Respond to these two discussions

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1) Written By Cicely

A great number of pregnancies in the U.S. are unintentional. Unintentional pregnancies increase the risks of adverse effects for mother and baby. Contraceptive counseling is an important strategy to prevent unintentional pregnancies. It is important for the provider to develop a trusting relationship that includes a shared-decision making approach to help meet the patient’s contraceptives needs and preferences (Dehlendorf, Krajewski, & Borrero, 2014). Contraception counseling uses strategies to inform, promote continuation and adherence, and optimize women’s use of contraception (Dehlendorf, Krajewski, & Borrero, 2014).

Medical Eligibility

Karen is a 33-year old who has a history of migraines. It is unknown whether the migraines are with or without aura. She also smokes a ½ a pack of cigarettes per day. Her father has a history of DVT and cardiac disease. Her mother has a history of cervical cancer. Karen’s BP is 138/76 and her pelvic exam is normal. According to the medical eligibility chart Karen is eligible for combination hormonal contraception (CHC), copper-containing IUD, Depo Provera, levonorgestrel-releasing IUD, progestin-implant, and progestin only pills. Even though Karen is a smoker it would be appropriate to prescribe CHC to her. Her age and the number of cigarettes she smokes put her at a category 2 meaning the benefit of the method outweighs the risk (CDC, 2017). Karen having a first degree relative with history of DVT is also a category 2. If Karen’s migraines are with an aura, then she would not be medically eligible for CHCs as this is a category 4 which is an unacceptable health risk.

Recommended Contraception Method

The contraceptive method that I would recommend for Karen is the levonorgestrel-releasing IUD such as the Mirena. It is a highly effective form of long-acting reversible birth contraceptive (LARC). ACOG recommends that IUDs be used as a first-line method for contraceptive (Schuiling, 2017). IUD’s such as the Mirena would give Karen at least 5 years of pregnancy prevention. LARC’s such as the Mirena have a high satisfaction and continuation rate (Schuiling, 2017). Karen suffers with dysmenorrhea and heavy bleeding lasting 7-8 days. The Mirena is approved by the FDA to help treat heavy menstrual bleeding and maybe helpful for treating dysmenorrhea (Schuiling, 2017). There is also a benefit of reduced risks of cervical and endometrial cancer with IUD use (Schuiling, 2017).

Contraceptive Method Not Recommended

Because of Karen’s history of heavy menstrual bleeding and dysmenorrhea, I would not recommend the copper IUD. The most common side effects of copper IUD are heavy bleeding and dysmenorrhea. There is a 50% increase in blood loss and potential for an increase in duration with the copper IUD (Schuiling, 2017).

Dehlendorf, C., Krajewski, C., & Borrero, S. (2014). Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use. Clinical obstetrics and gynecology, 57(4), 659. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC42166…

Schuiling, Kerri D. Women’s Gynecologic Health, 3rd Edition. Jones & Bartlett Learning, 2017. [South University].

Summary chart of U.S. medical eligibility criteria for contraceptive use. (2017). Centers for Disease Control and Prevention [CDC]. Retrieved from https://www.cdc.gov/reproductivehealth/contracepti…

2) Written By Mary

There are multiple contraceptive options available for women that can be chosen based on efficacy, effectiveness, convenience, cost, and safety. Contraception counseling is an important part of reproductive planning and should be driven based on the patient’s preferences when no medical contraindications exist (Schuling & Likis, 2017). The following sections will cover contraceptive methods that are appropriate for the patient in this case study as they pertain to her reproductive goals and medical, social, and family history.

Eligible Contraceptive Methods

History of Migraines

According to the case study, the patient has a known history of migraines for which she takes Imitrex as needed. It is unknown from the information provided if Karen’s migraines are with or without aura; this would affect the selection of contraception in this case. To err on the side of caution, Karen would be advised against combined hormone contraception (pills, patches, or rings) as the CDC has classified them as unacceptable for use in patients with migraine with aura (2017). Intrauterine devices (IUD) with and without hormones, progestin-only pills and implants, and depo injections are the remaining options available to this patient.

Heavy, painful menses

Heavy and painful menses are reported in this case study. According to the CDC (2017), patients with heavy menses and severe dysmenorrhea may use all types of contraception as advantages of each type outweigh the theoretical or proven risks. There are no absolute contraindications for any type of contraception with heavy, painful menses.

Smoking History

The patient’s age and number of cigarettes they smoke are both factors that determine eligibility of contraception use for women. There are no restrictions to contraceptive methods in patients who smoke and are under the age 35, except for combined hormone contraception (CHC) in which case the advantages still outweigh risks and can be taken. However, in patients aged 35 and up in combination with higher amounts of cigarettes smoked, combined hormone contraception is proven to be more risky than beneficial and is not recommended for use (CDC, 2017).

Family History of DVT and Cervical Cancer

Karen has a positive family history of DVT which does not limit her eligibility for contraception; even with use of CHCs the benefits outweigh the risks. A personal diagnosis of cervical cancer would make Karen ineligible for some contraceptive methods. A positive first-degree family history places Karen at higher risk of cervical cancer but does not impact her choice of contraception at this time (CDC, 2017).

Blood Pressure

Karen’s blood pressure reading of 138/76 is concerning for undiagnosed pre-hypertension. High blood pressure would affect her choices for contraception if she were interested in depo injections or CHC (CDC, 2017).

Most Beneficial Contraceptive Method

Considering the factors presented in the case study, the best method of contraception for Karen would be the levonorgestrel (LNG) IUD. There are no absolute contraindications for this form of contraception based on her known factors such as history of migraines, blood pressure reading, smoking history, and family history of DVT and cervical cancer. Also, initiation of LNG-IUD has been shown to improve symptoms of menorrhagia and dysmenorrhea without any adverse effects (Curtis et al., 2016). LNG-IUD are a long-acting reversible contraception method and would be available in three- or five-year options for Karen to choose from since she doesn’t want more children in the near future.

Methods of Contraception Not Recommended for Patient

Based on the factors discussed in the sections above, CHC would not be recommended for this patient. Migraines, smoking, and hypertension all are contraindications for taking CHC. While we don’t know if the patient has migraine with aura it is better to err on the side of caution when advising the patient about available methods. We also don’t have a diagnosis of hypertension from the facts stated in the case study, and her blood pressure reading may be a fluke. However, as a precaution, CHC should be avoided until a definitive measurement of blood pressure is made. Based on Karen’s age, her smoking status still allows her to take CHC, but unless she quits before she turns 35, it will then no longer be recommended as a safe contraceptive method.

References

Curtis, K. M., Tepper, N. K., Jatlaoui, T. C., Berry-Bibee, E. …& Whiteman, M. K. (2016). U. S. medical eligibility criteria for contraceptive use, 2016. Morbidity and Mortality Weekly Report, 65(3). Retrieved from https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503…

Centers for Disease Control and Prevention. (2017). Summary chart of U. S. medical eligibility criteria for contraceptive use. Retrieved from https://www.cdc.gov/reproductivehealth/contracepti…

Schuling, K. D. & Likis, F. E. (2017). Women’s Gynecologic Health, 3^rd ed. Burlington, MA: Jones & Bartlett Learning

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