Case study 1: Martyna

1. Case study 1: Martyna

2. Learning goals: Martyna After completing this case study, you should have greater insights into: • Managing the needs and expectations of an adolescent woman who is ambivalent about contraception and risk of pregnancy • Supporting mother-daughter communication during a consultation with an adolescent • Addressing the fears and misperceptions around use of some contraceptive methods • The relevance of STI risk and need for screening

3. Your patient: Martyna • 15 years old • Arrives with her mother, who is very insistent that her daughter uses a reliable method of contraception on a regular basis

4. Interactive question Is it appropriate to continue the consultation with Martyna alone?

5. Interactive question • Is it appropriate to continue the consultation with Martyna alone? • If yes, at what point would you ask her mother to leave? • If no, how would you use the joint consultation to obtain an accurate picture of Martyna’s needs and expectations?

6. Managing parental presence in an adolescent consultation 1. Sacks D, Westwood M. Paediatr Child Health 2003;8(No 9):554-556; 2. O'Rourke-Suchoff DK et al. Int J Adolesc Med Health. 2017 Jun 9. [Epub ahead of print]. • Carrying out the consultation alone could provide an opportunity to gather useful additional information1 • However, where it is permissible, it may be appropriate to start the consultation with the parent present1 • Potential benefits of parental presence include:1 • Increasing the speed at which medical and family history can be gathered • Identify opportunities to support communication between adolescent and parent • Parents can be an important source of information regarding contraception and should be included in discussions where possible and appropriate2 • Mothers in particular feel a strong responsibility to be involved and support their teenage daughters’ decisions regarding contraception2

7. Effective communication between mothers and daughters can shape long-term sexual behaviour1-4 Use of contraception and rate of unintended pregnancy amongst daughters who did or did not communicate with their mothers (n=299)1 1. Palatnik A, Seidman DS. Int J Women Health 2012;4:265-270; 2. Karofsky PS, et al. Fam Plann Perspect 1996;28:159-165; 3. Hutchinson MK, et al. J Adolesc Health 2003;33:98-107; 4. O'Rourke-Suchoff DK et al. IntJ Adolesc Med Health. 2017 Jun 9. [Epub ahead of print]. • It can also have a positive impact on adolescent sexual decision-making and use of contraception1,2

8. When asked, Martynasays she is happy for her mother to stay • 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 • You reassure Martyna that you ask all your patients these questions irrespective of their age

9. Martyna tells you… • There are no problems with her periods or known medical issues but there is a family history of breast cancer • She has been sexually active for almost a year during which time she has had three different partners • She uses condoms most of the time but her current partner doesn’t like them so sometimes she doesn’t bother • She isn’t particularly worried about contraception or getting pregnant as her friend’s sister (aged 17) is going to have a baby soon • She is only here because her mother insisted - her mother is divorced and does not want Martyna to be a single mother • Her mother tells you that Martyna does well at school and higher education is a definite possibility

10. Interactive question • How does Martyna’s sexual history affect the way you counsel her about contraception?

11. Interactive question • How does Martyna’s sexual history affect the way you counsel her about contraception? • What would your focus be? • Her high risk of STI? • Her attitudes towards contraception? • Her ambivalence towards pregnancy?

12. A contraceptive consultation provides an opportunity to discuss STI risk Rate (per 1000,000 population) Men Women Age 4000 3200 2400 1600 800 800 1600 2400 3200 4000 0 0 10-14 14.7 108.9 15-19 715.2 3043.3 20-24 1325.6 3621.1 25-29 757.9 1428.3 30-34 390.9 599.2 35-39 207.5 273.4 40-44 116.6 118.3 45-54 55.9 41.4 55-64 17.0 11.3 65+ 4.0 2.5 Total 262.6 623.1 Rates of reported cases of chlamydia by age and sex, United States, 2013 1. Murray PJ, et al. Pediatrics 2014;134:e302–e311; 2. Centers for Disease Control and Prevention. (2014, December). Accessed at:http://www.cdc.gov/std/stats13/surv2013-print.pdf. Prevalence rates of many sexually transmitted infections (STIs) are highest among adolescents1,2 Women aged <25 years have the highest rates of chlamydia1

13. Martyna’s multiple sexual partners and inconsistent use of a condom places her at risk of STI • 1. Murray PJ and Committee on Adolescence. Pediatrics 2014;134:e302–e311.2. Ott MA, Sucato GS and Committee on Adolescence. Pediatrics 2014;134(4):e1257–1281; 3. Hoopes AJ et al. J PediatrAdolesc Gynecol. 2017 Apr;30(2):149-155; 4. Centers for Disease Control and Prevention.2015. Accessed at: http://www.cdc.gov/condomeffectiveness/docs/condoms_and_stds.pdf; 5. Committee on Adolescent Health Care. Obstet Gynecol. 2017 May;129(5):e142-e149. Screening for chlamydia and gonorrhoea can be performed by nucleic acid amplification test (NAATs) of urine or cervical/vaginal swabs1 It is reasonable and possible to screen for an STI and initiate contraception on the same day and then administer treatment if the test results are positive2,3 Irrespective of method of contraception, a condom is recommended at all times for protection against STIs in women at risk4,5

14. Table discussion • 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 • How could you use the fact that someone Martyna knows is having a baby to motivate her regarding use of contraception?

15. Table discussion • Could you explore Martyna’s thoughts about: • The impact of the impending pregnancy on the girl concerned and/or her family? • How such an event might impact on Martyna and her family – in terms of attitudes, practical aspects of living at home, and her aspirations? • 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 • How could you use the fact that someone Martyna knows is having a baby to motivate her regarding use of contraception?

16. Asking the right questions, in the right way • Motivational interviewing (MI) techniques can be useful to:1-3 • 1. Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. 1991; New York: Guilford Press; 2. Ott MA, Sucato GS. Pediatrics 2014;134(4):e1257–81; 3. ACOG Committee Opinion No. 423. Obstet Gynecol 2009;113(1):243–6. • Explore and manage ambivalence towards pregnancy and contraception • Identify inconsistencies between life goals and sexual behaviour • Anticipate potential compliance or adherence issues • Assist in the selection of the most appropriate method

17. Motivational Interviewing techniques can be used successfully in a contraceptive counselling situation1 Using OARS2 Open-ended questions Affirmations Reflective listening Summaries • 1. Lopez LM et al. Theory-based interventions for contraception. Cochrane Database Syst Rev. 2016 Nov 23;11:CD007249; 2. Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. 1991; New York: Guilford Press. • Four guiding principles in motivational interviewing2 • Express empathy – seek to understand feelings and perspectives without judging • Develop discrepancy – create or amplify the discrepancy between current behaviour and broader goals and values • Roll with resistance – new perspectives are invited but not imposed and resistance is reframed to create a new momentum toward change • Support self-efficacy – use belief in the possibility of change as a motivator

18. Martyna’s attitudes towards pregnancy can be explored using the following types of question What does the friend’s family think about their daughter having a baby so young? Will having a baby affect this woman’s opportunity to stay in school and/or her future employment? How important to Martyna is doing well at school and going to college? If important, how would having a baby affect her ability to do that? What else would she miss out on if she had a baby at this point?

19. Martyna agrees that contraception would avoid the negative consequences of pregnancy • You move on to check: • Martyna’s awareness, knowledge, needs and expectations • The accuracy of her knowledge of methods, including her fears and concerns • The acceptability and affordability of her preferred option. For example, is she good at taking medicines regularly if needed

20. Your discussion reveals: • Martyna’s knowledge about contraceptive methods is minimal and mostly incorrect • She is concerned about the effects of the pill on her weight and risk of breast cancer • When you ask her if she has had any recent illness or is on any medication, she tells you that she recently had to take some antibiotics but unfortunately she missed some doses because she kept forgetting to take the tablets

21. Martyna’s poor knowledge of contraceptive methods is common amongst adolescents1 1. Craig AD, et al. Women Health Issues 2014;24(3):e281–9. * Depot contraception

22. Interactive questions • What method(s) would you discuss with Martyna at this point?

23. Interactive questions • What method(s) would you discuss with Martyna at this point? • Is there any method you think would be most suitable for Martyna and why? • Any method you think would not be suitable for Martyna and why? • How would you improve Martyna’s knowledge and understanding of her choice(s)?

24. In principle, all methods of contraception are an option for Martyna as an adolescent • The WHO Medical Eligible Criteria1 say that • ‘no medical reason currently exists to deny any method based on young age alone’ • 1. World Health Organization. Medical eligibility criteria for contraceptive use. 5th ed. Geneva: WHO; 2015

25. A consultation provides an ideal opportunity to address some myths or misperceptions that may artificially limit choice of method1 Bitzer J, et al. Eur J ContraceptReprod Health Care 2016;21:6,417-430; 2. Craig AD, et al. Womens Health Issues 2014;24(3):e281–9.

26. A consultation provides an ideal opportunity to address some myths or misperceptions that may artificially limit choice of method Bitzer J, et al. Eur J ContraceptReprod Health Care 2016;21:6,417-430; 2. Craig AD, et al. Womens Health Issues 2014;24(3):e281–9.

27. Addressing Martyna’s concerns about risk of breast cancer can help with her choice of method 1. Kahlenborn et al. Mayo Clin Proc 2006;81(10):1290-302; 2. Collaborative Group. Lancet 1996;347(9017):1713-27; 3. Hunter et al. Cancer Epidemiol Biomarkers Prev 2010;19(10):2496-2502; 4. Kumle et al. Cancer Epidemiol Biomarkers Prev 2002;11(11):1375-81; 5. Rosenberg et al. Am J Epidemiol 2009;169(4):473-9; 6. Marchbanks et al. N Engl J Med 2002;346(26):2025-32; 7. Heinemann et al. Geburtshilfe Frauenheilkd 2002;62:750-7; 8.Vessey et al. Br J Cancer 2006;95(3):385-9; 9. Colditz GA. Ann Intern Med 1994;120(10):821-6; 10. Hannaford et al. BMJ 2007;335(7621):651; 11. Vessey et al. Contraception 2013;88(6):678-83; 12. Gierisch et al. Cancer Epidemiol Biomarkers Prev 2013;22(11):1931-43. • Studies on breast cancer and oral contraceptive (OC) use suggest either modest1-5 or no6-11 effects of OC use on the breast cancer risk • Case-control studies provide conflicting results, but most cohort studies including long-term observation data, have found no increase in risk • When the relative risk was shown to be increased, this effect disappeared gradually during the course of 10 years after cessation of OC use2,12

28. COC use does not have an appreciable long-term effect on body weight 1. Vogt C, Schaefer M. Eur J Contracept Reprod Health Care 2011;16(3):183–93; 2. Gallo MF, et al. Cochrane Database Syst Rev2014;1:CD003987; 3. Beksinska M, et al. Expert Rev Obstet Gynecol. 2011;6(1):45-56; 4. Rosenberg MJ, Waugh MS. Am J Obstet Gynecol 1998;179(3 Pt 1):577–82; 5. Lindh I, et al. Hum Reprod 2011;26(7):1917–24. • Many women believe that COCs increase body weight,1 despite the fact that studies do not support this belief2,3 • Concerns about weight gain may • Deter women from starting COCs • Be a reason for early discontinuation4 • One study showed that COC use was not a predictor for weight gain5 • There was no correlation between weight increase and duration of COC use in these women

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

30. Table discussion • 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 • Do you now feel that Martyna is able to make an informed choice about a contraceptive method?

31. Table discussion • Are any other tests or investigations appropriate? • When would you arrange to see her next? • 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 • Do you now feel that Martyna is able to make an informed choice about a contraceptive method?

32. Maintaining consistency of use with user-dependent methods 1. Moreau C, et al. Contraception 2007;76(4):267–72; 2. Westhoff C, et al. Contraception 2002;66(3):141–5; 3. Society of Obstetricians and Gynaecologists of Canada (SOGC). Available at www.sexandu.ca. Accessed 30 April 2015. • Managing expectations or concerns regarding side effects of contraception may help prevent discontinuation1 • Other tips that may aid compliance include: • Quick start and extended regimens for oral contraceptives2 • Using smartphone technology to issue reminders and provide help and support if needed3

33. Regular follow-up can help address any issues with compliance • Regardless of the method chosen, scheduling follow-up appointments:1,2 • Creates an opportunity to discuss satisfaction with method and change if needed1 • Provides reassurance around potential short-term side effects2 • Improves contraceptive compliance1 • Allows screening for STIs1 1. Yoost JL et al. J Adolesc Health. 2014;55(2):222–7; 2. Grossman N. Am Fam Physician. 2010;82(12):1499-1506

34. Review of learning goals: Martyna After completing this case study, you should have greater insights into: • Managing the needs and expectations of an adolescent woman who is ambivalent about contraception and risk of pregnancy • Supporting mother-daughter communication during a consultation with an adolescent • Addressing the fears and misperceptions around use of some contraceptive methods • The relevance of STI risk and need for screening

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