1. Teenage Contraception – Womens Health Update Dr Jane Wilcock BSc FRCGP MA H.Ed. Med. Ed. Cert. Silverdale Medical Practice Salford CCG year 3 and 4 co-director University of Liverpool School of Medicine Community Clinical Tutor GP jwilcock@liverpool.ac.uk

2. session the law and teenage sex child safe-guarding STDs and cervical cancer in teenage groups emergency contraception for teenagers

3. The Law

4. The law and sex England and Wales The age of consent to any form of sexual activity is 16 for boys and girls regardless of gender preferences Teenagers 15 and under having consensual sex are not prosecuted so long as of similar ages But 18+ - against the law if having sex with a child of 15 or under, especially if that person is in a position of trust like their teacher or doctor or nurse Children 12 and under are presumed to be unable to consent and so sex with 12 and under is rape

5. Contraception provision Health professionals in UK can provide contraception to the under 16s if they believe it is in the young person’s best medical interests and the young person is able to give informed consent

6. Lord Fraser - a doctor could proceed to give advice and treatment: Provided he is satisfied that: the girl (although under 16 yrs old) understands his advice he cannot persuade her to inform parents or allow the doctor to inform the parents that she is seeking contraceptive advice she is very likely to continue having sex with/without contraceptive treatment unless she receives contraceptive advice or treatment her physical/mental health/both are likely to suffer her best interests require the doctor to give her contraceptive advice, treatment or both without parental consent

7. GMC 0-18 years guidance capacity and consent You decide if a young person can understand the nature, purpose and possible consequences of investigations or treatments you propose, as well as consequences of not having treatment. Only if they are able to understand, retain, use and weigh this information, and communicate their decision to others can they consent to that investigation or treatment. All relevant information has been provided and thoroughly discussed before deciding whether or not she/he has capacity to consent. The capacity to consent depends more on young people’s ability to understand and weigh up options than on age. When assessing a young person’s capacity to consent, you should bear in mind that: – a. at 16 a young person can be presumed to have the capacity to consent – b. a young person under 16 may have the capacity to consent, depending on their maturity and ability to understand what is involved.

8. Sexual abuse Taken from e-LfH child safeguarding NSPCC

9. Awareness of child abuse Four categories: Physical abuse Neglect Emotional abuse Sexual abuse Some level of emotional abuse is involved in all types Bullying Internet abuse Living with domestic violence or, in the case of teenagers, being involved in an abusive relationship FGM (female genital mutilation) Radicalisation, which can put a young person at risk of significant harm

10. Sexual abuse Many children do not tell anyone 5% - 10% of girls and 1% - 5% of boys are exposed to penetrative sexual abuse during childhood 25% report any form of sexual abuse Most perpetrators are males: adults or other young people known to the child/young person. Teenage girls aged 15-17 reported the highest rates of sexual abuse in the past year

11. FGM female genital mutilation as sexual abuse FGM is: All procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. There are no health benefits to FGM, it is not demanded by any specific religions. Sister siblings or daughters of FGM individuals might be at risk

12. Starting out... So take a history, ask if they want to discuss anything else, check for capacity to consent to contraception It may be appropriate to ask if they have any concerns about behaviour they don’t like, is it a “good” relationship? discuss STDs and condom use

13. STDs http://ww.bashh.org/

14. STDs asymptomatic screening BASSH guidelines heterosexual vaginal sex Offer HIV and syphilis screening to all Gonorrhoea and chlamydia boys first pass urine Girls self taken vaginal swabs for G and C An STI screen should be offered when an individual presents following UPSI. This will identify pre-existing infections and a repeat screen may be needed 2 weeks after UPSI re incubation May take 12 weeks to detect antibodies to HIV and syphilis Chlamydia now has a test of cure recommendation 12 weeks after treatment

15. STDs symptomatic heterosexual vaginal sex urethritis, recurrent UTI without MSU findings (pyuria), discharge, ulcers. Offer HIV and syphilis screening to all Genital ulceration- test for HSV by swab from the ulcer and syphilis bloods Boys: first pass urine and swab if discharge: G and C Girls: Cervix - swabs G and C Vagina – swab for BV, TV or candida Look at cervix if PCB/IMB

16. Cervical cancer is the most common cancer for women aged 15-34 - ONS_files

17. Emergency Contraception Obstetrics, Gynaecology & Reproductive MedicineObstetrics, Gynaecology & Reproductive Medicine Volume 24, Issue 1, January 2014, Pages 23–28 Antenatal management of teenage pregnancy Melissa Whitworth, Ruth CockerillVolume 24, Issue 1Melissa WhitworthRuth Cockerill http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf Contraceptive Choices for Young People Clinical Effectiveness Unit March 2010 FSRH family planning association patient leaflets http://www.fpa.org.uk/resources/leaflet-and-booklet-downloads

18. Conception in teenagers Teenage pregnancy rates in UK are at their lowest since records began In England and Wales, the number of conceptions in under 18yrs fell to 27,834 aged under 16yrs 5,432 in 2012 50% end in abortion pregnancy has an increased antenatal risks and increased perinatal mortality risk to teenagers prevalence of Chlamydia amongst antenatal patients aged <20 is 14%.

19. Emergency contraception Sadie is 18 years old and comes to see you for the MAP because her condom split last night. This is the 3 rd time this has happened in this cycle. Her periods are 5/28 and she is on day 10 at present. On no tablets or PMH. Long-term 2 year relationship which she is happy with. Not wanting a pregnancy. Used depo-provera a few years ago but has just forgotten about it and felt condoms were good as she had read about chlamydia being common. What do we do?

20. Emergency contraception POEC: Levonelle 1500mg stat levonorgestrel LNG within 72 hours (3 days) (3G if on anti-epileptics) 2% failure rate POEC can be used more than once in a cycle or for a recent indication even if there has been an earlier episode of UPSI >120 hours If at risk of further sex that cycle or wants to start POP immediately after EC, then ‘quick start’ POP or implant, but have a pregnancy test in ≥3 weeks. If its quick start CHC or POP after Levonelle then use condoms for 7 days CHC, 2 days for POP, 9 days for Qlaira. Women should be advised to seek medical advice if they vomit within 2 hours of taking POEC. A repeat dose of the same method or a Cu-IUD may be offered if appropriate. Women should be advised about menstrual disturbances after oral EC use. If there is any doubt about whether menstruation has occurred, a pregnancy test should be performed ≥3 weeks after UPSI has occurred. No C. Indications

21. Ella –one (ulipristal 30mg) UPA progesterone-receptor modulator within 120 hours (5 days). 1.2% failure rate Only once in cycle. Not if previous UPSI that cycle Not with liver metabolised meds. If vomit within 3 hours of administration a repeat dose or a Cu-IUD may be offered if appropriate. Menstrual disturbances can occur. If there is doubt about whether menstruation has occurred, a pregnancy test should be performed ≥3 weeks after UPSI has occurred. Not recommended in severe asthma insufficiently controlled by oral glucocorticoids.

22. Caution in women with liver dysfunction, hereditary galactose intolerance, lactase deficiency or glucose- galactose malabsorption After intake of Ella One breastfeeding is not recommended for 36 hours Dont use Ella one if taking antacids, histamine H2 antagonists and proton pump inhibitors Ella one can reduce the efficacy of hormonal contraception. Additional precautions are advised for 14 days after it (9 days if using or starting the POP, 16 days for Qlaira, estradiol valerate/dienogest pill)

23. IUCD copper coil within 120 hours (3 days) lowest failure rate The Cu-IUD may be used up to 5 days after the earliest expected date of ovulation regardless of the number of episodes of UPSI. Ovulation is 14 days from end of cycle length i.e. luteal phase is set. May not be able to swab in advance of insertion so swab at time. Ideally an emergency IUD should be inserted at first presentation, but if not possible oral EC can be given in the interim, and the woman advised to attend for insertion at the earliest appropriate time. Remember to do a pregnancy testing prior to EC administration if a woman has been at risk earlier in the cycle. 9 % of women aged under 25 years asking for EC have chlamydia. Recently acquired STI may not be detected and that they may need to be retested after the appropriate window period. Antibiotics should be considered for women presenting for an emergency IUD Can use ECs in advance of need if persuaded is in best interests

24. If you think she is at risk of further sex that cycle or she wants to start contraception immediately after EC, then ‘quick start’ CHC (not Dianette) or POP or implant, but have a pregnancy test in ≥3 weeks If its quick start after Ella one use condoms for 14 days (9 days for POP, 16 days for Qlaira) The CEU does not currently support use of Ella one more than once per cycle or if there has been another episode of UPSI outside the treatment window (>120 hours).

25. Common issues with Microgynon 30 CHC Microgynon 30. teens use alerts on smart phones to remember teens are on the net and can access the family planning leaflets easily if directed can have every day pills not in migraine common antibiotics do not interact not if BMI>35 Missed pills – 7 days stops ovulation. Missing pills either side of the pill free interval can cause ovulation – 2 or more pills missed sparks action

26. POP Cerazette; desogestrel - ovulation is inhibited in 97% of cycles and 12-hour window for missed pills. missed POPs: take the one missed and condoms for 2 days

27. Remember competency to consent Vulnerability to abuse Immediate problems like pregnancy, emergency contraception Longer term family planning STD risks

28. Thankyou