Contraception for young people. Dr Cindy Farmer Bristol Sexual Health Services Fri 8 th May 2015

Transcription

1 Contraception for young people Dr Cindy Farmer Bristol Sexual Health Services Fri 8 th May 2015

2 Learning objectives Be able to apply the principles of confidentiality, Fraser Guidelines, consent and safeguarding children in clinical scenarios Be able to address young people s health concerns and risks in relation to contraception use

3 NATSAL 3 15, years interviewed between Sept Aug Lower median age at first intercourse 30% of yrs have had sex with someone before age 16

4 What do young people need? Access to services Prevent, diagnose, treat STIs Protect against unintended pregnancy through provision of contraception

5 What do young people need -2. Confidential services Encourages young people to come forward and facilitate disclosure of consensual and nonconsensual activity

6 Tension between need to protect children from sexual abuse and exploitation and right to confidentiality

7 Freya Freya comes to see you with a friend, wanting to start some contraception. She is 14. What are some of the broader issues you need to consider?

8 Age of consent to sexual activity Capacity/Competence to consent to treatment Parental consent Fraser guidelines Duty of confidentiality to young people Safeguarding

9 Consent triangle What is required for consent to be valid?

10 For consent to be valid, the person must: Be competent to make the decision Have enough information to take the decision Be free from duress.

11 In law, any competent young person in the UK can consent to medical treatment including contraception. If a competent young person consents to treatment, a parent or legal guardian cannot override that consent For young people under the age of 16 years, competence to consent has to be demonstrated In E+W and NI, in order to provide contraception to young people < 16 years without parental consent, it is considered good practice to follow the Fraser Guidelines/criteria

12 Fraser Guidelines Understands the professional s advice.* cannot be persuaded to inform parents. likely to begin, or to continue having, sexual intercourse with or without contraception. Unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer. In best interests to receive contraceptive advice or treatment with or without parental consent.

13 Capacity Young people under 16 can give their own consent to treatment provided that they are judged capable of understanding what is involved ie they have capacity: Understand information relevant to the decision Retain that information for as long as necessary to make that decision Balance or weigh that information Communicate the decision. Mental capacity Act 2005

14 Having the Capacity to Consent to treatment is not the same as capacity to consent to sex Capacity may be impaired by: Level of consciousness Influence of drugs Illness Age Learning difficulties Young people cannot consent to their own abuse

15 NSPCC No one noticed, no one heard 2013 Report describes childhood experiences of abuse of young men and women and how they disclosed this abuse and sought help 5-17% <16 experience CSA 1 in 3 don t tell anyone

16 Tool to categorise the sexual behaviours of young people, to help professionals: make decisions about safeguarding children and young people assess and respond appropriately to sexual behaviour in children and young people understand healthy sexual development and distinguish it from harmful behaviour

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18 Spotting the signs proforma Child sexual exploitation

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21 Domestic violence Being a witness to or a victim of domestic abuse in the home is a key indicator for CSE Family Rights group report 800% increase on DV cases

22 FGM March 2015 : Female Genital Mutilation Risk and Safeguarding- Guidance for professionals em/uploads/attachment_data/file/418564/ _DH_FGM_Accessible_v0.1.pdf

23 If any under-18 has symptoms or signs of FGM, or if you have good reason to suspect they are at risk of FGM having considered their family history or other relevant factors, they must be referred using standard existing safeguarding procedures. Children s Services or the Multi-Agency Safeguarding Hub, From April 2015 mandatory data collection will extend to GPs

24 SRE 1 in 3 teens are turning to porn to fill the gaps left by SRE NUS- 2,500 surveyed

25 Freya Freya has a boyfriend who is also aged 14. They have been together for the last 6 months but have only started having sex last month. Her last period was 2 weeks ago. She last had sex 3 days ago. What methods of contraception could you start today?

26 Quick-starting If pregnancy cannot be excluded but is likely to continue to be at risk of pregnancy or has expressed a preference to start contraception without delay, immediate quick starting may be considered.

27 Quick-starting COC POP Implant Injectable NOT IUD unless fulfills criteria for em IUD NOT IUS

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29 Health concerns that health professionals (may) have Nulliparity Age Bone health Medical eligibility

30 Contraception choice There are no restrictions on using any method based on nulliparity alone Age alone should not limit contraceptive choices, including intrauterine methods. In women aged under 18 years DMPA may be used as first-line contraception after all options have been discussed and considered unsuitable or unacceptable.

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32 What do you think are some of the common health concerns that young people have when starting contraception? How would you address these?

33 Common health concerns that young people have Acne Weight gain Mood changes Family history

34 Acne COC use may improve acne Overall, few differences have been found between COC types in terms of their effectiveness for treating acne. co-cyprindiol (Dianette )should not be used solely for contraception and is licensed for treatment of severe acne that has not responded to oral antibiotics.

35 Strengthening of warnings about use of Dianette Concerns raised in France 2013 when co-cyprindiol product Diane-35 linked to death of 4 women over a 25 year period. review by the Pharmacovigilance Risk Assessment Committee (PRAC) of the European Medicines Agency (EMA) around the risk of thrombosis associated with co-cyprindiol ( not in response to publication of any new data)

36 PRAC recommendations re : cyproterone acetate 2mg/EE2 35 mcg indicated for the treatment of moderate to severe acne and/or hirsutism Not for use as contraception alone should only be used after topical therapy or systemic antibiotic treatment have failed. should not be used in combination with other hormonal contraceptives. letter issued to healthcare professionals strengthening warning about VTE European-wide review of other CHCs prompted

37 October 2013 PRAC recommendations for 3 rd and 4 th generation combined hormonal contraceptives Small risk of venous thromboembolism (VTE) associated with all CHCs and the risk of VTE differs among products depending on the type of progestogen ( see table). Risk of arterial thromboembolism (ATE) with CHC is very low and no evidence for a difference in the level of risk between products depending on type of progestogen. Benefits of CHC continue to outweigh the risks

38 Pregnancy 29 Immediate post-partum period Co-cyprindiol CHC containing: chlormadinone Dienogest (Qlaira ) Nomegestrol (Zoely ) 1.5-2x higher than LNG-containing CHC NOT yet known pregnancy 29 Immediate post-partum period

39 Weight gain no evidence of weight gain with COC use. weight gain can occur with DMPA use particularly in women under 18 years of age with a BMI 30kg/m2. Earlier replacement of implant may be considered in heavier women

40 COC and mood CEU statement Aug 2014 mood changes are often cited as a side effect and a reason for discontinuation evidence supporting an association is generally LACKING Some studies have found that previous depression was the only significant predictor of mood deterioration in those taking COC. Other studies suggest that COC does NOT lead to a worsening of depressive symptoms amongst premenopausal women with existing depression. Mainly observational studies not possible to exclude the possibility of confounding As there are a wide range of contraceptives available, women who report continuing mood changes can be offered suitable alternative The Royal College of Obstetricians and Gynaecologists recommend that that women with PMS, use the contraceptive pill continuously rather than cyclically.

41 Freya reveals that her grandmother has recently been diagnosed with breast cancer and wants to know more about her own risk and whether the pill is contra-indicated. How would you advise her?

42 UK MEC

43 Lifetime risk of breast cancer 1:8

44 COC and breast cancer CEU statement Aug 2014 New evidence -Cancer Research Study classified COC use according to formulation, dose and type of estogen progestogen used. Relative to never users or former users of COCs, recent users of oral contraception (within the prior year) experienced a small increased breast cancer risk (odds ratio [OR], 1.5; 95% confidence interval [CI], )

45 COC and breast cancer main findings of the study Risk was higher amongst those who had recently used certain types of COC: high-dose estrogen (50μg ethinylestradiol or 80μg mestranol) (OR, 2.7; 95% CI, ), Triphasic pills (OR, 3.1; 95% CI, ) In the UK, there are NO currently marketed COCs containing doses of EE2 higher than 35μg so the monophasic COCs observed as being associated with the greatest risk are NOT AVAILABLE in UK Moderate dose oral contraceptives (30-35μg ethinylestradiol or 50 μg mestranol) were associated with a small statistically significant increased risk (OR 1.6; 95% CI, ) When the findings were analysed by progestogen type: pills containing LNG or norgestimate were NOT associated with increased risk. pills containing NETwere associated with INCREASED risk Low dose pills (20 μg ethinylestradiol) were NOT associated with an increased risk (OR, 1.0; 95% CI, ).

46 Practical advice for practitioners Health professionals should be aware of and inform women of a possible small increased risk of breast cancer with use of oral contraceptives which declines with time after stopping. Women should be informed about the benefits of use in terms of ovarian and endometrial cancer and possibly colorectal cancer Women can be informed that evidence does NOT support an increased risk of cancer overall or an increased risk of death from cancer associated with use of oral contraceptives.