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UBC Objectives: Women's Health, Priority Topic: Contraception & Priority Topic: Sexually Transmitted Infections

11/5/2018

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Contraception

Key Feature 2: In patients using specific contraceptives, advise of specific factors that may reduce efficacy (ex: delayed initiation of method, illness, medications, specific lubricants).
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Key Feature 3a: In aiding decision-making to ensure adequate contraception: Look for and identify risks (relative and absolute contraindications).
Skill: Clinical Reasoning
Phase: History

Key Feature 3b: In aiding decision-making to ensure adequate contraception: Assess (look for) sexually transmitted disease exposure.
Skill: Clinical Reasoning, Patient Centered
​Phase: History

Key Feature 3c: In aiding decision-making to ensure adequate contraception: Identify barriers to specific methods (ex: cost, cultural concerns).
Skill: Clinical Reasoning, Patient Centered
​Phase: History

Key Feature 3d: In aiding decision-making to ensure adequate contraception: Advise of efficacy and side effects, especially short-term side effects that may result in discontinuation.
Skill: Clinical Reasoning
​Phase: Treatment

Key Feature 4: In patients using hormonal contraceptives, manage side effects appropriately (i.e., recommend an appropriate length of trial, discuss estrogens in medroxyprogesterone acetate [Depo– Provera]).
Skill: Clinical Reasoning
​Phase: Treatment

Key Feature 5: In all patients, especially those using barrier methods or when efficacy of hormonal methods is decreased, advise about post- coital contraception.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 6: In a patient who has had unprotected sex or a failure of the chosen contraceptive method, inform about time limits in postcoital contraception (emergency contraceptive pill, intrauterine device).
Skill: Clinical Reasoning
Phase: Treatment

Sexually Transmitted Infections

Key Feature 1: In a patient who is sexually active or considering sexual activity, take advantage of opportunities to advise her or him about prevention, screening, and complications of sexually transmitted diseases (STIs).
Skill: Patient Centered, Clinical Reasoning
Phase: Treatment

Key Feature 3: In high-risk patients who are asymptomatic for STIs, screen and advise them about preventive measures.
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment, Investigation

There is more than one way to not have a baby, but some of these methods are less effective than others. As well, there are certain methods that become less effective under particular circumstances. Below is a diagram put out by the wonderful website Sex & U that provides an overview of the common forms of contraception and just how effective they truly are.
Picture
On the Sex & U website, there is an interactive webpage called "It's a Plan." Here, a menu of contraception methods can be found, along with pros and cons for each option. When having a conversation about contraception choices with patients, I pretty well always mention It's a Plan. That being said, if there is time to have  an informed discussion and a patient feels prepared to make a decision during the current visit, I prefer to initiate a method of contraception in an otherwise unprotected person who does not desire pregnancy even if they haven't visited Sex & U already. In obtaining informed consent, for each method, I discuss:
  1. Its efficacy (per the table above)
  2. Benefits and risks/side effects (aka pros and cons)
    1. Side effects to discuss with patients if they are interested in the method (per Its a Plan)
      1. IUD
        1. Initially, irregular bleeding or spotting may occur. With the copper IUD, women may experience heavier bleeding or worsening of any pre-existing dysmenorrhea.
        2. With the hormonal IUD, menstrual bleeding tends to be much lighter and often stops altogether (depending on the person, this is more often seen as a benefit, but some women prefer to have a monthly menstrual cycle). With the hormonal IUD, some women may experience hormonal side effects: acne, headaches, breast tenderness, mood issues.
      2. Injectable contraception
        1. Initially, irregular bleeding is the most common side effect. But unfortunately the injectable contraception has many other possible side effects. Injectable contraception, much like the hormonal IUD, also has the effect of leading to less/lighter bleeding, which is generally perceived as a benefit but that may be a disadvantage to some women.
        2. Some women may also experience an opposite effect, whereby they get heavier menstrual bleeding and/or spotting.
        3. Note that if the woman is experiencing irregular bleeding that she is sufficiently bothered by, there are treatment options. If estrogen is not contraindicated, for example, a combined OCP can be used for to decrease irregular bleeding
        4. The injectable contraceptive may be associated with a change of appetite and/or weight gain in some women.
        5. Some women may have hormonal side effects: acne, headaches, breast sensitivity, mood issues/depression and a change in sex drive.
        6. And last but not least, it must be administered by a health care provider every 3 months, which some women feel is fairly inconvenient.
      3. `Oral contraceptive pill
        1. Effectiveness may be reduced by other medications.
        2. Like all hormonal methods, it may cause irregular bleeding or spotting.
        3. It may also cause breast tenderness, nausea, or headaches, but these are usually short-term side effects (usually resolving within first 3 months of use, so it is worth trialing the medication over this time frame).
        4. It must be taken every day, at the same time, which is hard for some patients to do consistently.
        5. Some women experience the following side effects with the progestin-only pill specifically: acne, headaches, breast sensitivity, mood issues.
      4. Contraceptive patch and ring
        1. Similar to the combined OCP.
        2. The patch may cause skin irritation, and the ring may cause vaginal irritation, discomfort, or discharge. The ring also requires remembering to replace it monthly.
  3. When it is contraindicated (per UpToDate)
    1. IUD: 
      1. Severe distortion of the uterine cavity
      2. Active pelvic infection
      3. Known or suspected pregnancy
      4. Wilson's disease or copper allergy (for the copper IUD)
      5. Unexplained abnormal uterine bleeding
      6. Breast cancer and other hormone-sensitive diseases (for the hormonal IUD)
      7. Dysmenorrhea and menorrhagia are relative contraindications to the copper IUD as it can worsen these symptoms
    2. Injectable contraception
      1. Breast cancer
      2. Known or suspected pregnancy
      3. Relative contraindications (because there are better options in these circumstances): 
        1. Women with severe cirrhosis, hepatocellular adenoma, diabetes with nephrosis or vascular complications, hypertension, ischemic heart disease or multiple risk factors for atherosclerotic disease, and some forms of lupus
        2. Unexplained vaginal bleeding
        3. Pregnancy planned within the next year, because a delay in return in fertility may occur with this method
        4. Long-term use of corticosteroid therapy in women with a history of, or risk factors for, nontraumatic fractures. 
        5. Current use of aminoglutethimide (usually for the treatment of Cushing's syndrome) because aminoglutethimide may increase metabolism of progestins 
    3. Oral contraception pill (much fewer contraindications if progesterone-only, these are identified in brackets)
      1. Age ≥35 years and smoking ≥15 cigarettes per day
      2. Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)
      3. Hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)
      4. Venous thromboembolism (VTE)
      5. Known thrombogenic mutations
      6. Known ischemic heart disease
      7. History of stroke
      8. Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)
      9. Migraine with aura
      10. Breast cancer (contraindication with progesterone-only pill as well)
      11. Known or suspected pregnancy (contraindication with progesterone-only pill as well)
      12. Undiagnosed abnormal uterine bleeding (contraindication with progesterone-only pill as well)
      13. Benign or malignant liver tumours, severe cirrhosis, or acute liver disease (contraindication with progesterone-only pill as well)
      14. Women who have undergone malabsorptive bariatric surgeries and those taking certain anticonvulsants (contraindication with progesterone-only pill as well)
    4. Contraceptive patch and ring
      1. Contraindications are the same as those for other estrogen-progestin contraceptives 
      2. Relative contraindication: obesity (decreased effectiveness)
  4. Any logistical information that influence decision-making, such as what using the method most effectively would entail in terms of regular behaviours on the part of the patient (ex: taking a pill at the same time every day). Note that hormonal contraceptives require a dual coverage period with a barrier method during the first week of use. As well, it is thoughtful to remind patients that oil-based lubricants can cause condoms to break. It is worthwhile asking patients if they think they can be successful the method(s) they are interested in, and if they foresee any barriers to its use, culturally or otherwise. Also, when discussing cost, it is useful to know that the upfront cost of the IUD is much more than a few months of the OCP, but after a couple of years of the OCP, the cost of the IUD becomes more favourable; if a women is not planning on conceiving for a couple of years plus, the IUD is cheaper in the end.

As part of contraception counseling I always inquire obtain a sexual health history, inquiring about the need for STI screening or investigation for symptoms that suggest an infection is currently present (ex: genital discharge pruritus, dysuria, constitutional symptoms). I counsel the patient to consider STI testing as frequently as they would like, such as after new sexual partners if sex is unprotected, and that this could be as simple as peeing in a cup. I always remind patients that contraception (unless using a barrier method such as a condom) does not prevent against STIs. An important part of this counseling is also explaining that STIs may present without symptoms, but can lead to problems such as loss of fertility. If a patient is suspected of having an active STI, it is best to delay insertion of an IUD until the infection is treated or ruled out with testing.

I also always advise patients about accessing emergency contraception if they have unprotected intercourse or failure of a contraceptive method (ex: broken condom), and the sooner the better as it loses its effectiveness with time. Options include the emergency contraception pill and the copper IUD, which can both be employed up to 5 days post-coitus.
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UBC Objectives: Care of Men, Priority Topic: Contraception, Priority Topic: Eating Disorders, Priority Topic: Immigrants, Priority Topic: In Children, Priority Topic: Substance Abuse, & Priority Topic: Trauma

2/20/2018

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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
  • Demonstrate awareness of ethical and cultural considerations and legislation involved in men’s health (ex: contraceptive and pregnancy counselling for minors, childhood sexual abuse, effects of poverty, low self-esteem and marginalization on the health of men)

Contraception


Key Feature 1: With all patients, especially adolescents, young men, postpartum women, and perimenopausal women, advise about adequate contraception when opportunities arise.
Skill: Patient Centered, Communication
Phase: Treatment

Eating Disorders

Key Feature 1: Whenever teenagers present for care, include an assessment of their risk of eating disorders (ex: altered body image, binging, and type of activities, as dancers, gymnasts, models, etc., are at higher risk) as this may be the only opportunity to do an assessment.
Skill: Clinical Reasoning
Phase: History

Immigrants

Key Feature 4c: As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Assess patients for availability of resources for support (ex: family, community organizations).
Skill: Clinical Reasoning, Patient Centered
Phase: History

In Children

Key Feature 2: As children, especially adolescents, generally present infrequently for medical care, take advantage of visits to ask about:
  1. Unverbalised problems (ex: school performance)
  2. Social well-being (ex: relationships, home, friends)
  3. Modifiable risk factors (ex: exercise, diet)
  4. Risk behaviours (ex: use of bike helmets and seatbelts)
Skill: Clinical Reasoning, Patient Centered 
Phase: History, Treatment

Key Feature 3: At every opportunity, directly ask questions about risk behaviours (ex: drug use, sex, smoking, driving) to promote harm reduction. 
Skill: Clinical Reasoning, Communication
Phase: History, Treatment

Key Feature 4: In adolescents, ensure the confidentiality of the visit, and, when appropriate, encourage open discussion with their caregivers about specific problems (ex: pregnancy, depression and suicide, bullying, drug abuse). 
Skill: Communication, Patient Centered
Phase: Treatment

Substance Abuse

Key Feature 4: Discuss substance use or abuse with adolescents and their caregivers when warning signs are present (ex: school failure, behaviour change).
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment, Diagnosis

Key Feature 6: Offer support to patients and family members affected by substance abuse. (The abuser may not be your patient.)
Skill: Patient Centered
Phase: Treatment

Trauma

Key Feature 11: Find opportunities to offer advice to prevent or minimize trauma (ex: do not drive drunk, use seatbelts and helmets).
Skill: Clinical Reasoning
Phase: Treatment

Being in the Pediatric Emergency Department for just over one week now, I've been getting much-needed exposure to sick kids. I need to know what they look like, how to recognise when they're at risk of decompensating, and how to intervene in this natural history. Being in the Pediatric ED has also reminded me that so many acute problems are really exacerbations of chronic issues with potential to be attenuated by strong primary care connections. This is because these problems are often significantly aggravated or alleviated by social issues that cannot be sufficiently addressed with fleeting relationships of care, as is the case with emergency department medicine. This is not to knock emergency medicine. It is a miraculous thing in a time of crisis. But it is not a solution (as it is not intended to be) to many problems grounded in and complicated by psychosocial factors, the rule rather than the exception when it comes to illness and wellness. 

The welfare of all people hinges on social determination. To have a significant positive impact on health and wellbeing it is necessary to modify the social factors that determine them. As a family doctor this means I must ask about patients' social factors to gain insight needed to modulate them, if possible. This is particularly important when it comes to managing the health of patients who are more vulnerable, having a reduced capacity to control the social factors that can seriously harm or help them. Children and adolescents make up a particularly vulnerable population for this reason, so although it is always important to gather any patient's social history, it is all the more critical when it comes to pediatric medicine. Furthermore, while the vulnerability of a child may decrease as they grow into adolescence with increased self-determination, this autonomy comes at a time when their capacity to manage emotions may be underdeveloped, increasing risk of harm by impulsive behaviour.

People present for medical care for medical concerns. They typically do not present to address social determinants that may create or contribute to medical problems before they have arisen. So when it comes to primary care and its priority for preventative health, it is necessary that the primary care practitioner suss out those social barriers and strengths. The classic acronym used to remember the important elements to always ask about when it comes to the adolescent social history is HEADS (with a variable number of trailing S's as people tack on more things to alliterate with the letter S to remember to include). This is my version, with the general categories laid out that need to be explored more in depth as indicated. I also use it to think about the important elements to ask when interviewing people of all ages, so certain questions listed here may not be all that relevant for pediatric patients specifically. It may in fact seem quite odd to think about applying parts of this acronym to a 5 year old (unlikely to be using illicit drugs, for example), but sometimes these can still be helpful to keep on the template because it prompts me to think about factors influencing their circumstances (ex: parental illicit drug use). In fact, this concept serves as a reminder to me to ask about problems with important relationships in general, when taking any complete medical history as any patient's family doctor: it is not uncommon for parents to have distress over the problems their children may have as well, such as may be the case in the setting of substance use as well.

HEADS
  • Home (ex: who do they live with, where do they live, what is their housing situation, does the household have difficulty making ends meet at the end of the month, can they afford any medications they may need, assessment of function +/- Advance Care Planning)
  • Education/Employment (ex: what have they done as far as obtaining education, how they are doing if currently studying and if they able to meet their goals, employment history and any concerns +/- screen for worksite exposures and counsel about injury prevention as indicated)
  • Activities (ex: how do they spend their time outside of school, what do they do for fun, counsel about injury prevention as indicated, what do they do to take care of their health and wellbeing, any associated risk factors for infectious disease such as traveling or camping or being around others who have been ill)
  • Drugs/Dieting
    • Do they use alcohol/smoke/other drugs
    • Do they have poor body self-image +/- any restrictive or binging behaviour, especially with teens who engage in certain types of activities, such as dancers, gymnasts, models, etc. that makes them at higher risk of developing an eating disorder
  • Social/Safety (ex: experiencing any forms of abuse [ex: child abuse, bullying, intimate partner violence, elder abuse], time spent using screens/social media, what social supports do they have, any intimate relationships, consider obtaining a sexual history as well, including inquiring about contraception use)

Gathering a history that includes the above elements, as tailored to the patient, +/- obtaining collateral history, can provide insight into salient social issues that may be impacting on - and that may be impacted by - the patient's health. I can then attempt to work with the teenager or parents of a child to address factors that may be the underlying reason they presented for medical care in the first place. 

One last comment I will make here is the importance of opening the process of gathering a social history from adolescents with a confidentiality statement. Adolescents are in a unique transitional period during which many aspects of their life are still being managed by parents or other guardians, but gradually they are assuming more responsibility. If the adolescent patient presents for care with a parent - after the parent has had opportunity to provide collateral information on the presenting concern - I have the parent leave the examining room so I can gather a social history from the adolescent in privacy. It goes without saying that many teenagers may not want to disclose sexual activity or substance use with a parent present, so this presumably increases my ability to gather accurate information. In the same vein, I always start this sans parents portion of the visit with a confidentiality statement, to ensure the adolescent understands that whatever they tell me at this point is confidential, and that unless they tell me something would warrant an exception to the rule of confidentiality (that they are hurting themselves or others, or that someone is hurting them), then whatever they disclose to me is just between the two of us. When the adolescent patient does disclose information that indicates they are having a hard time coping, and considering my HEADS assessment as it pertains to social supports, if the adolescent has trust in their parents then I do encourage patients to share their concerns with their parents or other supportive allies. I do leave it up to them to decide what exactly and how much they wish to disclose, and say that if they chose not to that is completely okay. I also let them know regardless that they can always return to the clinic for further support with their ongoing issues. And last but not least, I often end my adolescent visits with a recommendation to check out the Sex & U website, a wonderful resource for all adolescents to learn about sexual health and a plethora of related topics, all organized on an aesthetically-appealing interface that is easy to navigate and understand.
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