1. The Family Planning Clinic

2. For each of the cases Consider the factors raised by the case Advise about options, including alternatives

3. Case 1 A 22 year old who smokes 20/day comes wanting oral contraception. She does not have a regular partner. Her mother had a DVT after a fractured ankle

4. Risk of VTE? Smoking increases the risk X2. Increased risk from FH? Mother might have been screened. DVT occurred following fracture- low risk for genetic cause Risk of STDs? Screen for chlamydia and suggest barrier methods in addition to OC Health advice re smoking

5. Case 2 A 45 year old wants contraception and comes for advice. She is a non-smoker, BMI 25 and has developed increasingly heavy periods over the past 2 years

6. Clinical examination indicated ?any obvious structural abnormality Check history- if has IMB needs endometrial biopsy Any contraindication to OC? (no) Would help menorrhagia. Could take continuously Consider other options: POP, MIRENA

7. Case 3 A 25 year is 7 weeks pregnant and seeks termination of her pregnancy On what grounds may this be carried out and what are the methods used?

8. The Abortion Act 1967 allows TOP if 2 doctors agree that: A Continuance of the pregnancy involves risks to the life of the woman greater than if the pregnancy were terminated B Termination is necessary to prevent grave permanent injury to the physical or mental health of the woman CThe pregnancy has not exceeded 24 weeks and continuance involves risk of injury to physical or mental health of the woman greater than if the pregnancy were terminated D The pregnancy has not exceeded 24 weeks and continuance would involve greater risk to the physical or mental health of existing children E There is a substantial risk the child would be born with physical or mental abnormalities as to be seriously handicapped Methods of termination: surgical or medical with mifepristone (antiprogesterone) and misoprostol (prostaglandin analogue)

9. Case 4 A 35 year old who smokes 15/day wants to know if she can continue the pill. She feels well and likes this method of contraception

10. Risk X 20 of MI in smokers on OC >35 Risk X 7 of stroke VTE risk increases with age Smokers >35 are advised to stop OC as risks outweigh benefits Consider alternatives: POP, MIRENA, Implanon

11. Case 5 A 16 year old had sexual intercourse 4 days ago and wants to know if there is any emergency contraception When is the earliest she could find out if she is pregnant?

12. Emergency contraception licenced for use within 72 hours: Cu IUCD or levonorgestrel 1.5mg- this may be used up to 120 hours unlicensed but efficacy decreases with time Pregnancy may be diagnosed clinically when the next period is missed Biochemically: the blastocyst implants 1 week after fertilisation and hCG is produced by the syncytiotrophoblast Urinary hCG detectable at 25 iu/ml 3-4 days after implantation Test positive in 98% cases 7 days after implantation

13. Case 6 A 32 year old on O.C. is worried as her mother has recently developed breast cancer and her sister has been diagnosed with cervical cancer. She is well and a non-smoker. Should she reconsider her contraception?

14. Re: breast cancer Data not clear. Not obvious but may be a small increase in risk Re: cervical cancer. No genetic tendency. O.C. use associated with a slight increase risk ?x2 over 10 years of use. Important to participate in screening programmes for cervical cytology

15. Case 7 A 15 year old with Down syndrome is asking for the contraceptive pill

16. Competency Any “competent” young person can consent to treatment. Need to be able to understand what is involved and the alternatives. Consent to treatment must be based on sufficient and accurate information If patient not competent a holder of parental responsibility makes the decision or an appointed guardian if >18 Be alert to sexual exploitation or co-ersion in vulnerable adults

17. Case 8 A 39 year old with a BMI of 42 is asking for the pill. She is a non-smoker and has had the pill before having her 3 children

18. BMI >40 is “morbidly obese”. This carries an increased risk of VTE and cardiovascular disease with O.C use, and this reisk increases with age. Need to consider the risks and benefits (risk less than that of pregnancy) BNF advises to avoid O.C. if BMI >39 Higher risk of pregnancy if low-dose pill prescribed Consider alternatives

19. Case 9 A 28 year old woman has a 6 month baby and is still breast-feeding. She has just had her first period since delivery and wonders if she can take the pill?

20. Use of C.O.C. early post-partum (<6w) can suppress lactation and increase risk of VTE. 6w-6 months: risk of O.C outweighs benefits >6 months- O.C safe and will not suppress lactation as well-established Discuss alternatives ?L.A.R.K (long-acting reversible contraception- MIRENA, depo- provera, implanon)