Contraception in a Minor with Migraine

PLAB 2 CaseBank
1

Where you are:
FY2 in the GP surgery.

Who the patient is:
Heather Watson is a 15-year old female who has made an appointment to see you.

Other information:
None

What you must do
Talk to the patient and address her concerns.

Patient Information:

  • You are 15 year old Heather Watson and you suffer from migraines with aura.
  • The aura begins about an hour before the migraine and you experience visual problems where you see zigzag lines.
  • You also experience associated nausea and sometimes vomit.
  • The headache is usually left sided.
  • You take paracetamol for the headaches.
  • You are otherwise fit and well.
  • You have a 15 year old boyfriend and you are sexually active. Up till now you have been using condoms but your boyfriend doesn’t like them so you want to see the GP to discuss what other options you have for contraception.

Questions:

  • Can it be kept confidential?
  • How will I be taking POP?
  • What are the side effects?
  • What is the failure rate?

Examiner’s prompt: If the candidate says they want to take the BMI, tell them the BMI is 32.

Approach

GRIPS

  • May I know what brought you to the practice today?
  • Can I ask some questions to undertand your situation better?
  • Usually it is a prctice police that any one under 16 years of age should attend the practice with their parents.
  • Have you come on your own?
  • And do you parents know that you re here?
  • Ok, Its ok I will see you, now that you are already here.
  • And do your parents kow anut your sexual relationship?
  • Is there any particuar reason you have ot told your parents about your relationship?
  • Reassure that : We can definitely help with contraception.

Offer Confidentiality: Reassure that whatever is discussed will be kept confidential.

Ask about her sexual relationship and assess for abuse. Can I ask you about your sexual life:

  • Are you in a stable relationship ?
  • How long have you been together with your partner?
  • How old is your partner?
  • How has everything been going with your partner?
  • Has your partner ever been aggressive towards you?
  • Has he ever forced you to have sexual intercourse when you didn’t want to?

History of contraindications- Now I need to ask you few question to assess your suitability of contraception?

  • Diabetes , hypertension , heart problems. , fibroids, precious ectopic , epilepsy , headache, migraine , CVS risk , breast feeding .

Menstrual history-menorrhagia

  • Last menstrual period?
  • How many days do you bleed?
  • How many days is your cycle?
  • Are your periods regular?
  • Are your periods heavy?
  • Do you experience any pain during your periods?

Previous contrception:

  • What contraception have you tried in the past?
  • What about condoms –have you tried them?
  • How does your partner feel about using condoms?

Assess for Gillick competence :

  • I need to ask you some questions to check that you understand why you need contraception
  • Can you just explain to me why do you need contraception?
  • What would happen if you do not use contraception ?
  • And do you know some of the riks of being in a sexua relationship ?

Assess for fraser criteria:

  • Do you think you can try and talk to your parens abit yor relationship?
  • Your parents where of your age at one poin-they may undertand .
  • How would you fel if you not prescribed contraception today?
  • If you are not prescribed contraception, do you think that would stop from being in sexiual relatinship?
  • Would you consider using condoms-they would also protect you from sexually transmistted infection.
  • Contraception does not protect from STI.

Discussion- Fraser criteria : Prescribe contraception only if the following criteria are met:

  • The young person understands the practitioner’s advice.
  • The young person cannot be persuaded to inform their parents or will not allow practitioner to inform parents.
  • The young person is likely to begin or continue to have sexual intercourse with or without protection.
  • The young person’s best interest requires the practitioner to give contraceptive advice or treatment without parental consent.
  • Unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health is likely to suffer.

Rule out pregnancy:

  • Last menstrial period
  • Last sexual intercourse

Examinations:

  • Abdominal
  • Blood pressure
  • BMI

Explain different options of contraception:

  • Combined contraception (vaginal ring, transdermal patch and pill)
  • POP
  • IUCD
  • Levonorgestrel (IUS)
  • Barrier methods (condoms)

Screening for STIs if she has had unprotected sexual intercourse and explain that sometimes it can be symptomatic.

Prescribe the contraception you have reached agreement with and offer leaflets about contraception

Note:

  • This patient has got migrans so COCP can worsen headaches.
  • We should advise POP.
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