Key Points for Providers and Clients
• Unmarried and married youth may have different sexual and reproductive health needs. All contraceptives are safe for young people.
• Correct information can help men make better decisions about their own health and their partner’s health, too. When couples discuss contraception, they are more likely to make plans that they can carry out.
Women Near Menopause
• To be sure to avoid pregnancy, a woman should use contraception until she has had no monthly bleeding for 12 months in a row.
Young people may come to a family planning provider not only for contraception but also for advice about physical changes, sex, relationships, family, and problems of growing up. Their needs depend on their particular situations. Some are unmarried and sexually active, others are not sexually active, while still others are already married. Some already have children. Age itself makes a great difference, since young people mature quickly during the adolescent years. These differences make it important to learn about each client first, to understand why that client has come, and to tailor counseling and the offer of services accordingly.
Provide Services with Care and Respect
Young people deserve nonjudgmental and respectful care no matter how young they are. Criticism or unwelcoming attitudes will keep young people away from the care they need. Counseling and services do not encourage young people to have sex. Instead, they help young people protect their health.
To make services friendly to youth, you can:
• Show young people that you enjoy working with them.
• Counsel in private areas where you cannot be seen or overheard. Ensure confidentiality and assure the client of confidentiality.
• Listen carefully and ask open-ended questions such as “How can I help you?” and “What questions do you have?”
• Use terms that suit young people. Avoid such terms as “family planning” which may seem irrelevant to those who are not married.
• Welcome partners and include them in counseling, if the client desires.
• Try to make sure that a young woman’s choices are her own and are not pressured by her partner or her family. In particular, if she is being pressured to have sex, help a young woman think about what she can say and do to resist and reduce that pressure. Practice skills to negotiate condom use.
• Speak without expressing judgment (for example, say “You can” rather than “You should”). Do not criticize even if you do not approve of what the young person is saying or doing. Help young clients make decisions that are in their best interest.
• Take time to fully address questions, fears, and misinformation about sex, sexually transmitted infections (STIs), and contraceptives. Many young people want reassurance that the changes in their bodies and their feelings are normal. Be prepared to answer common questions about puberty, monthly bleeding, masturbation, night-time ejaculation, and genital hygiene.
All Contraceptives Are Safe for Young People
Young people can safely use any contraceptive method.
• Young women are often less tolerant of side effects than older women. With counseling, however, they will know what to expect and may be less likely to stop using their methods.
• Unmarried young people may have more sex partners than older people and so may face a greater risk of STIs. Considering STI risk and how to reduce it is an important part of counseling.
For some contraceptive methods there are specific considerations for young people:
Hormonal contraceptives (oral contraceptives, injectables, combined patch, combined vaginal ring, and implants)
• Injectables and the combined ring can be used without others knowing.
• Some young women find regular pill-taking particularly difficult.
Emergency contraceptive pills (ECPs)
• Young women may have less control than older women over having sex and using contraception. They may need ECPs more often.
• Provide young women with ECPs in advance, for use when needed. ECPs can be used whenever she has any unprotected sex, including sex against her will, or a contraceptive mistake has occurred.
Female sterilization and vasectomy
• Provide with great caution. Young people and people with few or no children are among those most likely to regret sterilization.
Male and female condoms
• Protect against both STIs and pregnancy, which many young people need.
• Readily available, and they are affordable and convenient for occasional sex.
• Young men may be less successful than older men at using condoms correctly. They may need practice putting condoms on.
Intrauterine device (copper-bearing and hormonal lUDs)
• lUDs are more likely to come out among women who have not given birth because their uteruses are small.
Diaphragms, spermicides, and cervical caps
• Although among the least effective methods, young women can control use of these methods, and they can be used as needed.
Fertility awareness methods
• Until a young woman has regular menstrual cycles, fertility awareness methods should be used with caution.
• Need a backup method or ECPs on hand in case abstinence fails.
• Requires the man to know when he is about to ejaculate so he can withdraw in time. This may be difficult for some young men.
• One of the least effective methods of pregnancy prevention, but it may be the only method available—and always available—for some young people.
Important Supporters, Important Clients
To health care providers, men are important for 2 reasons. First, they influence women. Some men care about their partner’s reproductive health and support them. Others stand in their way or make decisions for them. Thus, men’s attitudes can determine whether women can practice healthy behaviors. In some circumstances, such as avoiding HIV infection or getting help quickly in an obstetric emergency, a man’s actions can determine whether a woman lives or dies.
Men are also important as clients. Major family planning methods—male condoms and vasectomy—are used by men. Men also have their own sexual and reproductive health needs and concerns—in particular regarding sexually transmitted infections (STIs)—which deserve the attention of the health care system and providers.
Many Ways to Help Men
Providers can give support and services to men both as supporters of women and as clients.
Encourage Couples to Talk
Couples who discuss family planning—with or without a provider’s help—- are more likely to make plans that they can carry out. Providers can:
• Coach men and women on how to talk with their partners about sex, family planning, and STIs.
• Encourage joint decision-making about sexual and reproductive health matters.
• Invite and encourage women to bring their partners to the clinic for joint counseling, decision-making, and care.
• Suggest to female clients that they tell their partners about health services for men. Give informational materials to take home, if available.
Provide Accurate Information
To inform men’s decisions and opinions, they need correct information and correction of misperceptions. Topics important to men include:
• Family planning methods, both for men and for women, including safety and effectiveness
• STIs including HIV/AIDS—how they are and are not transmitted, signs and symptoms, testing, and treatment
• The benefits of waiting until the youngest child is 2 years old before a woman becomes pregnant again
• Male and female sexual and reproductive anatomy and function
• Safe pregnancy and delivery
Offer Services or Refer
Important services that many men want include:
• Condoms, vasectomy, and counseling about other methods
• Counseling and help for sexual problems
• STI/HIV counseling, testing, and treatment
• Infertility counseling
• Screening for penile, testicular, and prostate cancer
Like women, men of all ages, married or unmarried, have their own sexual and reproductive health needs. They deserve good-quality services and respectful, supportive, and nonjudgmental counseling.
Women Near Menopause
A woman has reached menopause when her ovaries stop releasing eggs (ovulating). Because bleeding does not come every month as menopause approaches, a woman is considered no longer fertile once she has gone 12 months in a row without having any bleeding.
Menopause usually occurs between the ages of 45 and 55. About half of women reach menopause by age 50. By age 55 some 96% of women have reached menopause.
To prevent pregnancy until it is clear that she is no longer fertile, an older woman can use any method, if she has no medical condition that limits its use. By itself, age does not restrict a woman from using any contraceptive method.
Special Considerations About Method Choice
When helping women near menopause choose a method, consider:
Combined hormonal methods (combined oral contraceptives [COCs], monthly injectables, combined patch, combined vaginal ring)
• Women age 35 and older who smoke—regardless of how much— should not use COCs, the patch, or the vaginal ring.
• Women age 35 and older who smoke 15 or more cigarettes a day should not use monthly injectables.
• Women age 35 or older should not use COCs, monthly injectables, the patch, or the vaginal ring if they have migraine headaches (whether with migraine aura or not).
Progestin-only methods (progestin-only pills, progestin-only injectables, implants)
• A good choice for women who cannot use methods with estrogen.
• During use, DMPA decreases bone mineral density slightly. It is not known whether this decrease in bone density increases the risk of bone fracture later, after menopause.
Emergency contraceptive pills
Can be used by women of any age, including those who cannot use hormonal methods on a continuing basis.
Female sterilization and vasectomy
• May be a good choice for older women and their partners who know they will not want more children.
• Older women are more likely to have conditions that require delay, referral, or caution for female sterilization.
Male and female condoms, diaphragms, spermicides, cervical caps and withdrawal
• Protect older women well, considering women’s reduced fertility in the years before menopause.
• Affordable and convenient for women who may have occasional sex.
Intrauterine device (copper-bearing and hormonal IUDs)
• Expulsion rates fall as women grow older, and are lowest in women over 40 years of age.
• Insertion may be more difficult due to tightening of the cervical canal.
Fertility awareness methods
• Lack of regular cycles before menopause makes it more difficult to use these methods reliably.
When a Woman Can Stop Using Family Planning
Because bleeding does not come every month in the time before menopause, it is difficult for a woman whose bleeding seems to have stopped to know when to stop using contraception. Thus, it is recommended to use a family planning method for 12 months after last bleeding in case bleeding occurs again.
Hormonal methods affect bleeding, and so it may be difficult to know if a woman using them has reached menopause. After stopping a hormonal method, she can use a nonhormonal method. She no longer needs contraception once she has had no bleeding for 12 months in a row.
Copper-bearing lUDs can be left in place until after menopause. They should be removed within 12 months after a woman’s last monthly bleeding.
Relieving Symptoms of Menopause
Women experience physical effects before, during, and after menopause: hot flashes, excess sweating, difficulty holding urine, vaginal dryness that can make sex painful, and difficulty sleeping.
Providers can suggest ways to reduce some of these symptoms:
• Deep breathing from the diaphragm may make a hot flash go away faster. A woman can also try eating foods containing soy or taking 800 international units per day of vitamin E.
• Eat foods rich in calcium (such as dairy products, beans, fish) and engage in moderate physical activity to help slow the loss of bone density that comes with menopause.
• Vaginal lubricants or moisturizers can be used if vaginal dryness persists and causes irritation. During sex, use a commercially available vaginal lubricant, water, or saliva as a lubricant, if vaginal dryness is a problem.