&PH – Contraception
She is 17 years old, student in secondary school in grade 12, she got married 2 months ago, her husband is a university student, she added that she and her husband preferred not to get pregnant until she finished her school (need one year to graduate),
she said that they relay on condoms but she is afraid that the condom can slipped off, she came asking first regarding the possibility of any emergent contraception in such a situation of unprotected intercourse , she was told by a friend about something called after the morning pills, further more she want to discuss her contraceptive choices in general
What should Dr Gill say to Sophie when she raises her concern about confidentiality?
Ignore this concern, there are more important things to discuss
Reassure Sophie immediately that absolutely everything they talk about is kept confidential between the GP and Sophie
Reassure Sophie that the consultation is confidential but that there are circumstances where confidentiality would have to be breached, which broadly the GP might outline as if he felt that she was at risk.
Further Case Information – Contraception
In case FM&PH – Contraception
The emergency contraceptive levonogestrel has been issued. This is an oral emergency contraceptive pill with a licence to be used once per menstrual cycle up to 72 hours after unprotected sexual intercourse. It has been issued by the pharmacist, without a prescription.
How has the pharmacist issued this medication without a prescription?
Certain medications can be issued without a prescription using a PGD (Patient group directive).
What is a Patient Group Direction (PGD)?
PGDs provide a legal framework that allows some registered health professionals to supply and/or administer a specified medicine(s) to a pre defined group of patients, without them having to see a prescriber. However, supplying and/or administering medicines under PGDs should be reserved for situations in which this offers an advantage for patient care, without compromising patient safety.
This creates a prescription for a group of patients that fall within pre- defined inclusion criteria.
What are the mechanisms of action of the ‘morning after’ emergency contraceptive pill levonogesterel?
The emergency contraceptive pill is thought to work through a variety of mechanisms.
1. The normal menstrual cycle is altered, delaying ovulation
2. Ovulation is inhibited, meaning the egg will not be released from the ovary;
3. It can irritate the lining of the uterus (endometrium) so as to inhibit implantation.
4. It aids prevention of fertilisation of the egg by making it harder for sperm to penetrate the outer wall.
Other options for emergency contraception
Copper coil IUD (intra-uterine device)
This is the most effective form of emergency contraception and can prevent pregnancy when fitted up to 5 days (120 hours) after unprotected sex. It can also be left in place for ongoing contraception. It requires a trained medical professional to fit it, which involves a procedure similar to a smear where the coil is inserted through the cervical os. The pharmacist generally would not be able to fit this. This is associated with a small risk of infection and perforation. If used for ongoing contraception, it can affect the periods, generally making them heavier or more painful.
EllaOne (Ullipristal acetate 30mg)
This is a newer oral emergency contraceptive pill than levonogestrel. It binds with high affinity to progesterone receptors, and delays ovulation. It has a license to be used up to 120 hours after unprotected sex. Due to this binding to progesterone receptors, consideration needs to be made if an oral contraceptive is going to be used following this morning after pill.
CASE COMPONENT
Background Science – Contraception MED 35
In case FM&PH – Contraception
Contraceptive Choices
There are several types of contraception, each with different modes of action, benefits and risks. It is important when you start to prescribe contraception, hat you discuss the benefits and risks with a patient, which might include comparison of different methods so that the woman can weigh up the information to make an informed choice. In contrast to many medications we prescribe, we are not ‘treating’ a condition, and so risks need to be clearly understood by the patient to achieve a shared partnership.
Contraception is often not considered to be ‘medication’ by a patient, and so special mention is prudent in a history. This is because not only do some contraceptives increase the risk or likelihood of other conditions e.g. clots with the oral combined contraceptive, but there may well be drug interactions with a medication that you wish to prescribe for another unrelated condition. This is important as the medication you want may not work as well due to the contraceptive, might be more risky or might make the contraceptive less effective.
IN PRACTICE:
Try asking a patient a medication history, to include over-the-counter and contraceptives. This may form part of one of your Logbook activities.
Watch this video from NHS Choices as a summary of the main methods:
There are useful resources regarding contraception here, which would be useful to access as revision for this case.
It is important to appreciate:
Perfect use means the method is used correctly every time.
Typical use is what is seen in terms of failures by women using the method and accepting that the method has not been used perfectly every time.
There is full information and guidance relating to prescription of all contraception types available through the Faculty of Sexual and Reproductive Healthcare (link above). This relates to UKMEC which are ‘UK Medical Eligibility Criteria’. This is a number from 1-4 as follows, against each type of contraception and various medical conditions. The categories are:
· Category 1: A condition where there is no restriction of use of that contraceptive
· Category 2: A condition where the benefits of using the particular method of contraception generally outweigh the risks
· Category 3: A condition where the theoretical or proven risks of using the method outweigh the benefits. The method may be used by a specialist, since use of the method is usually not recommended unless other options are not available or not acceptable
· Category 4: A condition which represents an unacceptable health risk if the method is used.
A healthcare professional prescribing a contraceptive may well consult this document prior to prescribing any contraceptive and would use this information to ensure all conditions, which would pose an unacceptable risk, are identified before the method is advised. The healthcare professional would also outline the benefits to the woman of each type of contraceptive, which can include reduced risks of certain cancers.
OneMedLearn Resources
You have come across the basic science about the menstrual cycle, and including contraception, Life Cycle Case 1,
You can revise previous ethics and law work on shared decision making with young people on OneMedLearn.
You can revise some BSS work on teenagers and their psychology
CASE COMPONENT
Case Conclusion – Contraception MED 35
In case FM&PH – Contraception
Dr Gill reviews the medical record during the consultation and sees that Sophie visits the practice every 12 months for a review of her eczema medication, which is well controlled. She is well adherent with her use of the steroid (hydrocortisone cream 1%) and emollient (epaderm cream). She has no other conditions on her summary and does not take any other medications, including over-the-counter or illegal/legal substances.
Her weight is 50kg and she is 158cm tall, which gives her a BMI of 20. Her BP is 120/70. Her periods have been regular since she started having them 12 months ago, with a bleed every 28 days and no inter-menstrual or post-coital bleeding. She has no vaginal discharge, pain on intercourse or abdominal or pelvic pains. She denies any personal or family history of any medical conditions including clotting disorders, breast cancer or liver disease. She has no risk factors for increased risk of heart disease, stroke or arterial disease.
Dr Gill goes on to ask specifically about other factors which are important to check, if a combined oral contraceptive is being considered. Sophie denies ever smoking, and has never had a migraine (migraines need further evaluation and could mean that the combined oral contraceptive could be contra-indicated).
Dr Gill discusses the options available to Sophie for contraception, including copper coil IUD, the intra-uterine system (IUS) which is a coil with hormones, the POP, the depot injection and the COCP.
She takes a patient information leaflet which outlines her options, and thinks that she would like to try the combined oral contraceptive. She would like to talk it through with her mum and husband first, and Dr Gill books her in for a routine appointment with her for the following week when her mum can come with her.
Formative Assessment – Contraception MED 35
Up to how many hours after intercourse can Levonorgestrel be used as an effective method of emergency contraceptive?
· 24 hours
· 48 hours
· 72 hours
· 96 hours
· 72 hours
Other options for emergency contraception include: (Select ALL that apply)
· Copper coil IUD (intra-uterine device)
· Cerazette
· EllaOne (Ullipristal acetate 30mg)
· Cilest
· Copper coil IUD (intra-uterine device)
.Correct answer.
This is the most effective form of emergency contraception and can prevent pregnancy when fitted up to 5 days (120 hours) after unprotected sex. It can also be left in place for ongoing contraception. It requires a trained medical professional to fit it, which involves a procedure similar to a smear where the coil is inserted through the cervical os.
· Cerazette
.This is the name of a progesterone-only oral contraceptive pill. Sometimes women know progesterone-only pills (POPs) as ‘the minipill’ although this term is used less now.
· EllaOne (Ullipristal acetate 30mg)
.Correct answer.
This is a newer oral emergency contraceptive pill than levonogestrel. It binds with high affinity to progesterone receptors, and delays ovulation. It has a license to be used up to 120 hours after unprotected sex. Due to this binding to progtesterone receptors, consideration needs to be made if an oral contraceptive is going to be used following this morning after pill.
· Cilest
.This is the name of a combined oral contraceptive pill (COCP). We will discuss different types of oral contraceptive pill in this case.
A 35-year-old woman comes for a pre-operative assessment. You are the FY1. What important things should you ask specifically about in the medication history?
· If using any contraception
· Over the counter medications
· When her last period was
· Prescribed medications
· Allergies and intolerances
· If using any contraception
.Correct answer.
Depending on the contraception, there might be associated risks of the surgery with that contraception, such as increased risk of dvt with the COCP. Medications, the anaesthetic agents or the surgery itself may also interfere with her contraceptive, which is important to consider to avoid an unplanned pregnancy.
· Over the counter medications
.Correct answer.
There may be medications which would be important to know about and which might need to be stopped before her operation which the patient can get over the counter, such as aspirin.
· When her last period was
.Only if concern about pregnancy or related to the surgery.
· Prescribed medications
.Correct answer.
This is important for any pre-operative assessment for many reasons. These include ensuring that the correct monitoring is in place, any medications given do not interact with what the patient is already taking and any medications which need to be stopped prior to the operation are known about in advance e.g. warfarin.
· Allergies and intolerances
.Correct answer.
This is clearly important so that a medication is not given which would cause the patient harm.
A 75-year-old woman comes for a pre-operative assessment. You are the FY1. What important things should you ask specifically about in the medication history? (Select ALL that apply)
· When her last period was missed.
· Allergies and intolerances
· Over the counter medications
· Prescribed medications
· If using any contraception
· When her last period was
.Only if concern about pregnancy or related to the surgery.
· Allergies and intolerances
.Correct answer.
This is clearly important so that a medication is not given which would cause the patient harm.
· Over the counter medications
.Correct answer.
There may be medications which would be important to know about and which might need to be stopped before her operation which the patient can get over the counter, such as aspirin.
· Prescribed medications
.Correct answer.
This is important for any pre-operative assessment for many reasons. These include ensuring that the correct monitoring is in place, any medications given do not interact with what the patient is already taking and any medications which need to be stopped prior to the operation are known about in advance e.g. warfarin.
· If using any contraception
.It would be generally considered unlikely that a woman would require contraception at the age of 75. However, you might want to ask specifically about Hormone Replacement Therapy, as this may have implications for her surgery in terms of increased risk of thrombosis.
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