CONTRACEPTION---CONTINUED

 Medical Assessment.

Before you are given contraceptive advice the care givers need to make a detailed medical assessment of your health.

Your age, is particularly important, if you are under 18 or nearing menopause. Other facts we need to know is your menstrual cycle, when did you start , is it regular, how often it comes, is it heavy or scanty(small bleeding), is it painful, does it give you  headaches? These are a lot of questions.  They are all important to choose the best contraceptive for you. You will also need to answer questions about your sexual history, and if you have had any sexually transmitted infections (STI’s or STD’s), or Pelvic inflammatory diseases (PID).  Besides these answers the caregiver will need to know about, high blood pressure, diabetes, kidney disease, liver disease, epilepsy, fibroids, ovarian cyst’s, polycystic ovarian syndrome,  ectopic pregnancy and any gynaecological surgery.  Are   you   on   any medications?  Are   you a smoker? Then there will be questions about your family medical history such as cardiovascular disease (CVD) or thromboembolism (DVT). They will also want to know if you have personally had any of the above   problems. Last but not the least is your Obstetric history. Have you had any pregnancy, miscarriages, abortions or babies? How many babies you have had, when will you likely have your next baby, or is this it? How old is your last child, are you currently lactating?

Do you have any history of taking herbal remedies as this is important, particularly   St John’s Wart. This is often given for   depression, anxiety and many other problems, not properly diagnosed. This   herb interacts with many drugs particularly oral contraceptives and antibiotics. In fact it is banned in France and some others countries are going to put a warning on its packaging. So if you are on any herbal remedies, please let your care giver know.

Examination and tests

The next step before the   contraceptive advice is given is to perform a detailed examination of the client and do the necessary tests. All the examinations and tests I am going to discuss are not done for everyone. The care giver makes a clinical decision, when and on whom to do which tests.

First of all a basic clinical examination   is    essential. This includes general appearance, height and weight (body mass index or (BMI), hearing, vision,   heart, blood pressure, lungs and reflexes. Abdominal examination can tell us if there are any problems with the abdomen. In my working life I have come across many young girls who were already a few months pregnant when I saw them for contraceptive advice.

I saw one, 13 year girl who was almost   full term with her pregnancy when she came to me for contraceptive advice. She had not started her periods as yet, she assured me that she had sex only once and her partner who was a little bit older than her and he had withdrawn his penis .  How   unlucky can you be? There   are   two lessons here. She got pregnant on her first ovulation. Withdrawal method did   not work.  It does not always work. You need a fair bit of experience for this.

The other question arises about pelvic examination. There is some controversy if it should be done for teen age girls. It depends on the history to some extent.

Pelvic Examination is the examination of a woman’s private organs both externally and internally. It is a delicate examination.

The care givers have to be careful performing this on any female particularly if she is a young girl and never had a pelvic examination before. She will be informed of what it involves and why it is being done. She needs to get undressed below the waist and put a gown or to be covered with a sheet. The external parts are inspected for normal appearance or any discharge. Often an internal examination is performed to feel for the Cervix, Uterus or any enlarged Ovaries or pelvic masses. Normal ovaries are not felt on this examination. The next examination is a pap test or Papanicolaou test. This not required if the woman has never had sex. Recently changed recommendations on pap tests do not need to be initiated until 21 years of age. Thus visualizing the cervix with an instrument call the speculum is often not required. It is good to relax if you are having this done otherwise your muscles contract and the examination becomes painful. Tests that are now available on urine and vaginal swabs to look for STI’s and non STI infections also eliminate the need for speculum examination.

Always keep the possibility of current or past sexual abuse in mind

This examination if performed in a sensitive manner without any rush can be a positive experience especially if the teen ager is reassured that all is normal and well.

To summarize pelvic examination before advising contraception to teenagers is required:

 1) Any developmental defect noted on

     external inspection.

 2) Persistent vaginal discharge or urinary    symptoms

 3) Painful periods

 4) Missing periods

 5) Excessive or irregular vaginal bleeding

 6) Contraceptive request for an IUD

      Or diaphragm

7) Need to do a pap test

8) To exclude pregnancy

9) In cases of suspected rape or sexual abuse

Tests

1) Pregnancy test if required

2 ) Blood tests ; for anaemia, general blood test, Hormone tests if the menstrual cycles are abnormal like in cases of Polycystic Ovarian syndrome, or nearing menopause.

3) Pelvic ultrasound this is a most important test. It can be done abdominally or from the vulva ie: from outside our pelvic organs. Both these tests are totally simple and non invasive. Internal ultrasound if explained and done with sensitivity, is also simple and can give a lot more information. it is particularly useful if the patient is older and they do not need a full bladder.