Pediatric Primary Care Case Studies (114 page)

   
Disadvantages:
Methods require varying amounts of training and cost, which detracts from spontaneity; causes friction between partners if not in agreement; difficult to use if recent childbirth, breastfeeding, recent menarche, approaching menopause, recent discontinuation of a hormonal method, irregular cycles, or unable to interpret fertility signs (Caufield, 2004; Jennings & Arevalo, 2007).

   Option for Jaime: This method takes training, enthusiasm for the method, and support from the partner. At Jaime’s time of life, this is probably not a good method for her.

•   Permanent sterilization

   
Advantages:
Permanent, highly effective, safe, quick recovery, lack of significant long-term side effects, cost-effective, partner cooperation not required, not coitus linked.

   
Disadvantages:
Possibility of patient regret, difficult to reverse in the future, achieving pregnancy could require assistive reproductive techniques (Caufield, 2004).

   Option for Jaime: This is a permanent method, so it would not be an option for a 15-year-old girl.

•   Emergency contraception

   
Advantages:
To be used for contraceptive failure, error in withdrawal or periodic abstinence, rape, any unintended sperm exposure.

   
Disadvantages:
Not to be considered ongoing contraception (Caufield, 2004; Stewart, Trussel, & Van Look, 2007).

   Option for Jaime: In the incidence of method failure, emergency contraception could be an option, but not as an ongoing method of contraception.

Making the Diagnosis

Given her history and physical information, it is helpful to identify Jaime’s risk factors. In this case, Jaime is at risk for unhealthy lifestyle choices such as unprotected sexual intercourse, STIs, partner violence, and binge drinking. These risks must be addressed. Also, due to her menorrhagia, Jaime is at risk of becoming anemic. Jaime should be encouraged to discuss these issues with her mother. Her mother could be a tremendous help for her in dealing with them.

Although her maternal grandmother had a stroke and her maternal grandfather has adult onset diabetes, these do not significantly alter Jaime’s choices of contraception.

Management

After much discussion, Jaime decides she would like to try combined oral contraceptive pills (COCs).

You explain to Jaime what she needs to know regarding taking COCs, including how to take the pills, when to start the pills, risks and benefits, and warning signs of problems (
Box 28-1
). Providing accurate and understandable information relating to using the method of choice increases the chance that the contraception will be used properly and consistently, thus decreasing unwanted pregnancies (Frost et al., 2007). Explain that Jaime may also experience less bleeding during her period and less cramping. You could give her a nonsteroidal anti-inflammatory medication (such as Anaprox DS or ibuprofen) to decrease her pain from the cramping. A prescription for no more than 3 months of COCs should be given at this visit.

You explain to Jaime that her partner must also use a condom every time she has intercourse, even though she is taking COCs. This is to help prevent the transmission of STIs. You explain that using condoms every time does not prevent the transmission of all STIs, but it does decrease her risk. The only way to be 100% sure of no risk of STIs is with abstinence.

Box 28–1   Instructions for Taking Combined Oral Contraceptive (COC) Pills

When you get home after having your prescription filled, make sure you read the package insert. There is a lot of information in there that is very helpful. It has directions for how to take the pills, what to do if you miss a pill, and warning signs of problems. Always keep a copy of the package insert tucked away in a drawer.

Most combined oral contraceptive pills come in a package with 28 pills in them. The first 21–24 pills are “active” pills, which means they have the estrogen and progesterone in them that prevent pregnancy. The 4–7 pills at the end of the package are “inert,” meaning there is no medicine in them. They are there to remind you to keep taking a pill once every day. The last 4–7 pills are a different color from the “active” pills.

Starting Your Pills

There are three different ways to start taking COCs:

•   
Sunday start method:
This means you take the very first pill in the package on the Sunday
following
the start of your period. If your period starts on Sunday, take your first pill that same day. Most pill packages are set up for a Sunday start. The theory behind this is that you will always start your pill packages on a Sunday and finish taking the last pill on a Saturday. You will probably start your period on the Tuesday or Wednesday following the last “active” pill in the pack. For most women, their period will finish before the weekend. If you choose this start method, you should use a backup method of contraception (condom and/or spermicide) until you have taken at least seven consecutive active pills. I encourage my patients to use a back-up method for the entire first month they are taking their pills.

•   
First day start:
This method has you start your first active pill on the first day of your menstrual period no matter what day of the week it is. Even though the majority of pill packages are set up for a Sunday start, they will usually have stickers with the days of the week on them that you can place on the package to remind you what day you are on. Start with the very first pill in the package. When using the first day start, you should not need a back-up method, but I still encourage my patients to use condoms for the first month they are on the pills.