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Module B3: Sexual and reproductive health
Entry Scenario
The entry scenario addresses a variety of issues and problems associated with the module topic. It may be used at the beginning of the course to stimulate the students to identify their own needs and interests. The results may be utilized by the individual to assess own learning process, or be integrated with class objectives.
A 15-year-old girl comes to a consultation complaining of vaginal discharge. She had her menarche at age 11, and her periods are irregular. She is sexually active and has had three sexual partners in the last year. She has always used condoms when having intercourse except the last time, four days ago. She claims that her 19 year-old partner complained of losing sensitivity, and her girlfriend told her it was safe since it had been four weeks since her last menstruation.
General Goals for Learners
by completing the module the participant will be able to :
- Distinguish normal and pathological forms of development and function of the reproductive organs
- Provide contraceptive counseling, prescription and follow up
- Diagnose sexually transmitted infections, understand the implications for adolescents, and provide appropriate treatment
- Counsel a pregnant adolescent, and provide adequate services or referral
- Provide information about and skillfully respond to problematic issues of sexuality
Goal 1 : Distinguish normal and pathological forms of development and function of the reproductive organs.
Knowledge
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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A. Understand the physiology and pathophysiology of menstruation - normal reproductive cycle, normal variations
- menstrual disorders including premenstrual syndrome, dysmenorrhea, abnormal uterine bleeding, amenorrhea, hyperandrogemia
- psycho-social dimension of problematic menstruation
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Interactive lecture Anatomic models Group work
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Adjust lecture to level of audience knowledge Suggested discussion topic: Myths, fears and misunderstandings an adolescent may have about menstruation. Case study: A girl presents with troncular obesity, acne and hypertrichosis and oligo-amenorrhea. Case study: A 15 year-old girl who previously had only occasional irregularity with her monthly bleeding complains of missed periods in the last seven months. Describe the typical complaints and impairment of social life (pain but also possibly associated Premenstrual syndrome)
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Ref 1/Chs 2, 5, 6, 15-17 Ref 2/Ch 49 Refs 2-5
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B. Understand non-sexually transmitted disorders of the reproductive tract, and know the appropriate treatments. - vulvovaginitis
- polycystic ovarian syndrome
- endometiosis
- genital tumors
- orchitis
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Lecture and discussion Reading
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Adapt lecture to audience knowledge Discuss symptoms and causes, including common misunderstandings or hygiene mistakes that contribute to these problems. Case study: A 16 year-old girl presents with an increasing abdominal circumference. She has no pain. Although a pregnancy test was negative, the girl remains fearful of being pregnant.
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Ref 1/Chs13 -16, 37 Refs 6-9
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Knowledge / Skills
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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C. Recognize normal variations, and congenital or acquired malformations of the reproductive organs and breasts, including genital mutiliation and circumcision - gynecomastia
- asymetrical breast development
- pink pearly penile papules
- vulvar dermatological problems
- scrotal glands
- congenital pathologies
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Lecture with slides and discussion
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Lecture may include description of complaints typical of residual problems resulting from genital mutilation and unusual forms of circumcision, or from other surgery (eg. urine leakage from cordee repair). Possible discussion topic: recreational use of marijuana (a phytoestrogen) has been associated with gynecomastia. Case study: A 14 year-old boy complains about painful erection and penile distortion. Case study: A 14 year-old girl with primary amenorrhea who has had lower abdominal pain monthly for the last 1 to 2 years, suddenly experiences very severe cramps.
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Ref 1/Chs 11, 13, 14
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Skills
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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D. Demonstrate skill in interview and exam techniques that facilitates the interaction with an adolescent who presents with reproductive tract complaints.
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Role playing
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Case study: A Somalian girl complains about painful menstruation but is fearful and unwilling to be examined, especially by a male Create sample phrases to ease the situation for a girl’sfirst pelvic exam.
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Ref 10 Module A3 Website 1
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Goal 2 : Provide contraceptive counseling, prescription and follow up
Knowledge
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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A. List contraceptive methods and their properties which need to be taken into account when counseling adolescents - mode of action
- technical properties
- non-contraceptive benefits (especially condom)
- factors influencing contraceptive counseled
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Handout sheet with methods and prompting list of technical features Class discussion
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The ideal contraceptive for an adolescent would be safe, effective, reversible, inexpensive, convenient, private, and have few side effects. Discuss the methods available for adolescents according to these criteria. Introduce concept of contraception as protection from sexually transmitted infections (STI) (refer to Goal IV).
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Ref 2/Chs 42, 43 Refs 11, 12, 13
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Skills
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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B. Assess the indications for contraception, and the disposition of the individual adolescent(s) regarding contraceptive choice - physical and medical indications, including sexual history
- expressed needs and wants of adolescent and partner, whether absent or present
- patients’ attitude toward contraception, including resistance, beliefs and concerns
- situational factors such as lifestyle, parental attitudes, partner cooperation
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Group discussion
Case studies, role play
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Issues to include: - How to bring up a discussion about the sexual life of a teenager. What ways (phrases, approach) could be used to get the teen to talk about sex? Participants share ideas of what has worked in their practices.
- Discuss the statement “every contraceptive method is better than no contraception.”
- Distinguish between emergency contraception and long-term-contraception.
Case study: a girl presents asking for post-coital contraception (PCC) because her partner did not want to use condoms. Partner did not accompany her.
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Ref 1/Ch.19 Refs 14-17
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C. Negotiate choice, provide related services and follow-up - integration of issues of all persons concerned
- compliance
- assessment of side effects
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Group discussion Role play
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Case study: A 16-year old girl comes for contraceptive help. Apparently her bedtime is very irregular and she uses recreational drugs on weekends. Discuss how to negotiate compliance.
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Refs 18-20
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Goal 3 : Diagnose sexually transmitted infections, understand the implications for adolescents, and provide appropriate treatment
Knowledge
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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A.Recognize symptoms of sexually transmitted infections (STI), know consequences, and provide clinical diagnosis - types of diseases and infections, rates, and consequences.
- signs, symptoms, and indications for screening
- laboratory testing procedures
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Interactive lecture List and slides of presenting symptoms
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Slides for lecture may be found at Website 1. Differentiate between sexually transmitted and sexually associated infections. Discuss nucleic acid amplification tests.
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Ref 2/Ch. 60 & 61 Ref 21 Website 1
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B. Understand STI risk factors that are particular to adolescents - biological susceptibility
- psychological vulnerability, immaturity
- socio-environmental risks
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Class discussion
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Discuss what characteristics of their age group make adolescents particularly vulnerable to STI. Develop a list of risk factors and a list of short and long term consequences. Discuss issues of protection and prevention.
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Ref 1/Ch. 22 & 23
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Skills
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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C. Make knowledgeable use of treatment options for suspected case of STI, or exposure. - appropriate management/ treatment for suspected case
- available emergency treatment in case of significant STI exposure (HIV, hepatitis)
- criteria for referral
- follow-up procedures and counseling issues
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Group work with case studies, role play
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Review updates on what treatments are currently available. (Consult resources for treatment, official guidelines for infectious diseases.) Discuss pros and cons of treatment options. Create flow chart of management/treatment using case studies; include case on preventive emergency treatment Role play follow-up counseling, dealing with such issues as fertility, contraception, and promotion of safe sex. How can the risk-reduction approach to counseling be applied?
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Ref 22 Websites 2, 3
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Goal 4 : Counsel a pregnant adolescent, and provide adequate services or referral
Knowledge
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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A. Be informed about the various aspects of the three choices open to a pregnant adolescent - consequences of adolescent parenthood
- medical aspects of different abortion procedures
- local resources on adoption and foster parenting
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Small group work followed by plenary Minilecture
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Groups list consequences of early parenthood, including the impact on the individuals, on the new family unit as well as on the families of origin, and on the baby. Plenary discussion follows to discuss these consequences in light of statistics showing rates of adolescent divorce, child abuse, and outcomes of the children. Lecture presents the procedures, with a discussion of the less and more harmful methods for the adolescent age group. Detail the physical and psychosocial consequences of an early versus a late procedure. Detail the considerations that affect the choice of a procedure (e.g. parity, age and development of mother, physical development). Discuss the advantages and disadvantages of the adoption option.
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Ref 1/Ch.20 Refs 23, 24
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Skills
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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B. Comprehensively assess the pregnant adolescent’s situation, and assist the teenager in decision-making process - Familial, financial, emotional and physical issues connected to each of the options.
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Small group role play
objectives B and C
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Role play the situation of a 15 year-old pregnant girl who wants to have a baby although her parents insist on her having an abortion.
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C. Provide appropriate care, guidance, and referral of the adolescent who chooses to keep pregnancy Follow-up contraceptive counseling
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Discuss possible differences between adolescent and adult pregnancies, and age-specific risks. What extra support should the professional be prepared to provide? What is the professional’s role after the baby’s birth?
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Ref 25
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D. Provide a professional response to the adolescent who chooses to terminate pregnancy. - appropriate information about procedures
- referral protocol
- care and guidance to affected persons
- follow-up contraceptive counseling
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Case study 1:
A 16 year-old girl from a remote area elects an abortion for an 8- week pregnancy. She got pregnant at her first sexual intercourse, having used no contraception. Her parents do not know about her situation. Case study 2:
A 17 year-old city girl who is 11 weeks pregnant chooses abortion for the second time in a year. She has sex education in school, and is familiar with different contraceptive methods, some of which she uses from time to time.
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Refs 26, 27
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Attitudes
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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E. Identify personal attitudes that may interfere with a provider’s ability to provide non-judgmental care of the pregnant adolescent
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Small group work
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Small groups discuss how the individual professional’s values can influence the counseling process. What personal attitude or belief would be a reason for the professional to refer the adolescent to someone else’s care?
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Goal 5 : Provide information about and skillfully respond to problematic issues of sexuality
Knowledge
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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A. Be conversant with the problematic experiences of emerging sexuality - gender-specific concerns and expectations, communication problems
- consensual vs. non-consensual aspects of sexual contact and intercourse
- issues of sexual orientation
- needs of developmentally disabled
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Interactive lecture Class discussion Readings Discussion Class discussion
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Class make list of concerns (tampon use, premature ejaculation, masturbation, dyspareunia, penis size) and discuss appropriate responses. Case study: A boy feels pressured by his girl friend to use condoms but he is afraid to loose his erection. What constitutes non-consensual sex? Include in discussion what is inappropriate contact by significant adults such as parents, teachers and physicians. At what point does “inappropriate” contact become “assault”? Explore the implications for adolescents of same-sex sexual experiences; discuss the meaning of sexual orientation, sexual behavior, and sexual identity; list what problems and questions an adolescent of either gender might have about gender orientation. What constitutes “exploratory” behavior, and “mixed” behavior? If possible, include in the discussion some input from homosexual support groups List specific problems/concerns and possible solutions
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Ref 1/Ch.18 Ref 19 Ref 28 Ref 1/Ch.7
Module B5
Ref 1/Ch. 30
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Attitudes
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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B. Understand own biases and personal feelings regarding issues of sexuality that may affect provider’s professional care of adolescents
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Self-reflection exercise, small group discussion
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What situations involving one’s own teenage daughter or son would a participant find upsetting? Bring into awareness where your sensibilities lie and what your limits are (e.g. sex at age 13, same sex contact with older person, an abusive relationship). Share in a group discussion how this could affect your professional care of adolescents. Is neutrality always desirable?
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Skills
Training Objectives
Key topics to be covered
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Educational Methodology
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Activities, Issues, and Questions
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Pertinent resources
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C. Demonstrate skill in bringing out underlying concerns (hidden agenda) of an adolescent patient
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Group discussion
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Case study: A15-year old girl complains of recent vaginal discharge but in fact suffers from dyspareunia and abdominal pain during sexual intercourse. Case study: 15 year-old male presents who attempted suicide after being “abused” by a 17-year old male. Discuss how to respond to negative forces/feelings about one’s emerging sexuality
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D. Take leadership role in addressing sexuality-related issues on societal level
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Group discussion
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Discuss the role the professional can play regarding such issues as: - alleviation of stigmatization, especially regarding sexual orientation
- Increase availability of condoms and post-coital contraception (PCC) to adolescents.
- Reviewing legal restrictions (eg. age of sexual majority, abortion, STI reporting requirements)
- Promoting a healthy environment for healthy reproduction
Identify different levels of involvement, according to the provider’s ability or willingness to play a role.
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Module C3
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References
- Sanfilippo JS, Muram D, Dewhurst J, Lee PA (eds): Pediatric and adolescent gynecology. W.B. Saunders Co. Philadelphia, London, New York, St Louis, Toronto, 2001.
- Chapter 2: Normal growth and pubertal development
- Chapter 5: Precocious puberty
- Chapter 6: Delayed puberty
- Chapter 7: Disorders of sexual orientation
- Chapter 8: Abnormal sexual differentiation and hypogonaddism: management and therapy
- Chapter 11: molecular biology and genetics aspects
- Chapter 13:Vulvovaginitis in children and adolescents
- Chapter 14: Dermatologic conditions of the vulva
- Chapter 15: Vaginal bleeding in childhood and menstrual disorders in adolescence
- Chapter 16:Dysmenorrhea and pelvic pain
- Chapter 17: Androgens and the adolescent girl
- Chapter 18: Adolescent sexuality
- Chapter 19: Adolescent contraception
- Chapter 20: Pregnancy in adolescence
- Chapter 22: Sexually transmitted diseases in adolescence
- Chapter 23: Human Immunedeficiency Virus infection in adolescence
- Chapter 30: Reproductive health care needs of the developmentally disabled
- Chapter 37: Oncologic problems
- Neinstein LS. Adolescent Health: A Practical Guide, 4th edition, Lippincott Williams and Wilkins, Philadelphia, 2002.
- Schroeder B, Sanfililppo JS. Dysmenorrhea and pelvic pain in adolescents. Ped Clin N Am 1999;46:555Gidwani GP.
- Amenorrhea in the athlete. Adolescent Medicine. 1999;10:275.
- Minjarez DA, Bradshaw KD. Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am, 2000;27:63.
- Kovacs GT, Polycystic ovary syndrome. Cambridge University Press. Cambridge, New York, Melbourne, Madrid, 2000.
- Carmina E. Lobo RA. Polycystic ovary syndrome (PCOS): arguably the most common endocrinopathy is associated with significant morbidity in women. J Clin Endocrinol Metab 1999;84:1897.
- Gordon CM. Menstrual disorders in adolescents: excess androgens and the polycystic ovary syndrome. Pediatr Clin N Am 1999;46:519-543.
- Kahn JA, Gordon CM. Polycystic ovary syndrome. Adolescent Medicine. 1999;10:321.
- Omar H, Richard J: Cultural sensitivity in providing reproductive care to adolescents. Curr Opin Obst and Gynecol, 2004; 16:5, 367-70.
- Hatcher RA, Trussel J, et al. (eds): Contraceptive technology. Seventeenth Revised Edition. Ardent Media, Inc., New York, 1998.
- Knijff SCM, Goorissen EM et al. (eds): Summary of contraceptions to oral contraceptives. The Parthenon Publishing Group. New York, London, 2000.
- Hannaford PC, Webb AMC (eds): Evidence-guided prescribing of the pill. The Parthenon Publishing Group. New York, London, 1996.
- Family planning and reproductive health in CCEE and CIS. World Health Organization Europe. Sexual and Family Health. Copenhagen, 1997.
- The reproductive health kit for emergency situations. UNFPA. Geneva, 1998.
- Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med. 1998;339:1.
- Conard LAE, Gold MA: Emergency contraceptive pills: a review of the recent literature. Curr Opin Obst and Gynecol, 2004. 16:5, 389-95.
- Smith R: Gynecologic decision making. WB Saunders Company. Philadelphia, 2001.
- Adolescent sexuality. Guides for professional involvement. Second edition. ACOG. Washington DC. 1992.
- Glasier A, Gebbie A (eds): Handbook of family planning and reproductive health. Fourth edition. Churchill Livingstone. London, 2000.
- STD case management workbook 1. Programme introduction and the transmission of STD/HIV. World Health Organization. WHO/GPA/TCO/PMT/95.18A. Geneva, 1995.
- HIV in pregnancy: a review. World Health Organization. WHO/CHS/RHR/99.15. Geneva, 1999.
- Clinical management of abortion complications: a practical guide. Maternal Health and Safe Motherhood Programme, Division of Family Health, Word Health Organization. Genava. WHO/FHE/MSM/94.1. Geneva 1994.
- Unsafe abortion. World Health Organization. WHO/RHT/MSM/97.16. Geneva, 1997.
- Guidelines for monitoring the availability and use of obstetric services. UNICEF, WHO, UNFPA. New York, 1997.
- Winkler J, Oliveras E, McIntosh N (eds): Postabortion care. A reference manual for improving quality of care. Postabortion Care Consortium. USA 1995.
- The care of women requesting induced abortion. Evidence-based Guideline No. 7. Royal College of Obstetricians and Gynaecologists. London, 2000.
- Danielson CK, Holmes MM: Adolescent assault: an update of the literature. Curr Opin Obst and Gynecol, 2004. 16:5, 383-8.
Websites
- www.usc.edu/adolhealth
- http://www.cdc.gov/node.do/id/0900f3ec80009a98 (Centers for Disease Control)
- Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002; 51 (No RR-6). (http://www.cdc.gov/std/treatment/rr5106.pdf)
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