Victoria Davis

Female gamete preservation

The use of multiple agent chemotherapy and combined modality treatment of childhood and adolescent cancers has markedly increased survival rates. Thus, the majority of young cancer patients survive into adulthood and the potential long‐term consequences of the therapies are of ongoing concern. Alkylating agents have proven to be the most toxic to the ovaries; however radiation is also extremely gonadotoxic. In addition, combination of these modalities will produce additive effects in terms of ovarian damage (follicle depletion). As a result, there are increasing numbers of young cancer survivors with impaired or absent gonadal function. Advances in the field of assisted reproductive technology (ART) provide hope that the reproductive impact of cancer therapy can be reduced. Those technologies that may be applicable prior to gonadotoxic therapy are pretreatment ovarian protection with oral contraceptives or gonadotropin releasing hormone agonist; ART using pretreatment cryopreservation of embryos or gametes; posttreatment ART with donor gametes or embryos; or adoption. However, ovarian protection is not of proven benefit and oocyte/ovary cryopreservation has had only limited success to date. Information regarding cancer treatments possible effects on fertility and ways to potentially circumvent these should be part of routine counseling to allow the patient to make an informed decision. Cancer 2006.

Missed Hormonal Contraceptives: New Recommendations

OBJECTIVE To provide evidence-based guidance for women and their health care providers on the management of missed or delayed hormonal contraceptive doses in order to prevent unintended pregnancy. EVIDENCE Medline, PubMed, and the Cochrane Database were searched for articles published in English, from 1974 to 2007, about hormonal contraceptive methods that are available in Canada and that may be missed or delayed. Relevant publications and position papers from appropriate reproductive health and family planning organizations were also reviewed. The quality of evidence is rated using the criteria developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS This committee opinion will help health care providers offer clear information to women who have not been adherent in using hormonal contraception with the purpose of preventing unintended pregnancy. SPONSORS The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. Instructions for what women should do when they miss hormonal contraception have been complex and women do not understand them correctly. (I) 2. The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than seven days, either by delaying the start of combined hormonal contraceptives or by missing active hormone doses during the first or third weeks of combined oral contraceptives. (II) Ovulation rarely occurs after seven consecutive days of combined oral contraceptive use. (II) RECOMMENDATIONS: 1. Health care providers should give clear, simple instructions, both written and oral, on missed hormonal contraceptive pills as part of contraceptive counselling. (III-A) 2. Health care providers should provide women with telephone/electronic resources for reference in the event of missed or delayed hormonal contraceptives. (III-A) 3. In order to avoid an increased risk of unintended pregnancy, the hormone-free interval should not exceed seven days in combined hormonal contraceptive users. (II-A) 4. Back-up contraception should be used after one missed dose in the first week of hormones until seven consecutive days of correct hormone use are established. In the case of missed combined hormonal contraceptives in the second or third week of hormones, the hormone-free interval should be eliminated for that cycle. (III-A) 5. Emergency contraception and back-up contraception may be required in some instances of missed hormonal contraceptives, in particular when the hormone-free interval has been extended for more than seven days. (III-A) 6. Back-up contraception should be used when three or more consecutive doses/days of combined hormonal contraceptives are missed in the second and third week until seven consecutive days of correct hormone use are established. For practical reasons, the scheduled hormone-free interval should be eliminated in these cases. (II-A) 7. Emergency contraception is rarely indicated for missed combined hormonal contraceptives in the second or third week of the cycle unless there are repeated omissions or failure to institute back-up contraception after the missed doses. In cases of repeated omissions of combined hormonal contraceptives, emergency contraception may be required, and back-up contraception should be used. Health care professionals should counsel women in these situations on alternative methods of contraception that do not demand such stringent compliance. (III-A).

Success of medical management of labial adhesions

Abstract BACKGROUND: The treatment of labial adhesions with topical estrogen has been reported to have a success rate between 88% and 89%, with almost 50% of these requiring some form of manual separation in the office. The purpose of this study was to evaluate the management of labial adhesions at the Hospital for Sick Children in Toronto, Canada. METHODS: A retrospective chart review of all patients with labial adhesions at the pediatric and adolescent gynecology clinic from 1993 until November 2000. RESULTS: A total of 251 patients were diagnosed with labial adhesion. Of these 168 (67%) were primary diagnoses and 83 (33%) recurrent. The age ranged from four months to sixteen years. All patients without urinary obstruction were treated with topical estrogen cream (Premarin ® by Wyeth or Ortho ® Dienestrol) BID for two to six weeks. Patients were re-evaluated every two weeks; the cream was discontinued once separation occurred. A total of 23 (9%) had surgical/mechanical separations performed; 3 for urinary obstruction, 4 because of maternal demands, 3 had reactions to the cream, 13 were medical failures. Children over six years of age were more likely to require surgical intervention despite prolonged medical therapy (up to 10 weeks). Medical therapy effected separation in 228 (91%); the treatment period was 2 weeks 94 (38%), 4 weeks 111 (44%), 6 weeks 21 (8%). Limiting the application of estrogen cream solely to the labial join minimized systemic estrogen effects. In 1996 preventive measures were taught after separation and this appeared to reduce recurrences. CONCLUSION: Surgery is rarely necessary for the management of labial adhesions if topical estrogen cream is used appropriately. Complete separation may take up to six weeks so perseverance may be necessary to avoid the potential complications from a surgical procedure. The older the child the greater the incidence of dense adhesions and risk of medical failure. Preventive measures may decrease the recurrence rate.

The Rights of the Adolescent: The Mature Minor

Health care providers who treat adolescents may also be required to diagnose and treat the reproductive health conditions of minor patients and to facilitate health prevention measures, including contraception and testing for sexually transmitted diseases. Teens who do not want their parents to know about their sexual behaviour may consult a health care provider for reproductive or sexual health care services and treatment without parental knowledge or consent. This may present legal and ethical dilemmas for health care providers. Common law recognizes that adolescents under the legal age of majority who are sufficiently mature (the mature minor) may have the capacity to consent to health care services with the same independence as adults. Such capacity to consent needs to be determined on an individual basis. Where there is disagreement between a mature minor and her parent(s) about a medical procedure or treatment, the wishes of the adolescent should prevail. Under law, a married minor is usually treated as having attained majority status; however, fertility services cannot ethically be denied if the unmarried adolescent is found capable and they are required medical services for that individual. Parents or legal guardians generally have the legal authority and responsibility to act as surrogate decision makers for adolescents found incapable of making their own health care decisions. Although confidentiality is essential, there are some exceptions to absolute confidentiality.

Emergency contraception: no. 280 (replaces No. 131, August 2003).

To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting.

Sexual and Reproductive Health Counselling by Health Care Professionals

This document reflects emerging clinical and scientific advances on the date issued, and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC. This policy statement was prepared by the Social and Sexual Issues Committee, reviewed by the Family Physicians Advisory Committee and the Clinical Practice Gynaecology Committee, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. SOCIAL AND SEXuAL ISSuES COMMITTEE Margaret Burnett, MD (Chair), Winnipeg MB Anjali Aggarwal, MD, Toronto ON Victoria Davis, MD, Scarborough ON Jeffrey Dempster, MD, Halifax NS William Fisher, PhD, London ON Karen MacKinnon, RN, PhD, Victoria BC Rosana Pellizzari, MD, Peterborough ON Viola Polomeno, RN, PhD, Ottawa ON Maegan Rutherford, MD, Halifax NS Vyta Senikas, MD, Ottawa ON Marie-Soleil Wagner, MD, Montreal QC FAMILY PHYSICIANS ADVISORY COMMITTEE William Ehman, MD (Chair), Nanaimo BC Anne Biringer, MD, Toronto ON Andrée Gagnon, MD, Blainville QC Lisa Graves, MD, Sudbury ON Jonathan Hey, MD, Saskatoon SK Jill Konkin, MD, Edmonton AB Francine Léger, MD, Montreal QC Cindy Marshall, MD, Lower Sackville NS

Contraception d’urgence

Résultats : Les études publiées en anglais entre janvier 1998 et mars 2010 ont été récupérées par l’intermédiaire de recherches menées dans Medline et la base de données Cochrane, au moyen de mots clés appropriés («emergency contraception», «post-coital contraception», «emergency contraceptive pills», «post-coital copper IUD»). Les directives cliniques et les déclarations de principe élaborées par des organisations de santé ou de planification familiale ont également été analysées.

Sexually Transmitted Diseases Among Teens

Abstract Although prevalence rates of sexually transmitted diseases are declining in the general population in Canada, they remain high in adolescents, and therefore high in adolescents who are pregnant. Sexually transmitted diseases can cause significant morbidity in the form of infertility, ectopic pregnancy, chronic pelvic pain, and malignancy, as well as transmission of disease to newborns. Sexually transmitted diseases may also cause teen deaths. Health care providers working with adolescents need to discuss responsible sexual behaviours, including use of condoms, abstinence, and other strategies, to avoid the potential negative consequences of sexual intercourse.