Definitions of the grades of recommendation, based on levels of evidence (A-C, Good Practice Point), are provided at the end of the "Major Recommendations" field.
How can a clinician assess a young person's capacity to consent to contraceptive use?
- A clinician should assess a young person's competence to consent to treatment by her ability to understand information provided, to weigh up the risks and benefits, and to express her own wishes (Grade C).
- If a young person is assessed competent this should be documented in case notes as her being "Fraser ruling competent" (advice understood, will have or continue to have sex, advised to inform her parents, in her best interest) (Grade C).
- A clinician can provide contraceptive advice or treatment to a competent young person (aged less than 16 years) without parental consent or knowledge using the Fraser criteria (refer to table 1 in the original guideline document) (Grade C).
How can a clinician be alert to the possibility of maltreatment, coercion, or exploitation of a young person?
- A clinician may wish to inform a young person of the law in relation to sexual activity (Good Practice Point).
- All staff involved in services for young people should receive appropriate training to alert them to the possibility of exploitation or coercion and should be aware of local mechanisms for reporting in line with child protection policy and procedures (Grade C).
- All services should have a named clinician identified as the local lead on child protection policy and procedure (Grade C).
How can a clinician address confidentiality and disclosure with a young person?
- Each young person should be made aware of the confidentiality to be expected from all members of the health care team (Grade C).
- Each young person may be advised that other professionals, such as teachers and youth workers, may not have the same duty of confidentiality (Good Practice Point).
- A young person aged less than 16 years should be made aware, in advance, that confidentiality might be broken if current maltreatment, exploitation, or coercion is suspected (Grade C).
- A young person should be made aware that her consent would be sought if information is to be shared or confidentiality breached. However, consent is not essential if the disclosure is justified (Grade C).
- The timing of reporting or breach of confidentiality should be carefully considered and made jointly with the professional lead (Good Practice Point).
How can a clinician assess medical eligibility for contraceptive use?
- A young person should be assisted in making contraceptive choices by considering her individual contraceptive needs and wishes as well as other factors relating to lifestyle and risk of pregnancy or sexually transmitted infection (STI) (Good Practice Point).
Puberty and Menarche
- Young women should be advised against the use of regular hormonal contraception before menarche. If they are sexually active, condoms should be advocated (Good Practice Point).
Bone Mineral Density
- Young women should be informed that normal pubertal development, exercise, diet, and smoking influence bone mineral density (BMD) (Grade B).
- Young women should be informed about the effects of hormonal contraception on BMD (Grade B).
- A young woman may choose a progestogen-only injectable over other contraceptive methods despite uncertainty about the long-term effect on BMD (Good Practice Point).
Sexually Transmitted Infection
- Young people should be advised that, when correctly used, condoms are effective in the prevention of human immunodeficiency virus (HIV) (Grade B).
- Although evidence for a protective effect of condoms against STIs other than HIV is limited, young people should be advised on the consistent and correct use of condoms in the promotion of safer sex (Good Practice Point).
How can a clinician optimise a young person's compliance with contraception?
Contraceptive Choices
- Age alone should not limit contraceptive choices for young people (Grade C).
- A young person should be enabled to use her chosen method of contraception as long as there are no medical contraindications (Good Practice Point).
Gynaecological Cancers
- Young women may be advised that combined oral contraception (COC) reduces the risk of ovarian and endometrial cancer and, with less than 5 years use, does not increase cervical cancer risk (Grade B).
- Young women may be advised that depot medroxyprogesterone acetate (DMPA) does not appear to have any effect on ovarian, endometrial, or cervical cancer risk (Grade B).
Breast Cancer
- Young women should be advised that any increase in risk of breast cancer associated with hormonal contraception is small and there is no effect of duration of use (Grade B).
Venous Thromboembolism
- Young women should be advised that although the risk of venous thromboembolism (VTE) increases with COC use the absolute risk is very low (Grade B).
- Young women may be advised that progestogen only contraceptives do not appear to increase the risk of VTE (Grade B).
Weight Gain
- Young women may be advised that there is no evidence of weight gain with COC use (Grade B).
- Young women may be advised that weight gain can occur with some progestogen-only methods, but may simply reflect the normal increase in weight expected during the early reproductive years (Grade C).
Acne Vulgaris
- Young women can be advised that COCs may improve acne vulgaris (Grade B).
- Young women should be advised that the occurrence of acne can be a reason for discontinuation of progestogen-only implants and injectables (Grade B).
- Dianette® is indicated to treat severe acne which has not responded to oral antibiotics. It should be withdrawn 3 to 4 months after the treated condition has resolved or if there is no improvement (Grade C).
Mood Changes and Depression
- Young women should be advised that it is unclear whether hormonal contraception has an adverse effect on mood (Grade B).
Appropriate Follow-up
- Young people should be encouraged to return at any time if they develop problems with contraception (Grade C).
- A young woman should be advised to return for follow-up in the 3 months after the initiation of hormonal contraception. This allows side effects or other concerns to be addressed and helps ensure correct use of the method (Good Practice Point).
How can clinicians ensure access to contraception for young people?
- Sexual health providers should adapt services to meet the needs of young people (Grade C).
- Services for vulnerable young people may be delivered within mainstream services with outreach facilities provided where appropriate (Grade C).
- Young people attending any reproductive health care setting (e.g., postnatal wards, abortion services, or genitourinary medicine [GUM] clinics) should have access to contraceptive advice and/or treatment (Grade C).
- Reproductive health providers should engage in multi-agency working to promote services for young people (Good Practice Point).
- Sexual and reproductive health services should support school nurses in their development and training (Good Practice Point).
How can clinicians ensure young people receive appropriate information on contraception?
- Young people should have adequate time during consultations to address contraceptive and broader health issues (Grade C).
- Contraceptive and sexual health services may develop links with education authorities and schools to promote and provide the planning, delivery, and evaluation of sex and relationship education (Good Practice Point).
- Sex and relationship education should be provided from childhood and within the context of emotional and social development (Grade C).
- Any service providing contraception or sexual health advice should be able to provide young people with leaflets about contraception, sexual health, and other lifestyle issues, appropriate Web site addresses and highlight other relevant local services for young people (Grade C).
How can health professionals involve young people?
- Young people should be involved in the development of contraceptive and sexual health services (Good Practice Point).
Definitions
Grades of recommendation are based on levels of evidence as follows:
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point where no evidence exists but where best practice is based on the clinical experience of the Expert Group
