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Combined oral contraceptive pill

Combined oral contraceptive pill Posted by Nibedita R.
A 14 years old woman has recently become sexually active and requests the combined oral contraceptive pill. Justify your management.

A detailed history should be taken with a very sensitive and non-judgemental approach to gain her confidence. Menstrual history: menarche, LMP, regularity of cycle, menstrual loss and dysmenorrhoea (irregular cycle, dysmenorrhoea and excessive flow are common). Careful sexual history: age of the partner (child protection issue), multiple sexual partners (risk of STD), barrier contraception use and any possibility of pregnancy should be excluded.

History to exclude contraindications of COCPS: active liver disease, focal migraine with aura, strong family history of VTE, porphyria and personal history of VTE (unlikely at her age). History of drug intake like phenytoin, phenobarbitone, rifampicin and carbamazepine, can reduce the effectiveness of COCPS and needs additional precaution while use.
Social history including the life style should be enquired, which can give an idea about her compliance.
Examination includes BP and BMI. BP-160/100 and BMI >39 are relative contraindications to COCPS use, although, these are unlikely in 14 year old.

Legal age for consent in UK is 16 years. Contraceptive could be prescribed to a 14 years girl if she understands doctor?s advice. GILLICK competence states that a girl?s physical and mental health is likely to suffer unless she receives contraceptive advice. She is likely to continue her sexual life even if she does not receive any
contraceptive advice. She cannot be persuaded and forced to inform her parents. Reassurance should be given about confidentiality.

For the pill to be effective it has to be taken daily preferably at a fixed time for 21 days a month and a 7-day pill free interval. Failure rate of COCPS is< 0.1 per 100 women year even with proper intake.

Information should be given about the common side effects like breast tenderness, acne, headache, bloating, oily skin and weight gain, which are relatively less with low dose COCPS. There is also a possibility of serious risks like VTE (15/100,000-25/100.000 users) and breast cancer (relative risk of1.24in current users). The potential benefits of COCPS must be stressed as well. Besides good cycle control it also relieves dysmenorrhoea and decreases menstrual flow, thus improving anaemia. It also has beneficial effect on benign breast disease and functional ovarian cyst, prevention of PID and ectopic pregnancy and also protects against ovarian and uterine cancer.

She must also be taught about the problems with missed pill and how to overcome these.

She should be informed about other contraceptive options like injectable preparation (depo provera), which can be administered once a month but disadvantages are irregular bleeding and amenorrhoea, which can be confused with pregnancy. Contraceptive implant (implanon) is another option which has a long lasting effect upto 3 years but is associated with side effects like irregular spotting and amenorrhoea. IUD is another effective form of long-term contraception but difficult to insert in nulliparous, increases the risk of pelvic infections and ectopic pregnancy.

She should be encouraged to inform her parents, as they also would help her to choose the best contraceptive amongst the available options.

Whatever form of contraception may be, use of condom should be stressed to prevent sexually transmitted disease.

She should be provided with 3 months supply of COCPS. Written information, contact number and address of family planning services and helpline should be given. A further appointment should be fixed within 3 months. In the interim if there is any further concern she can get in touch with her GP.




Posted by narmin B.
Prescribing a combined oral contraceptive pill to a 14 year old girl can be justified if this is in her best physical and psychological interests and it is more likely that she continue sex without contraception. This girl should be encouraged to inform her parents or to allow the doctors to inform them. However if she declines this, her psychological maturity should be noticed. A contraceptive pill can be prescribed if she is mature enough to understand the risks and benefits of the pill and without her parent?s consent. These issues constitute what is called Gillick competence.

A detailed history should be taken. History of her menstrual period with the date of last period. As there is possibility of pregnancy and this should be excluded by a sensitive pregnancy test. Presence of focal migraine and thrombosis and history throbophlia should be explored as these are contraindication to COC and alternative methods should be advised.
An examination is required to measure blood pressure. Although hypertension is uncommon in this age, but baseline record is necessary for future reference. As the risk of sexually transmitted disease is high in this age group, a vaginal examination is required to take high vaginal and endocervical swabs for Chlamydia and gonorrhoea infection. However this examination is likely to be declined, therefore the importance of this examination should be explained beforehand.
Transmission of Human deficiency e virus (HIV) is another risk and if there is high possibility of HIV infection, adequate time should be allocated to explain the importance of testing for HIV.

Continuation of sex at this early age will put her not only at the risk of sexually transmitted infections but also unplanned pregnancy and cervical cells abnormalities. These should be explained to her and continuation of sexual activity should be discouraged.

A low dose contraceptive pill such as microgynon can be given. The failure rate is very low as long as it is taken regularly. Its side effects which include irregular bleeding, breast tenderness, weight gain and thrombosis should be told. Method of use should be explained carefully and regular use should be stressed. In addition use of barrier method should be recommended to protect her from sexually transmitted diseases.

In spite of careful recommendations, she may have unprotected sex. Therefore the availability of emergency contraception should be also need to be explained.

Verbal information should be supplemented by written material. Follow- up appointment should be given in order to ensure regular use and to supply the pill.
In the case of positive results for sexually transmitted diseases and HIV she should be referred to genitourinary clinic for treatment and contact tracing.
Posted by Iman B.
It is very important during the counselling process not to come out judgemental. A sympathetic attitude will gain the patients confidence and ensure a proper detailed history will be given.
During the sitting, the Gillick competence of the patient should be established and whether she is competent enough to understand and mae her own decisions.
A history which includes menstrual to establish whether she is pre or post pubertal as administration of oestrogen in prepuberty may stunt her growth.
If menstruating, asking about the last menstrual period as delayed menses may mean she is pregnant. If in doubt a pregnancy test should be done.
Sexual history, with the number and age of the sexual contacts, this is very important to deduce any possible abuse and her liability in contracting sexually transmitted diseases.
Medical history for any contraindications of oral contraceptives, as porphria, or active liver disease, or cardiac patient with septal defect, or pulmonary hypertension, or coarctation of the aorta, or an epileptic on liver enzyme inducing anti convulsants(the dose of COCP would have to be doubled)a family history of several members with deep vein thrombosis, in case she has a hereditary thrombophilia.
General examination for the heart and presence of jaundice, blood pressure shold be taken for hypertension, in coarctation of the aorta.
The patient should have the COCP use explained to her in detail and she should be encouraged to involve her parents, with assurance that her confidence is safe.
She should be given three courses of either second or third generation COCPs, if there is no contraindication to their use, and she should be advised on the need for barrier contraception to decrease the incidence of STDs. She is given information leaflets to read at home on sexually transmitted diseases, and given a telephone helpline in case she needs to ask about anything or develops any problems.
She is scheduled to return after three months, to check on her use of the pill, and encouraged to come before that if any problems arise.
Posted by Olubunmi O.
Dear paul,
is it Gillick competence or frazer competence that is required to be assessed in this girl?.My experience recently in the family planning clinic is that its Frazer competence that is assessed nowadays.
What are the differences between the 2?
Bunmi Paisley