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Week 3 Case Studies

Case Study 1

Case Study: Contraception

Scenario 1

Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss contraceptive options.  She states that she

is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs.  She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems.

· Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68  

· HEENT:  wnl  

· Neck: supple without adenopathy  

· Lungs/CV: wnl  

· Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge  

· Abd: soft, +BS, no tenderness  

· VVBSU: wnl, except 1st degree cystocele  

· Cervix: firm, smooth, parous, without CMT  

· Uterus: RV, mobile, non-tender, approximately 10 cm,  

· Adnexa: without masses or tenderness  

QUESTION:

What other information do you need?  

MORE QUESTIONS:

1. What has she used in the past?  Why did she stop a method?  How many partners in past 12 months?  

2. What are her current cycles like?  

3. When was her last gyn exam and what were the results of the tests?   

4. Are her migraines with or without auras?  

5. What method has she considered.  

ANSWERS:

Elaine relates to you that she has used birth control pills before but “would keep messing them up.”  After that she switched to the patch, which she found worked well but discontinued use for reasons she does not remember. After that she used natural family planning but still conceived her last two children unexpectedly.  She has had three partners in last 12 months and has been with her current partner for the previous two months. She believes that he is “the one.”    

Elaine relates that her cycles come every 28-32 days, for a duration of 5-8 days, and on her heaviest day she must use a super tampon every hour and get up to change her pad 2-3 times at night. Her last gyn exam was one year ago and she shows you a copy of the results on her patient portal. The results for the pap were NILM, HPV negative, and her cultures for GC/CT were negative.  

In further questioning, you ask her about her migraines. She shares that these migraines occur just before her period, or when she’s stressed, and are preceded by a vision change in her right eye. She takes Excedrin Migraine for them and rests in a dark room until the migraine is done.  

She has heard about a pill where she will only get her period four times a year and feels now that she’s older she can remember to take the pill daily and plans on putting a reminder in her phone.  

QUESTIONS:

· What are your next steps/considerations?  

· What teaching should you do?  

· What methods are appropriate for Elaine?  

  
ANSWERS:

Elaine is not a candidate for any estrogen containing contraceptives due to her history of migraines with aura. The patch and the ring also contain estrogen, so they are not options either. She can be offered progestin only contraceptives such as Nexplanon, progestin only ocp or depo Provera.  

She can be counseled on all methods appropriate to her such as barrier, progestin containing contraceptives.  The ParaGard (copper) IUD would not be an appropriate choice as she already has heavy periods  

Progestin containing IUD also a good option especially since she has heavy periods.  Elaine should also be counseled on condom usage until she is in a long term mutually faithful relationship.  

Reference 

Schuiling, K. D. (2017). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Learning.  

· Chapter 11