Margaret is a 40-year-old white female in for her annual examination. She states she has been under increased stress in her life for the past few months. She and her husband are currently separated and considering divorce. Her teenaged sons are acting out and she is working extra hours to make ends meet. Secondary to the increased stress she has started smoking again, “about a pack per day” and states “I know that I am not eating right.”
Margaret has been on the “pill” for almost 20 years and has always liked the method. She states the she has heard that smoking and taking the pill are not good, and she is worried about that. “I really do not need birth control since I am separated but just in case I probably need something.” She states that she has been in a mutually monogamous relationship (as far as she knows) since her marriage 18 years ago. She denies a new partner since her separation. Menarche was at 11 years, her cycles when on the pill are regular and very light. Her menstrual period should start tomorrow as she just finished her active pills. She denies a personal history of abnormal Pap smears, gynecological issues, hypertension (HTN), or diabetes. She is G2P2002, and her pregnancies were full term and uncomplicated at ages 24 and 26. Family history is significant for both parents with HTN and mom has type 2 diabetes. Her paternal grandfather died at age 64 years from type 2 diabetes, HTN, and coronary artery disease. Her other grandparents died in their late 70s early 80s and she is unaware of any medical issues.
Margaret’s examination finds her height 5’5″, weight 172 lb (up 10 lb. from last year), current body mass index (BMI 28.6), and blood pressure (BP) 148/88. Head, eyes, ears, nose, and throat (HEENT) are grossly within normal limits (WNL). No thyromegaly or lymphadenopathy. Heart rate is regular and rhythm is without murmurs, thrills, or rubs. Lungs are clear to auscultation in all lobes. Breasts are without masses, nipple discharge, asymmetry, or lymphadenopathy; self breast examination techniques and frequency reviewed during examination. Abdomen is soft, nontender, with no masses or hepatosplenomegaly; bowel sounds present in all four quadrants. Pelvic examination reveals normal vulva and negative Bartholin’s and Skene’s glands; vagina is pink, rugated, with minimal white nonodorous discharge; cervix is pink, multiparous os. Pap smear collected during speculum examination was normal. Bimanual examination reveals a retoverted, firm, mobile, nonenlarged, nontender uterus with negative cervical motion tenderness; adnexa nontender; and ovaries palpable bilaterally, mobile, without masses. Lower extremities were without edema or varicosities.
1. What options are appropriate for this patient?
2. What contraceptive options are contraindicated?
3. What type of patient education is indicated?
4. Given that she has a normal pelvic exam, does that change would that influence your decision?
What options are appropriate for this patient?
Margaret is a 40 years old patient who smokes a pack of cigarettes daily; she has a borderline blood pressure reading and a family history of diabetes, hypertension, and coronary artery disease. These factors influence the type of contraceptive appropriate for her. She is currently taking the combined oral contraceptive pill and smokes a lot, increasing the chances of severe side effects. According to CDC (2018), taking combined contraceptives with hypertension significantly increases the risk of a stroke or myocardial infarction. Although Ms. Margaret has never received a hypertension diagnosis before, the current physical assessment shows elevated blood pressure, and there is also a family history of hypertension. Therefore, there is a likelihood of Ms. Margaret having undiagnosed HPN meaning the combined oral contraceptives should be replaced with an alternative birth control method immediately.
The best options for Ms. Margaret are those that do not have estrogen, which her current birth control has, considering she has hypertension and smokes (Bastianelli et al., 2018). Therefore, the available options for Ms. Margaret include continuing with the daily pill but take a pill with only progestin, intrauterine devices like Mirena, and the Depo-Provera birth control is an option for her and is given every three months.
What contraceptive options are contraindicated?
Margaret smokes a pack of cigarettes daily, is above 35 years old, and has elevated blood pressure, making the combined oral contraceptive pill she is currently using contraindicated.
What type of patient education is indicated?
Margaret needs to understand the effects of smoking on her health and stop it, thus requires education on smoking cessation. Secondly, she needs education on stress reduction or control, monitoring her blood pressure levels, and eating healthy. She needs a healthy diet plan and should practice simple exercises to improve her health (Pazol et al., 2018). Lastly, she needs education on the available contraception options, including barrier methods like condoms, to enable her to select the one she prefers.
Given that she has a normal pelvic exam, does that change would that influence your decision?
The patient pelvic exam is normal, which signifies to me the unlikelihood of other issues being present. However, if she had any issues, this would not affect my decision to change Ms. Margaret’s birth control method.