Case Presentation
Michelle is a 16-year-old high school student who became sexually active about 8 months ago with her boyfriend of 1 year. Initially, they did not use any form of contraception but Michelle was worried about becoming pregnant. About 5 months ago, she was seen at a Planned Parenthood clinic to find out more about her contraceptive options. She chose the Ortho Evra® patch because it was convenient, did not require her to remember to take a daily pill, and was discreet. She has used the patch for the past 5 months and has had a favorable response to it, with few side effects. However, she presents to you today feeling frightened and panicked because she had recently read a story on Facebook about a college student whose death was attributed to a blood clot that Michelle describes was “caused by the patch.” You are familiar with this case, which received a great deal of media attention. Several points not mentioned by Michelle but relevant to the woman’s risk of venous thromboembolism (VTE) included a positive family history of VTE as well as the fact that the young woman smoked and was obese. Michelle is unaware of this information and indicates that all of her friends are using oral contraceptives. She states that she would like to switch to oral contraceptives and discontinue use of the patch.
Decision aids increase individual’s involvement in the decision-making process and are associated with a higher likelihood of making informed, value-based decisions. The following decision aid may help you to discuss the risks and benefits of hormonal contraception with your adolescent patients.
- Clarify the situation
- Provide information on benefits and harms
- Clarify patient values
- Screen for implementation problems
You recognize and acknowledge Michelle’s concerns about the possibility of a serious problem with the patch. You emphasize that it is her choice to stop or continue using the patch, but offer some additional information to help Michelle put the possibility of a serious problem with the patch into perspective.”
You explain that the patch and oral contraceptives are both hormonal methods with similar side effect profiles. This is new information for Michelle who did not understand that both were hormonal contraceptive methods with similar but not identical risks. You further explain to Michelle that the benefits of hormonal contraceptives generally far exceed those of their risks, noting that “on the benefit side, hormonal contraceptive methods are very good at preventing pregnancy and because most women find both the patch and oral contraceptives easy to use, they are at lower risk of unintended pregnancy.” You emphasize to Michelle that oral contraceptives will require her to take a pill daily. You also note that “pregnancy itself increases the risk of blood clots, heart attack, and stroke—although these problems are not common.”
With respect to harms associated with hormonal contraceptive methods, you explain to Michelle that the chance of having a serious problem like heart attack, stroke, or blood clot is greater for women using hormonal contraceptives than for women who don’t use them. This is especially true if they smoke or have had a blood clot before. You discuss research findings with Michelle that confirm that the risk per 10,000 women-years for venous thromboembolism (VTE) among users of oral contraceptives increases as body mass rises and women age, rising to a high of 57.1 per 10,000 women-years among women 40 years or older with a body mass index of 30 or higher. The risk of VTE decreases to 26.5 per 10,000 women-years among the oldest age group of women who are also obese but have no other risk factors for VTE. You provide Michelle with additional information about risk factors that may have contributed to the development of VTE in the college student using the patch including her weight, use of tobacco products, and a positive family history of VTE. You explain to Michelle that she is less than 25, does not use tobacco products, and is at a healthy body weight. Therefore, her risk of having a blood clot caused by hormonal contraceptives is very low.
In an effort to better understand Michelle’s values, you explore her concerns about the patch and her preference to switch to an oral contraceptive by asking: “do you think the benefits of the patch are more important to you than the chance of a serious problem?” You also ask Michelle “do you think that an oral contraceptive will be more acceptable to you than the patch after learning that both are hormonal methods of contraception?”
Using a scale ranging from 1 to 10 with 1 indicating not at all important, you ask Michelle “With the information we have just discussed in mind, how important is it to you to switch from the patch to another method of contraception?” You then use a similar scale to assess how confident Michelle feels about her ability to use a daily oral contraceptive. Michele reports that her friends say that the pill is easy to remember to take and has few side effects. However, she acknowledges that she does “not have the best memory in the world” and admits that she “sometimes forgot when she was supposed to apply a new patch each month. With the new information she received about risk factors for VTE and use of oral contraceptives, Michelle indicates that she is willing to continue to use the patch for 3 more months, acknowledging that it “will be easier than trying to remember to take a daily pill.” Michelle will return in 3 months for a follow-up appointment to assess if her concerns with the patch have been addressed, review her ability to remember to apply a new patch at the right time, and discuss any other concerns or issues she might have.
References
- ACOG Committee Opinion No. 491: Health literacy. Obstet Gynecol. 2011;117(5):1250-3.
- Engebretson J, Mahoney J, Carlson ED. Cultural competence in the era of evidence-based practice. J Prof Nurs. 2008 May-Jun;24(3):172-8.
- Grimes DA, Snively GR. Patients’ understanding of medical risks: implications for genetic counseling. Obstet Gynecol. 1999;93(6):910-4.
- Noone J. Cultural perspectives on contraception: a literature review. Clin Excell Nurse Pract. 2000;4(6):336-40.
- O'Connor AM, Bennett CL, Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2009;(3):CD001431.
- O’Connor A, Legare F, Stacey D. Risk communication in practice: the contribution of decision aids. BMJ. 2003;327(7417):736-40.
- Rabe T, Luxembourg B, Ludwig M, et al. Contraception and thrombophilia—A statement from the German Society for Gynecological Endocrinology and Reproductive Medicine (DGGEF e.V.) and the Professional Association of German Gynaecologists (BVF e.V). J Reproduktionsmed Endokrinol. 2011;8(special issue 1):178-218.
- Steinberg L. Cognitive and affective development in adolescence. Trends Cogn Sci. 2005;9(2):69-74.
- Steinberg L. A behavioral scientist looks at the science of adolescent brain development. Brain Cogn. 2010;72(1):160-4.
Communicating about Risk and Contraceptive Choice with Your Adolescent Patients
