Monday, April 28, 2008

Emergency Service?

Gentle readers, I have to confess to being a bit perplexed by this next diagnostic conundrum. I’m hoping there are some of you out there amongst my varied readership who could help me to unravel it, but before I get going I have to issue a tiny health warning, in that the subject of today’s enquiry is of an hem-hem, Adult nature, as they say. (Well they do if they are Nigel Moleswoth at least). Needless to say, given the usual inane tone of these meanderings, it might not attract a suitably, hem-hem, adult treatment, but then that’s not what you all come here for is it?

In a nutshell the problem is of a somewhat intimate nature, in that a young lady attended surgery last week seeking help with contraception. She was asking for a handful of “morning after” pills*. It seems that her previous GP had hit upon this unusual approach to family “planning” after she presented her rather delicate problem to him a while ago. Perhaps it would help if I explained why such an approach is at variance with accepted practice, before I go on to detail why it had been chosen in this instance.

In effect the “morning after” pill is intended as a single shot treatment for an isolated indiscretion, or failure of other method (principally condoms). To require several such pills suggested an intention to serial indiscretions, which, as health care professionals, causes us some pause for thought. So I had to ask the poor girl why she needed such a “Russian Roulette” method.

It transpires that she has never really been suited to either of the usual varieties of pill through adverse effects such as significant weight gain, or troublesome skin changes. For that reason she had also fought shy of implantable or injectable methods using similar hormones as their basis. As a nullipara (a lady yet to deliver a baby) she is not a candidate for a “coil” either, and, as any fule kno, caps and the wretched “femidom” female condom are about as effective as the old fashioned “hot bath and Gin” method and as spontaneous as a line of Pinter dialogue. And so she and her boyfriend have been diligently trying to use condoms, but about one time in three they burst and she finds herself in need of emergency contraception in the form of the good old “morning after” pill.

So here’s my problem. She and I are both aware that certain substances have a deleterious effect on rubber that can occasion such failures (baby oil being chief amongst these) and she is quite certain that there is no risk of this. She reports that her boyfriend is just “too big”.

Now, having spent many a late night in Doctor’s Messes the length and breadth of the midlands in my formative years, I watched quite a lot of late night Channel Four youth TV. You could guarantee that once every couple of weeks or so some drunken idiot would appear on “The Tube” “The Word” or some other hip and trendy show with “The” in the title, and perform his (yes they were always plug ugly, synaptically challenged herberts) party piece, namely the unrolling of a Rubber Johnny over the top of the unappealing visage to just below the oft fractured hooter. Thereupon said herbert would inhale though his mouth and exhale through his monstrously deformed nose, inflating the aforementioned prophylactic to roughly the size of a London Bus, before it explosively decompressed, sadly leaving the perpetrator unscathed though now adorned by a slightly slimy latex “Alice Band”.

So now I’m wondering just what this couple are doing to occasion such a spectacular failure rate, unless it is just that Boy Friend thinks that the technique described above is the approved method of use?

* for the uninitiated the "Morning After" pill is a monster dose single shot treatment of an oral contraceptive that can be taken anywhere up to 72 hours after an incident of "Unprotected Sexual Intercourse" ** so "Morning After" pill is a bit of a misnomer. Oh, and it used to be two doses of same taken at a twelve hour interval which made it even more so, though not now that both doses have been amalgamated so the name is at least half right these days....

** the acronym is UPSI. There is a trend for naming little girls Daisy round these parts, so I'm looking forward to being able to record my first "UPSI-Daisy" in around 15 years time...

9 comments:

Z said...

I don't think they're putting it on properly. Maybe one of them has very long or jagged nails?

I understand that, among those for whom artificial contraceptive devices are not acceptable, mutual oral sex is an enjoyable substitute that gives no risk of pregnancy. Maybe the suggestion from a family doctor is a touch intrusive, however. I can't help thinking that she might as well go ahead and have a baby - nine months with no need for contraception, after which she could use a coil if she wanted to.

Dr Andrew Brown said...

The pun is most satisfactorily dreadful! Thanks, Dr J. :-)

orchidea said...

Do the adverse effects of taking the contraceptive pill really outweigh those of taking the morning after pill (too) frequently?

Perhaps it's her boyfriend who should be consulting you.

BenefitScroungingScum said...

I'm amazed no-one else has mentioned this, but here goes....

The combination of petite woman and well endowed man (actually doesn't have to be much more than average now I think about it), in my experience has led to condoms breaking so frequently I would always check they're intact after initial penetration. It seems to be something about the forces applied to the condom and that they become too great causing the breakage, typically on initial penetration.

I'm in a similar position to the lady you describe so was offered a coil by a fam planning consultant. It wouldn't hold and had to be removed in A&E a day later as it was 'stuck'. A consultant might be willing to offer your patient a trial of a coil considering the circumstances. Mine was done under colposcopy (sp?) to improve the chances of accuracy. Ironically.

The best thing I can suggest is huge amounts of ky jelly (or similar) Enough lube seems to go some way counteract the the different forces, but were I desperate not to get pregnant I wouldn't be relying on it without checking the condom every time.

Having been through the process with the input of a consultant I can't come up with any real answers. Withdrawl seems to work best as a method of contraception and is probably no more risky than their current situation.

I wish them luck, and if you come up with any better suggestions, please do let me know!
Bendy Girl

orchidea said...

Bendy Girl - I'm a petite woman with an... erm... tall man. We've used condoms in the past with no problems at all (except being out of condoms). One thing I know for sure is that if withdrawal worked, I'd have 50% less children than I have now!

:)

Elaine said...

... and you don't require penetration to result in impregnation...

Becks said...

I am a nullipara who regards her coil as the best thing since sliced bread. I'm not sure if there is any official guidance on this, but clearly some doctors are willing to fit them and surely in this case it would be better than "handfuls" of morning after pills!

Doctor Jest said...

z- wise words as ever, though I seem to recall reading a report of a pregnancy resulting after an abdominal stab wound following oral sex...

Dr A- always happy to be of service doc ;-)

orchidea- in this young lady's case yes she prefers the latter aproach and I would certainly not argue with her. I hope the extra strong or large fit condoms I supplied to her for him will do the trick, and yes, perhaps he ought to be the one to consult, but since it is she that would have to bear the consequences if we don't get it right I'm happy to try to "treat" him through her as it were.

bendy girl- thanks for a fascinatin insight. perhaps there is some unusual shear force at work here. I'll be sure to pass your advice on if I can.

elaine- indeed. A point well made in the interests of public health.

becks- welcome. as you say some family planners and GPs are ok with the idea of IUCDs for nulliparas, but fitting can be a tad trickier, and there are still some hangups about the small increase in risk of pelvic infections and their effect on future fertility, though I accept this is probably overplayed and based on experience now 3-4 decades out of date.

Z said...

input of a consultant? Oh, okay.

You've a good memory (so have I), I remember reading about that case too, some years ago - it was in Africa, I think, and the girl concerned had no opening to her cervix, so it should have been impossible for her to become pregnant. It was an angry husband or brother who stabbed her, not the boyfriend who had impregnated her. It could be a shaggy dog story, of course - all seems highly unlikely.