Pediatric Primary Care Case Studies (115 page)

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Today start
. Take your first pill in the package today, no matter where you are in your cycle. You can only use this method if you are
ABSOLUTELY POSITIVE
that you are not pregnant. Start with the very first day of the package and take each one of the pills. Because you are starting your pills in the middle of your cycle, it is very common to have some break through bleeding for a while until your body matches the hormone cycle of the pills. If there is any way that you could possibly be pregnant, I do not recommend starting your pills this way.

Always remember: COCs prevent pregnancy. They do
NOT
protect against sexually transmitted infections. If there is any possibility that your partner has an infection, always use a condom along with your pills. Always using a condom is just a smart thing to do, anyway.

Taking Your Pills

You need to take one pill every day at about the same time every day. You need to take it at a time when you will easily remember to take it. For some women, that is first thing in the morning. For others, it is the last thing at night. Try to take them when you can consistently take them at the same time (or close) every day. If you usually get up at the same time every day, that may be good. If you go to bed at the same time every night, that may work. You need to find a time that works for you and stick with it. Keep taking one pill each day until the end of your pack. When you start taking the “inert” pills, you know that your period should start in the next day or two. When you have taken the last pill in that package, start the next package the very next day.

Benefits

The nice thing about taking COCs is that your period will become very regular. You may be able to set your watch by it. You should be able to know what day, and maybe even what time it will start. That way you can always be prepared for it. You should notice less bleeding and less cramping with your periods. Depending on what pill you are taking, some women notice that they do not get as much acne as they had before. Others may not have as many PMS symptoms, like bloating, moodiness, and so on. Taking COCs helps to decrease your chances of some types of female cancer like ovarian and endometrial cancer (inside of the uterus). The research on whether COCs play any role in breast cancer is inconclusive.

Side Effects

It sometimes takes our bodies a few months to get used to being on COCs. It would not be unusual for you to feel some mild
nausea
or have some
breast tenderness
. If you take your pills at night or with a meal, the nausea should go away. If you keep taking your pills, the nausea and breast tenderness should go away on their own. Some women may have some
spotting
between their periods. Others may notice
mood changes
or
headaches
. If you get a headache that doesn’t go away with a mild pain reliever and rest, call the office. If the headache is severe and won’t go away, go to the emergency room. Most side effects resolve by themselves within 3 months. You need to keep taking your pills for at least 3 months. If you continue to have problems, you need to call the office and come in to see me.

Warning Signs

A warning sign is one that says something may really be wrong. If you have any of these signs, we want you to call the office right away or go to the emergency room. To help you remember them, we use the mnemonic ACHES:

    A: Abdominal pain (severe)

    C: Chest pain (severe), cough, shortness of breath

    H: Headache (severe), dizziness, weakness, or numbness

    E: Eye problems (vision loss or blurring, speech problems)

    S: Severe leg pain (calf or thigh)

So remember ACHES!

Other Questions

If you forget to take an “active” pill, take it as soon as you remember it. Take your next pill at its usual time. That may mean that you are taking two pills at the same time. If you forget to take an “inert” pill, that is OK as long as you start your “active” pills at the normal time.

If you forget to take two pills in a row, take two pills as soon as you remember and then take two pills at the next scheduled time. That should catch you back up. It would not be unusual to have some spotting when you miss pills. You should also use a back-up method of contraception for 7 days.

If you miss more than two pills, take one “active” pill each day until you can talk to me. You should use a back-up method of contraception for the rest of the cycle.

Remember: COCs are only effective if you take them! If you forget pills, you put yourself at risk for pregnancy.

If you miss a period and have taken every pill on time on the right day, there is little chance that you could be pregnant. Go ahead and start your new package of pills when it is time. If you are concerned, or you miss a second period, call the office and come in for a pregnancy test, just to make sure you are not pregnant. If you have forgotten one or more pills and then miss a period, keep taking one pill each day and come in for a pregnancy test.

There are many different types of COCs, just like there are many different types of women. Not all pills work well for all women. Keep taking the pills that were prescribed for you for at least 3 months. If you are not feeling “right” or you are having side effects that are unpleasant, call and come in for an appointment. Sometimes we need to adjust the dosages. We are almost always able to find a pill that works well.

You also caution Jaime about the potential for partner violence, explaining that it is important that she should
never
feel pressured to do something that she doesn’t want to do. Blair should
always
respect her right to say no to anything that doesn’t feel right. She needs to talk to Blair ahead of time about what she will and will not do (U.S. Department of Health and Human Services, 2008). Some tips for healthy and safe relationships that you give her include getting to know a person by talking on the phone or at school before going out with him for the first time, going out with a group of friends to a public place, planning fun activities other than being alone, talking to her parents about the person and giving them the specifics on where she is going and when she will be home, and always carrying her cell phone or change to make a call, if necessary (U.S. Department of Health and Human Services).

Jaime has become drunk a couple of times, so you let her know that not everyone drinks. There are many teens who do not drink. It does not make a person cool to drink alcohol. She does not need to drink to have fun, be popular, or be comfortable with other
people. In fact, alcohol can cause her to lose control over what happens to her and her body. She could end up in potentially dangerous situations. You also warn Jaime about the potential of people spiking her drink with a date rape drug (U.S. Department of Health and Human Services, 2008). You encourage Jaime to talk to her mother or another safe adult about what is going on in her life.

Research has shown that adolescent girls who talk and have meaningful communication with their parents are less likely to experiment with high risk behaviors (Stiffler et al., 2007).

What other issues would you like to discuss with Jaime?

You want to discuss the following with Jaime:

   
Healthy lifestyle habits:
Jaime should be encouraged to eat a nutritious diet following the U.S. government’s food pyramid (U.S. Department of Agriculture, 2008). She should exercise 60 minutes on most days (U.S. Department of Health and Human Services, 2008). She should take a multivitamin every day that contains at least 400 micrograms of folic acid. Folic acid helps to prevent neural tube defects in children, and all women of childbearing age should make sure they get enough folic acid. She should be encouraged to keep a menstrual diary or keep track of her menses to note improvement after initiation of COCs or continued problems.

   
Healthy sexuality decisions:
Throughout the history, physical, and discussion of findings, Jaime should be counseled on knowing whether she is ready for intercourse. Healthy relationships should be discussed as well as signs of potential partner violence.

   
Immunizations:
Jaime should keep current on her usual childhood vaccinations. She should be encouraged to receive the human papillomavirus (HPV) vaccine, if she has not already done so. The HPV vaccine is a series of three injections that help protect against the strains of HPV that are most likely to cause external genital warts and internal cervical, precancerous changes. She should also be encouraged to receive the meningococcal vaccine (U.S. Department of Health and Human Services, 2008).

Jaime says that she understands what you have told her. She has had concerns for a while now and would like to change some of her behaviors, especially drinking alcohol. She is still hesitant about talking with her mother, but she promises you that she will think about it.

When would you like to see Jaime again?