Contraception Case Studies. VETERANS HEALTH ADMINISTRATION Case Study 1 Ashley, a 23-year-old unmarried veteran comes for an initial visit to request

Contraception Case Studies

VETERANS HEALTH ADMINISTRATION

Case Study 1

Ashley, a 23-year-old unmarried veteran comes for an initial visit to request birth control. She asks about birth control pills, but also wants information about the newer hormonal methods on the market. Vital signs: 5 feet 6 inches tall, 210 lbs., BMI 33.9, HR 76, RR 16, 98.7 F, 142/88

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1. Blood pressure2. Smoking history3. Pap smear and pelvic exam4. History of migraines with auras5. All of the above are needed prior to starting

hormonal contraception

Q1. What information do you NOT need prior to starting Ashley on hormonal contraception?

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1. Blood pressure2. Smoking history3. Pap smear and pelvic exam4. History of migraines with auras5. All of the above are needed prior to starting

hormonal contraception

Q1. What information do you NOT need prior to starting Ashley on hormonal contraception?

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Prior to starting COC, check for the following: •Blood pressure measurement•Family history of thrombotic disorders•Migraines with aura•Smoking history (not necessary for Ashley who is 23 yo, but important for women ≥35 or approaching this age) •It is NOT necessary to do a Pap smear and pelvic exam prior to initiation •This might be a good time to discuss the HPV vaccine since the patient is under age 26

Discussion Points

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Q2. Which of the following is NOT an absolute contraindication for oral contraceptives?1. Smoking and age ≥352. Acute liver disease3. Migraine without aura4. History of clots, stroke, or heart disease5. Undiagnosed abnormal vaginal bleeding

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Q2. Which of the following is NOT an absolute contraindication for oral contraceptives?1. Smoking and age ≥352. Acute liver disease3. Migraine without aura4. History of clots, stroke, or heart disease5. Undiagnosed abnormal vaginal bleeding

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Absolute contraindications include:• Breast cancer history

• History of blood clots, stroke, heart disease

• Undiagnosed abnormal vaginal bleeding

• Pregnancy

• Acute liver disease

• Migraine with aura

• Smoking & age ≥ 35

Discussion Points

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Relative contraindications include: • Migraine – “classic”

• High blood pressure

• High cholesterol

• Diabetes

• Obesity

• Breastfeeding

Discussion Points

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Ashley thinks she may like to go on “the pill”, as many of her friends are happy with it. She has seen advertisements on TV for Yasmin®, and would like to try it because she gets very moody around the time of her period.

Case 1, continued

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1. Mid-dose (30-35 mcg ethinyl estradiol) pills2. Low-dose (20 mcg ethinyl estradiol) pills3. Extended cycle (13 week) pills 4. Drosperinone-containing pills5. All of the above are options

Q3. Which of the following are options for her?

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1. Mid-dose (30-35 mcg ethinyl estradiol) pills2. Low-dose (20 mcg ethinyl estradiol) pills3. Extended cycle (13 week) pills 4. Drosperinone-containing pills5. All of the above are options

Q3. Which of the following are options for her?

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• Low-dose (20 mcg of ethinyl estradiol) pills – More breakthrough bleeding when initially started compared

to mid-dose estrogen– Not shown to be associated with fewer thrombotic events

• Mid-dose pills contain 30-35 mcg of ethinyl estradiol• Non-contraceptive benefits of COCs include:

– Regular cycles – Decreased: bleeding, dysmenorrhea, acne, risk of

endometrial and ovarian cancers

Discussion Points

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• Yasmin® − Contains “drosperinone”, a spironolactone derivative progestin with

anti-mineralicorticoid and anti-andrenergic effects• Drosperinone-containing COCs may be associated with higher risk for

blood clots than COCs containing other progestins− May be better than placebo for PMDD− Few head-to-head studies comparing Yasmin® to other COCs that may

also help with PMDD− Use caution when prescribing to women at risk for hyperkalemia

• COCs appear to protect against ovarian and uterine cancer (5 yrs: 50% and 60% reduction) and colon cancer. Literature is mixed with regard to risk of breast cancer. Do not protect against cervical cancers.

Discussion Points

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1. Reduce frequency of menses2. Manipulate timing of menses3. Control menorrhagia4. Manage dysmenorrhea5. All of the above

Q4. Extended cycle use of combined oral contraceptives is useful to:

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1. Reduce frequency of menses2. Manipulate timing of menses3. Control menorrhagia4. Manage dysmenorrhea5. All of the above

Q4. Extended cycle use of combined oral contraceptives is useful to:

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Traditional COCs have 21 days of active pills and 7 days of placebo pills. Extended cycle COCs have 13-week cycles. Advantages of an extended cycle:

• Only four periods a year• Desirable for women who travel frequently or have

menstrual-related problems (heavy bleeding, mood swings, acne)

Breakthrough bleeding can occur, especially at 9-12 weeks

Note: Many COCs can be taken continuously without placebo pills. This

requires prescribing 4 pill packs for a 90-day supply.

Discussion Points

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1. Headache and nausea2. Spotting 3. Breast tenderness4. Decreased libido5. All of the above are side effects of the pill

Q5. Ashley should watch for all of the following side effects with an OCP EXCEPT?

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1. Headache and nausea2. Spotting 3. Breast tenderness4. Decreased libido5. All of the above are side effects of the pill

Q5. Ashley should watch for all of the following side effects with an OCP EXCEPT?

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• OCP side effects include headache, nausea, spotting, and breast tenderness

• Placebo-controlled trials have NOT found mood changes or weight gain to be more frequent on OCPs compared to placebo

• If she is not happy with her OCP, but wants to continue taking a pill, it is reasonable to try another formulation with either a different dose of estrogen or a different progestin before switching to a different method

Discussion Points

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After listening to your instructions on how to use an oral contraceptive, Ashley worries that she will not be reliable in taking the pill every day, and asks about other options.

Case 1, continued

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1. Irregular bleeding is uncommon during the first 6-9 months of use

2. DMPA never causes amenorrhea3. Fertility may be delayed after discontinuation4. DMPA increases the risk of gynecologic cancers5. DMPA does not affect bone mineral density6. Weight gain is not a reported side effect

Q6. Which of the following side effects is TRUE about depot medroxyprogesterone acetate (DMPA, Depo-Provera®)?

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1. Irregular bleeding is uncommon during the first 6-9 months of use

2. DMPA never causes amenorrhea3. Fertility may be delayed after discontinuation4. DMPA increases the risk of gynecologic cancers5. DMPA does not affect bone mineral density6. Weight gain is not a reported side effect

Q6. Which of the following side effects is TRUE about depot medroxyprogesterone acetate (DMPA, Depo-Provera®)?

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• Irregular bleeding; amenorrhea with prolonged use• Delay in return to ovulation after cessation (avg time is 10 mos)• Nausea, breast tenderness, headaches, decreased libido, weight

gain• Avg weight gain is 5.4 pounds in first year; weight gain is greater

for women already obese• Decreases menstrual cramps, endometriosis pain, endometrial

cancer risk, and possibly ovarian cancer risk• Good choice for women who can’t use estrogen, safe to use

during lactation, decreases sickle cell crisis, may reduce seizures in epileptics

Discussion Points

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Q7. Which of the following options might be less suitable for Ashley?

1. Ortho Evra® patch

2. NuvaRing®

3. Depo-Provera®

4. Implanon®

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Q7. Which of the following options might be less suitable for Ashley?


2. NuvaRing®

3. Depo-Provera®

4. Implanon®

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• Of the 15 pregnancies that occurred during the clinical trial of Ortho Evra®, five were in women greater than 90 kg. Thus, patch may not be as effective in obese women. However, contraceptives are only effective if patient will use them, so shared decision-making is very important in this case.

• Average weight gain with Depo-Provera® is 5.4 pounds in first year. Weight gain is greater for women already obese.

Discussion Points

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Kanisha, a 35-year-old female comes to your clinic to ask about contraception. She and her husband have one child. She wants some type of birth control that she doesn't have to think about for as long as possible. She is otherwise healthy, and her only complaint is heavy periods.

She is currently using the “rhythm method” and adding condoms during high-risk times.

Case 2

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Q8. Which of the following contraceptives would you recommend?


2. NuvaRing®

3. Depo-Provera®

4. Implanon®

5. ParaGard®

6. Mirena®

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Q8. Which of the following contraceptives would you recommend?


2. NuvaRing®

3. Depo-Provera®

4. Implanon®

5. ParaGard®

6. Mirena®

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• ParaGard® IUD provides contraception for 10 years, and is a good choice for women who do not or cannot tolerate hormones, smokers, or women who have other contraindications to oral contraceptives. However, cramping and heavier periods may occur with ParaGard®.

• Mirena® IUD/IUS provides contraception for 5 years and is a good choice for women with heavy periods, as the progestin component can lead to amenorrhea. It can also be used by women for whom estrogen-containing contraception is contraindicated, such as smokers over the age of 35. Women may experience irregular bleeding while using Mirena®.

Discussion Points

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Q9. Would your recommendations change if Kanisha had never been pregnant?

1. Yes

2. No

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• Nulliparous women can safely use an IUD

Discussion Point

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Q10. Would your recommendations change if Kanisha has a history of chlamydia one year ago?

1. Yes

2. No

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• Only women at very high risk for STIs would not be candidates for IUD placement (i.e., sex workers). A past history of an STI does not preclude a woman from having an IUD inserted.

• Additionally, cultures are obtained prior to having the IUD placed to decrease the risk of infection during the most high-risk part which is IUD placement.

Discussion Points

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Q11. Would your recommendations change if Kanisha was unmarried?

1. Yes

2. No

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• Previously, it was thought that only married women were candidates for an IUD based on the premise that having only one partner would decrease the potential risk for infection. Also, married women were likely parous (experienced childbirth) and thus would be less affected in case of infection-related infertility.

• Today, we know that unmarried women can be good candidates for IUD placement, after the usual risk/benefit discussion with the patient. If a woman meets criteria, then the IUD can be placed regardless of marital status.

Discussion Points

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Ginger, a 32-year-old veteran, calls on Monday morning to ask about the “morning after pill”. She had unprotected sex on Saturday night.

Case 3

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Q12. Which of the following statements about Plan B® is FALSE?

1. Plan B is thought to work mainly by delaying ovulation. 2. If Ginger is already pregnant, Plan B will not harm the fetus

or cause an abortion. 3. Plan B can be used up to 5 days after unprotected

intercourse. Plan B’s two pills can be taken simultaneously if this is more convenient for the patient

4. Plan B® use is associated with an increased incidence of unprotected sex and STIs

5. Plan B is on the VA National Formulary

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Q12. Which of the following statements about Plan B® is FALSE?

1. Plan B is thought to work mainly by delaying ovulation. 2. If Ginger is already pregnant, Plan B will not harm the fetus

or cause an abortion. 3. Plan B can be used up to 5 days after unprotected

intercourse. Plan B’s two pills can be taken simultaneously if this is more convenient for the patient.

4. Plan B® use is associated with an increased incidence of unprotected sex and STIs.

5. Plan B is on the VA National Formulary.

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• Plan B: Levonorgestrel 150 mcg/dose• Plan B is on the VA National Formulary• Taken as a single dose within 5 days • Mechanism

− Delayed ovulation− Depending on timing of administration, inhibits ovulation,

fertilization, or implantation• No risk to developing fetus if patient should be pregnant;

Plan B will not cause an abortion• Side effects: Nausea, abdominal pain, fatigue, headache

Discussion Points

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Q13. Is there anything else you’d discuss with Ginger?

1. Yes

2. No

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• Ask Ginger about her sexual practices − Does she have multiple sexual partners? − Are all of her sexual encounters consensual? − What are the settings in which she has sex? − Try to ascertain her motives for having multiple sexual

partners.• Discuss her high risk of STI exposure due to

unprotected sex• Discuss contraception

Discussion Points

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Documents

Contraception Case Studies. VETERANS HEALTH ADMINISTRATION Case Study 1 Ashley, a 23-year-old unmarried veteran comes for an initial visit to request