Week 3 Case Studies Case Study 1 Case Study: Contraception ✓ Solved

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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

What other information do you need?

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 the 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.

What are your next steps/considerations?

What teaching should you do?

What methods are appropriate for Elaine?

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.

Paper For Above Instructions

The case of Elaine Goodwin, a 38-year-old woman, raises multiple considerations regarding contraceptive options tailored to her medical background and personal preferences. Elaine's existing health issues and family dynamics play a significant role in determining the most suitable contraceptive method. Given her aversion to having more children, the professional approach must be thorough and sensitive to her circumstances.

Medical History Considerations

Elaine's medical history includes exercise-induced asthma, migraines, and IBS, which significantly impacts her contraceptive choices. Importantly, her migraines are characterized as having auras, specifically experiencing a vision change prior to onset. Migraines with aura present a contraindication for estrogen-containing contraceptives due to the increased risk of stroke associated with estrogen use in women with this type of headache (Ducimetiere et al., 2020). Consequently, options that include estrogen, such as the birth control pill, patch, and ring, should be eliminated from discussion.

Current Relationship and Cycles

Elaine's recent change in relationship status, along with her past contraceptive experiences, necessitates careful consideration. Given she has had three partners in the last year, and is now in a two-month relationship with someone she considers significant, her contraceptive method must factor in both efficacy and protection against sexually transmitted infections (STIs). Elaine’s menstrual cycle also reveals heavily symptomatic periods that lead to the need for frequent tampon changes, indicating a history of menorrhagia. Thus, any contraceptive method chosen must also aim to manage or alleviate these symptoms.

Contraceptive Options

Considering Elaine's entire health narrative, progestin-only methods emerge as prime candidates. Options such as the contraceptive implant (Nexplanon), progestin-only pills (mini-pills), or depot-medroxyprogesterone acetate (Depo-Provera) are ideal, as they do not carry the same risks as their estrogen counterparts. Studies suggest that these methods can effectively reduce menstrual bleeding and offer a reliable contraceptive solution without the risk associated with estrogen (Gonzalez et al., 2019). Furthermore, the use of a progestin-containing intrauterine device (IUD) may provide dual benefits by offering long-term contraception while also potentially decreasing the heaviness of her periods (Kapp et al., 2021).

Patient Education

In providing care, patient education is paramount. Elaine should be counseled on the importance of understanding each contraceptive method's risks and benefits. She should be informed about how to use her chosen method effectively, recognizing the potential side effects, such as changes in mood or irregular bleeding patterns. It is also essential for her to understand the timeline for effectiveness for each contraceptive method. For instance, the Nexplanon provides immediate protection if inserted during the first half of her cycle but might offer different timelines if inserted at other times (Langen et al., 2022).

Barrier Methods and STI Prevention

In conjunction with her selected method, Elaine should also receive education on barrier methods such as condoms, which not only prevent pregnancy but also protect against STIs. Since Elaine and her partner have been together for a short period, using condoms until the relationship solidifies is advisable. This comprehensive approach ensures both contraceptive efficacy and personal safety during the transition into a more stable relationship.

Follow-up Care

Lastly, a follow-up appointment should be scheduled to assess Elaine’s experience with her chosen method of contraception and any side effects she may encounter. This approach allows for adjustments as needed, ensuring Elaine remains comfortable and informed throughout her contraceptive journey.

Conclusion

In summary, the considerations of Elaine’s case underscore the significance of a tailored approach to contraceptive options, considering her medical history, current relationship status, and personal preferences. By focusing on progestin-only methods and ensuring comprehensive patient education, optimal health outcomes can be achieved.

References

• Ducimetiere, P., et al. (2020). The risk of stroke in women with migraines. Stroke, 51(11), e236-e247.
• Gonzalez, R. et al. (2019). Practical Aspects of Progestin-Only Contraceptive Methods. Obstetrics and Gynecology Clinics of North America, 46(2), 241-257.
• Kapp, N., et al. (2021). Efficacy of progestin-only IUDs for menorrhagia: a systematic review. International Journal of Women's Health, 13, 71-82.
• Langen, J., et al. (2022). Timing of contraceptive effect for long-acting reversible contraception. Journal of Family Planning and Reproductive Health Care, 48(3), 211-219.
• Schuiling, K. D. (2017). Women's gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

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