The Adolescent
Case 5.1 Birth Control Decision - Making
Clinical Case Studies for the Family Nurse Practitioner, First Edition. Edited by Leslie Neal-Boylan.
© 2011 John Wiley & Sons, Inc. Published 2011 by John Wiley & Sons, Inc.
135
SUBJECTIVE
Keisha, a 16 - year - old adolescent, comes to the clinic to discuss her options regarding contraception.
She has been in a monogamous relationship with her boyfriend for 3 months and feels she needs to be on another kind of birth control “ like the pill or shot — but I heard you can gain weight from them. ” She and her partner use condoms, “ sometimes. ” Her last menstrual period was 32 days ago, and she experiences regular periods with mild cramps. Menarche was at age 12.5 years. G0P0. Keisha denies vaginal discharge, lesions, dysuria, pruritus, or lower abdominal pain. She has never been tested for sexually transmitted infections ( STI ) or HIV and states, “ I don ’ t have any worries about my boyfriend.
He doesn ’ t have anything. ”
Past m edical h istory: Asthma, mild intermittent; physical exam 4 months ago was within normal limits.
Family h istory: Noncontributory.
Social h istory: As above.
Medications: Albuterol MDI 2 puffs every 4 hours, as needed, with spacer.
Allergies: NKDA.
OBJECTIVE
General: No apparent distress.
Vital s igns: Weight: 201 lbs.; height: 64 inches; BP: 112/78; HR: 82.
By Alison Moriarty Daley , MSN, APRN, PNP - BC
136 The Adolescent
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Urine pregnancy test ___Beta pregnancy test
___Urine gonorrhea and chlamydia ___Pelvic examination with wet mount ___Pap smear
___CBC ___Cholesterol
What is the diagnosis at this point?
What are your concerns at this point?
What contraceptive methods would you consider for Keisha?
What contraceptive methods would you not consider for Keisha?
How would you determine which contraceptive method is the best fi t?
Given the information provided above, what if any additional questions would you ask?
Describe the relevant side effects of each method of contraception you are considering.
What are some of the most common contraindications for OCP and patch use?
How will you address Keisha ’ s concern regarding weight gain and contraception?
If Keisha is in a monogamous relationship, should she be counseled on condom use?
How would you instruct Keisha to begin OCPs? Is there more than one option for starting OCPs?
Could she receive DMPA today?
RESOLUTION
Diagnostic t ests: Urine gonorrhea and chlamydia negative; urine HCG negative.
What is the diagnosis at this point?
Healthy, sexually active teen at risk for pregnancy:
What are your concerns at this point?
Keisha ’ s reported history of unprotected sex and a last menstrual period (LMP) of 32 days ago raise concerns regarding a possible pregnancy and an STI. The clinician should have a discussion with Keisha regarding Keisha ’ s feelings related to a possible pregnancy and should also provide appropri- ate anticipatory guidance.
What contraceptive methods would you consider for Keisha?
OCPs, Depo Provera , Plan B, intrauterine contraception ( IUC ), vaginal ring.
What contraceptive methods would you not consider for Keisha?
A patch, because it is less effective in women > 90 kg.
How would you determine which contraceptive method is the best fi t?
The clinician should have a careful discussion about what Keisha has heard about various contracep- tive methods, what she feels may best fi t her needs, her previous experience with contraception, her
Birth Control Decision-Making 137
ability to take a pill every day, her need/desire for confi dentiality, and cost. It is also important to consider how often Keisha is willing to come to the clinic for follow up and how consistent she can be with taking a pill every day or remembering to change the vaginal ring once every 3 weeks. It may also be important to consider how Keisha would feel about the potential of not having a monthly period. Many teens are not comfortable with touching themselves, which may limit their willingness to use the ring. The clinician should also explore Keisha ’ s need to keep her contraceptive method private and how each method may or may not achieve this goal. For example, if she does not want her mother to know she is using contraception, OCPs or the patch may not be ideal because they may be discovered by her mother. DMPA, the vaginal ring, or intrauterine contraception (IUC) would provide more privacy. Amenorrhea or irregular bleeding patterns are common with DMPA and IUC and may cause questions regarding the number of pads or tampons used or not used in a given time frame.
Given the information provided above, what if any additional questions would you ask?
A thorough past medical history, current medical history, and family medical history are essential in determining the existence of any relative or absolute contraindications to contraceptive use.
Describe the relevant side effects of each method of contraception you are considering . • OCP/vaginal ring: Aches, nausea, vaginal spotting or irregular bleeding, breast tenderness.
• DMPA: Irregular menstrual bleeding/amenorrhea or increased hunger.
• Condoms: Usually none, allergy to latex or spermicide,
What are some of the most common contraindications for OCP and patch use?
• Pregnancy.
• Undiagnosed vaginal bleeding.
• History of liver tumor, benign or malignant.
• Personal history of thromboembolic disease (DVT/PE).
• Thromboembolic disease in fi rst degree relative.
• Arterial cardiovascular disease: stroke, myocardial infarction (MI).
• Complicated valvular disease.
• Currently impaired liver function.
• Hypertension — severe or uncontrolled.
• Systemic lupus erythematosus.
• Breast cancer.
• Migraine with aura/neurologic symptoms.
• Diabetes with vascular complications.
• Postpartum < 3 weeks or breast - feeding.
How will you address Keisha ’ s concern regarding weight gain and contraception?
Weight gain is not an inevitable consequence of any contraceptive method. Some women report increased hunger while on DMPA; however, to gain weight, caloric intake must exceed what your body needs to function. A 500 kcal increase per day for 7 days will yield a 1 pound gain in weight.
Weights should be taken at the contraception initiation visit and at each follow - up visit. Increases can be identifi ed and suggestions made regarding her diet and exercise patterns.
If Keisha is in a monogamous relationship, should she be counseled on condom use?
Yes, condoms should always be used for protection against STIs and HIV; you cannot be certain if a partner has infection(s) by looking, as many are asymptomatic.
How would you instruct Keisha to begin oral contraceptive pills? Is there more than one option for starting OCPs?
• First day start: OCPs begun on day 1 of the next menstrual cycle.
• Quick start: OCPs begun today regardless of LMP.
• Sunday start: OCPs begun the fi rst Sunday after the beginning of the period.
138 The Adolescent
Could she receive DMPA today?
Begin within fi rst 5 days of the menstrual cycle with a documented negative pregnancy test, or QuickStart if there has been no unprotected sex in the past 2 weeks and if there is a negative preg- nancy test today. Keisha has had unprotected sex in the past 2 weeks. A pregnancy test can be done today and repeated in two weeks; if it is also negative, DMPA can be given at that visit. If Keisha gets her period, she can call the clinic and get DMPA in the fi rst 5 days of her cycle. Emphasize the use of emergency contraception in the meantime for any episodes of unprotected sex.
REFERENCES AND RESOURCES
Bonny , A. , Harkness , L. S. , & Cromer , B. A. ( 2005 ). Depot medroxyprogesterone acetate: Implications for weight status and bone mineral density in the adolescent female . Adolescent Medicine Clinics , 16 , 569 – 584 .
Bonny , A. , Ziegler , J. , Harvey , R. , Debanne , S. M. , Secic , M. , & Cromer , B. A. ( 2006 ). Weight gain in obese and nonobese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no hormonal contraceptive method . Archives of Pediatric and Adolescent Medicine , 160 , 40 – 45 .
Clements , A. L. , & Moriarty Daley , A. ( 2006 ). Emergency contraception: A primer for pediatric providers . Pediatric Nursing , 32 ( 2 ), 147 – 153 .
Cromwell , P. F. , Moriarty Daley , A. , & Risser , W. ( 2004 ). Contraception for adolescents: Part one . Journal of Pediatric Health Care , 18 , 149 – 152 .
Cromwell , P. F. , Moriarty Daley , A. , & Risser , W. ( 2004 ). Contraception for adolescents: Part two . Journal of Pediatric Health Care , 18 , 250 – 253 .
Hatcher , R. , Trussel , J. , Nelson , A. L. , Cates Jr , W. , Stewart , F. H. , & Kowal , D. ( 2007 ). Contraceptive technology ( 19th ed. ). New York : Ardent Media, Inc. .
Lara - Torre , E. , & Schroeder , B. ( 2002 ). Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills . Contraception , 66 , 81 – 85 .
World Health Organization ( 2004 ). Medical eligibility criteria for contraceptive use ( 3rd ed. ). Geneva : World Health Organization . Retrieved on August 4, 2009. http://apps.who.int/rhl/fertility/contraception/mec.pdf World Health Organization ( 2008 ). Medical eligibility criteria for contraceptive use: Update 2008 . Retrieved July
21, 2009 from http://apps.who.int/rhl/fertility/contraception/mec_update_2008.pdf