Joanne, who is 15, has come with her friend to ask for the 'morning after Pill'. She has not been seen at the surgery for three years. It is worthy of credit that she has been brave enough to come this far.
Opening the consultation
If Joanne wants her friend to be with her in the consultation, see them together, but be certain who the patient is. Smile, be aware of her anxieties, recognise that she is now beyond the limit of her own experience and invite her to talk.
Using open questions as far as possible, establish when she last had sex and whether there have been other episodes, particularly since her last period. Is there a chance that she may already be pregnant?
Establish that emergency contraception is needed and appropriate.
Try to determine whether sex was consensual and exclude coercion or abuse. As a rule of thumb, consensual sex between young people whose ages do not differ by more than five years is unlikely to indicate abuse.
During the consultation, establish that she is competent to be treated without parental consent, as defined by the Fraser Ruling of 1985, and make a record of this.
When discussing contraception, make sure that she understands that progestogen-only emergency contraception (POEC) is not guaranteed.
Try to explain this risk in absolute terms - it may be higher than she expects. For example, nearly one in every 20 women who use POEC within 72 hours of unprotected sex (efficacy 84 per cent) at mid-cycle (conception risk around 30 per cent) will still conceive. Between 72 and 120 hours after unprotected sex, efficacy drops further but off-license use may still be an option, with appropriate information and documentation.
Make sure that she understands that the timing of her next period may vary a little, but that if it is more than a week late pregnancy testing is necessary.
You should also explain that a copper-bearing IUD offers a more effective method of emergency contraception. Being 15 does not preclude this as an option and between 72 and 120 hours after exposure it is the only licensed method.
The information you give Joanne should include mode of action, failure rate, insertion procedure, possible complications and potential use for ongoing contraception.
There is no reason why both methods cannot be used and she could be given POEC and allowed to go away to consider and discuss the option of having an IUD.
Full contraception counselling may not be possible in the time available but leaflets summarising the options for ongoing contraception should be provided.
Consider asking her to return for further discussion a week after her next period is due.
If you can agree that she will not have sex till she sees you next, then any of the methods remain available to start at that point.
Finally, consider the risk of STI. Discuss screening and when and where this might occur. Advise on the importance of using condoms in addition to ongoing contraception for both infection prophylaxis and added contraceptive benefit.
Prescription and supply
Consider having a supply of levonorgestrel 1,500(mu)g available in the surgery. This allows a patient like Joanne to take it while she is with you. This confirms compliance and avoids further delay.
Check that she has no questions, that she knows what she has to do, how she might tell her parents, what she should do if she decides to also have an IUD and when she is coming back regarding ongoing contraception.
Finally congratulate her on being responsible and that coming to the surgery was a brave and adult decision.
This type of consultation is a lot to get through in 10 minutes and needs to be documented thoroughly.
Dr Gray is a GP in Truro, Cornwall, and a medical advisor at Women's Health Concern
Steps to follow
- Establish the need for emergency contraception.
- Exclude coercion or abuse.
- Establish Fraser competency.
- Establish STI risk.
- Explain options and allow choice.
- Engage for follow-up.