Case Study Discussion: Gynecologic Health
Elaine Goodwin is a 38-year-old G1 P1 LC 1 presenting to your clinic today to discuss contraceptive options. She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, seizure disorder (her last seizure was five years ago), and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs. She has no known drug allergies and takes Lamictal (lamotrigine) and Trileptal (oxcarbazepine). Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems.
- Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68
- HEENT: wnl
- Neck: supple without adenopathy
- Lungs/CV: wnl
- Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge
- Abd: soft, +BS, no tenderness
- VVBSU: wnl, except 1st-degree cystocele
- Cervix: firm, smooth, parous, without CMT
- Uterus: RV, mobile, non-tender, approximately 8 cm,
- Adnexa: without masses or tenderness
What other information do you need?
- What has she used in the past? Why did she stop a method? How many partners in past 12 months?
- What are her current cycles like?
- When was her last GYN exam and what were the results of the tests?
- What method has she considered?
Elaine relates to you that she has used birth control pills before but “would keep messing them up”. She has had three partners in last 12 months and has been with her current partner for the previous two months. She believes that he is “the one.”
Elaine relates that her cycles come every 28-32 days, for a duration of 5-8 days, and on her heaviest day she must use a super tampon every hour and get up to change her pad 2-3 times at night. Her last gyn exam was one year ago and she shows you a copy of the results on her patient portal. The results for the pap were NILM, HPV negative, and her cultures for GC/CT were negative. She has heard about an implant that is put in your arm, but her sister had it and she bled all the time.
- ; What are your next steps/considerations?
- ; What teaching should you do?
- What methods would be appropriate for Elaine?
By Day 6
Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests you might recommend and explain why. Use your Learning Resources and/or evidence from the literature to support your position.
Post from MARISA (Respond to Post)
CC (chief complaint): Discuss contraceptive options
HPI: 38-year-old G1T1P1 presents to the clinic to discuss contraceptive options. She denies any current problems today. She has a past medical history of exercise-induced asthma, seizure disorder, and IBS. Her last seizure was five years ago and was controlled with medication. She has used birth control pills in the past but “would keep messing them up.” She states she heard about an implant in your arm but wants to know if it causes you to bleed all the time. She voices no other concerns today.
2.Trileptal- for seizures
Allergies: No known Drug Allergies
3.Irritable Bowel Syndrome.
Soc & Substance Hx: Denies the use of alcohol, tobacco, and recreational drugs
1.Maternal grandmother alive with dementia
2.Maternal grandfather alive with COPD
3.Paternal grandparents both deceased from an automobile accident
4.Mother alive with fibromyalgia and osteopenia
5.Father is alive with a history of skin cancer (basal cell).
Surgical Hx: tonsillectomy as a child
Mental Hx: No known history.
Violence Hx: reports on the history
Reproductive Hx: LMP unknown, G1P1L1
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: History of exercise-induced asthma, no complaints of SOB
GASTROINTESTINAL: History of IBS, no complaints of bad. Pain.
GENITOURINARY: LMP unknown
NEUROLOGICAL: history of seizures. states last seizure was 5 years ago.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
Vitals: height 5’7, weight 148lbs(BMI 23.1), BP 118/72, P-68
HEENT: wnl, neck supple without adenopathy
Breast: Soft, fibrocystic changes bilaterally, without masses, dimpling, or discharge
Gastrointestinal: abd. Soft, positive bowel sounds, no tenderness noted
VVBSU:wnl, except 1st degrees cystocele
Cervix: firm, smooth, parous, without CMT
Uterus: RV, mobile, non-tender, approximately 8cm
Adnexa: without masses or tenderness
1.Urine pregnancy test to rule out pregnancy prior to starting contraception
1.Contraceptive management- Z30.9
2.Seizure Disorder -G40.89
3.Irritable Bowel Syndrome-K58.9
1.Educated on contraceptive options and the effects on preexisting medical conditions.
2.Urine pregnancy test was negative
- Educated on the importance of practicing safe sex and the use of condoms to prevent sexually transmitted infections in addition to the use of contraception
- Discussed the use of barrier contraceptives and intrauterine devices and the patient opted for the barrier device.
According to the clinical information provided in the case study, there are some additional questions needed. The history states that the patient’s cycles are every 28-32 days but did not state the date of her last cycle. A urine pregnancy test is needed to confirm the patient is not pregnant prior to starting her on contraception management. HCG is most used as a biomarker of pregnancy and can be tested through serum or urine (Greene & Grenache, 2015). Additional questions include: pregnancy history, type of delivery, pregnancy complications, history of blood clots, when is the last time she had an asthma flare-up. My first concern in determining the safest method of contraception is the seizure disorder and the use of Lamictal and Trileptal as the method of treatment. According to a recent study, antiepileptic drugs that are characterized as enzyme-inducers enhance the metabolism of contraceptive steroids to include combined hormonal contraception and progestin-only pills, classifying them as category 3 drugs based on the U.S. Medical Eligibility Criteria for Contraceptive use (Loder,2019). Category 3 drugs suggest risk outweigh the benefits and categories 1 and 2 indicate the contraceptive method is safe and without restrictions (Loder,2019). Elaine is on two enzyme inducers Lamictal and Trileptal and based on the indications, OCP’s are not recommended. The best methods of contraceptive management for Elaine will be barrier devices or intrauterine devices(IUD). Common side effects of IUDs are bleeding, dysmenorrhea, abdominal pain, breast tenderness, headaches, nausea, and mood changes (Schuiling & Likis, 2017). After discussing her options and side effects, she opted to continue with barrier methods, Her current relationship is serious and he has no children, she does not want to proceed with a long-term method of contraception due to the likelihood of having more children.
Greene, D. N., & Grenache, D. G. (2015). Pathology consultation on human chorionic
Gonadotropin testing for pregnancy assessment. American Journal of Clinical
Pathology,144(6), 830-836. DOI:10.1309/AJCP707VAREDUYIJ
Kamp, K. J., Han, C., Shulman, R. J., Cain, K. C., Barney, P., Opp, M. R., Chang, L., Burr, R. L., &
Heitkemper, M. M. (2020). Cytokine Levels and Symptoms Among Women With Irritable Bowel
Syndrome: Considering the Role of Hormonal Contraceptive use. Biological Research for
Nursing, 1099800420941252. https://doi-org.ezp.waldenulibrary.org/10.1177/1099800420941252
Schuiling, K. D., & Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Jones and Bartlett Publisher