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					ECP CHATLINE 15                                                                  20th January 2003
Article 1

Dear Diane

Please help.

Peter and I wanted clarification on how ECP works exactly so that we can clarify what to do in this situation.

Young girl whose last period started 25/12/02 with an unknown cycle but at least 28 days, she thought.

Had sex Friday night 3/1/03, presented at Pharmacy Monday after, 6/1/03. Sperm obviously could still be
present when she ovulates.

Assuming she may not ovulate until 8/1/02, is there any point in giving ECP on the 6th, if there has not been
any union of egg and sperm yet.

Advised her to take ECP but that she should also go and see Doctor next day re possible IUD.

Linda Jones
==============================================================================

Preliminary immediate response from Diane, while forwarding question to Dr Mimi Tanaka -
From my knowledge I would say that it is not known exactly how ECP works, but it could be a mixture of
inhibition of ovulation or fertilisation (although this is the least likely) , inhibition of implantation or thickening of
the cervical mucus.
Hence it would be worthwhile if it is inhibition of implantation, however, not much point if it is thickening of the
mucus. I would agree with your recommendation of ECP and an IUD to make sure that everything possible is
done for the girl.
================================================================================
Response from Dr Mimi Tanaka

Basically, you are absolutely correct.
>I would agree with your recommendation of ECP and an IUD to make sure that
everything possible is done for the girl.<

Absolutely, except that in most cases most people would probably feel a
postcoital IUCD is gilding the lily - that the ECP would be 'adequate' - but if
when I spoke to the girl she was absolutely certain she wanted as close to 100%
effectiveness as possible, and she felt that the benefits of that outweighed the
risks, I would be 'happy' to insert it.

Inserted comments by Mimi in the original case study –

RE: your >Young girl whose last period started 25/12/02 with an unknown cycle but
at least 28 days, she thought.Had sex Friday night 3/1/03, presented at Pharmacy
Monday after, 6/1/03. Sperm obviously could still be present when she ovulates.<
YES

>Assuming she may not ovulate until 8/1/02, is there any point in giving ECP
on the 6th, if there has not been any union of egg and sperm yet.< YES:
Most possible mechanism to work in this case, is that the ECP may DELAY
ovulation, so that there WON'T be any union of egg and sperm (fertilisation)
before the sperm disperses.
If there's been early ovulation, the transport of the egg through the tubes may
be affected, so fertilisation is again blocked. But mainly, as you know, the most
likely effect will be that the ECP impairs implantation.

So your advice:
>Advised her to take ECP<
is absolutely appropriate, and not futile, and as I said above, your advice that
> but that she should also go and see Doctor next day re possible IUD.<
also appropriate though ultimately she might decide not to use it. Doesn't
matter- she's discussed it and has made the decision based on consideration of
all options!

Hope this is helpful;\
Mimi

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Article 2
This response relates back to the case in Chatline 4:

Regarding    “I had a situation where the mother brought in a 12 year old
physically mature young girl. The girl had been at a big Marae social occasion.
Had consumed alcohol. Was found covered in dirt late at night with no panties.
The family assumed that someone had taken advantage of her. She wouldn't let her
Mum out of her sight. She would answer and didn't know whether she had had sex.
They did not want to go to the Dr. for examination. What would you do? A very
difficult situation. They would not go to the Dr. no matter what. (Eric Garvin
Shackleton,   Kaitaia.)"

The response is …
Yep, a yucky situation. I would supply ......if intercourse did not occur, no
major risks in taking ECP. If intercourse did occur then definitely is a need.
I suspect that if they could not obtain the ECP from pharmacy, they would not
have got it at all (if they are very resistant to going to Dr). I think the
essential thing here is that the ECP is supplied.
?? Did you suggest they go to family planning (is there a family planning in
Kaitaia??) - FPA might seem less threatening than "Dr".
I also would have discussed existence of Rape crisis (Police don't necessarily
need to be involved). They can always go later if they decide\need to. Just b/c
they are resistant to it today, doesn't mean that they won't come to it later -
imagine how many issues both the mum and the daughter would have been dealing
with. Perhaps once the concern of an unwanted pregnancy is removed, they might
be better able to address the other issues! Perhaps mum was resistant to
reporting, b/c of implications of 12 yr old being drunk (perhaps mum is scared
she will loose child). Perhaps the assault is being dealt with "in house"
(apparently can be more effective that legal system).
  In this sort of instance we can (must) offer support and information and
encourage reporting. We need to respect our patient's wants (if we want them to
respect us). While it would probably be ideal to get the police involved, at
least we can (hopefully) prevent a potential unwanted pregnancy. We might be
able to get the girl to rape crisis for some counselling. All we can do in any
situation is the best that we can do.

This is an especially difficult situation b/c of the abuse/neglect aspects.
Are we obliged to report this (potential) sexual assault/child abuse??(In fact is
the mum "further abusing" her daughter by not reporting this (potential) rape to
the police?? - Do we have a duty to protect the child?)
. I am worried that if I did report without consent I could 'scare' people away
from seeking ECP. (I possibly would not be able to report it anyway, if the
patient exercised her right not to give her name and address - or if the patient
did not trust that we would not report could relatively easily give false
details). I'm not sure what I would do - I think it would depend on the situation
(basically making an instinctive judgement as to the health and safety of the
child).

Lara Blaikie (Waikato)


Article 3

Guild ECP Consultation Record Pads

Most of you will probably by now have seen the Guild ECP Consultation Record Pads. These were developed
to help accredited pharmacists provide the service in a consistent manner and also to provide a record of the
consultation. Side one of the form includes a checklist of questions that should be asked before deciding
whether the ECP is appropriate, with space to record the woman's response and any additional comments you
may wish to note. On side two is a checklist of information and advice that should be given to the woman. The
form can then be used as a record of the consultation.

If you add the prescription number generated by your computer to this record you have fully documented the
interaction. This may be invaluable should there be any queries regarding the supply.

Guild member pharmacies employing an ECP accredited pharmacist receive one complimentary ECP
Consultation Record Pad as soon as the Guild is notified of the pharmacist's name. Further pads can be
purchased from Pharmaceutical Services Limited (PSL). The contact person there is Kelly Betteridge phone
04 802 8215 or email k.betteridge@pharmacy-house.org.nz. Please note that the pads are available for
purchase by non-Guild pharmacies also.




Kia Ora fellow ECP chatters

My interesting scenario ....

I had a young woman come in requesting the ECP. I established that she did
require supply, however the issue that I was confronted with was that she
had taken St Johns Wort (Hypericum) for "about a week" (she had a cold,
found some at home and thought it might help her get better faster !),
stopping "about a week" before the UPSI/consultation.
I was unsure
    1). whether 1 week of Hypericum would cause significant enzyme
induction, and
    2). how long it takes for enzyme levels to return to 'normal' after
stopping taking an enzyme inducer.
As it was a Sunday, I could not think of anyone I could phone to clarify
this issue. I explained the situation to the patient, and we both decided
that it would be safest for her to take the 2+2 dose (she was happy to pay
$50 for the 4 tablets, and was aware that it would have cost her $30 for 2
tablets. She was also well within the 72 hours, and could have waited until
Mon lunchtime when I might have been able to clarify what dose she
required.)
            On Monday, I phoned another (CPC/ ECP) pharmacist, who was not sure either.
            She did some research for me, and later let me know that while she could not
            find any specific data regarding Hypericum, for most enzyme inducing
            medications, the washout period (i.e time until enzyme levels can be
            considered to have returned to normal) is 2 weeks. She wasn't sure how long
            it takes for "significant" enzyme induction to occur.   It appears that 2+2
            was the correct dose.

            From now on I will use 2 weeks, as washout period after stopping any enzyme
            inducer. Is this correct ?
            Does anyone know how long the med has to be taken before "significant"
            enzyme induction has occurred ?

      Inserted comment from Diane – this refers back to ECP Chat 10, which I include below as
an attachment for convenience, if anyone wants to look back at the St John’s Wort comments.

            Another ?2+2 query I had, was whether a woman on amoxycillin would need 2+2.
            This consultation was during working hours so I was able to phone FPA for
            clarification. They told me that antibiotics do not interact with ECP, and
            that the standard 1+1 dose is appropriate.

            A brief summary of my ECP experiences....
            I am a locum who often works Sundays in a mall pharmacy. I have supplied
            the ECP at least 50 times. One day I supplied the ECP to 6 different
            women!!!
            Most of the women I supply the ECP to would be between 20-35 (tending
            towards the older end !!). I agree with one chatters comments that many of
            these women appear to be single. It seems to me that most women requesting
            the ECP seem reasonably aware of their cycle/fertility, and in most cases
            did require the ECP.
            On the occasions where I explained that "theoretically, it is very unlikely
            that you will become pregnant at this stage in your cycle" the woman elected
            to take the ECP anyway for 'peace of mind'. The only situations where I
            have not supplied the ECP, have been for cost reasons (the pharmacies I work
            in charge $25 or $30 for 1+1), fortunately in all of these cases the woman
            has been under 21 so I have been able to send her to FPA for free
            consultation/supply. (If they are over 21 I explain that she can go to FPA,
            and ECP will only cost $3, or may be supplied free, BUT that she will have
            to pay a consultation fee of $20, and also wait (for up to 2 hours) to see
            a Dr. At this stage she usually decides $30 isn't 'too expensive' after
            all.)

            I am often surprised about how long women seem to wait before seeking ECP
            (esp knowing that difference b/t effectiveness at 24 hrs vs 72 hrs)..... at
            a guess 20% within 24 hours. 40% within 48hrs. 40% within 72. Haven't yet
            had anyone in who had passed the 72 hours, which suggests to me that there
            is awareness of "how long you've got"

            Lara Blaikie,   Locum (Hamilton area)

				
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