Week 3 discussion comment

Make a comment using your own words in each discussion but please provide at least one reference for each comment.

Do a half page for discussion #1 and another half page for discussion #2 for a total of one page.

Provide the comment for each discussion separate.

Discussion #1

· Discuss the contraceptive methods using the latest evidence-based guidelines that Karen would be medically eligible for. 

We know that Karen has heavy and painful menses, she smokes half a pack of cigarettes a day, and presents today with elevated blood pressure. All of these risk factors must  be assessed when determining which contraceptive methods Karen is eligible for. 

Her father having a history of DVT and cardiac disease is important to know, as it places Karen in a category 2 on the CDC’s Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use for combined hormonal contraception. We must consider this factor, but the advantages of taking this birth control outweigh the risks typically. Also, her mother has a history of cervical cancer which we must consider, however, it does not change which contraception we can choose to use for Karen.

We likely would not consider using combined hormonal contraception for Karen, as she presents with elevated blood pressure today. As far as we know, she does not have a diagnosis of HTN, however, we must be mindful that she was hypertensive today, and she is a smoker which places her at greater risk for developing hypertension. Karen would be medically eligible for using progestin only contraception and non hormonal contraception. She would be able to use oral progestin only pills, receive progestin injections, or use progestin intrauterine devices. For non-hormonal contraception, she could use the barrier method such as condoms as she has been using, diaphragms, cervical caps, and spermicides (Hawkins, Roberto-Nicholas, & Stanley-Haney, 2016). Additionally, she can use a copper IUD, which can prevent pregnancy up to 10 years. Female sterilization is also an option. 

· Identify one method that you feel would be most beneficial to Karen and discuss why you selected it.

We know that Karen does not want to become pregnant anytime soon and desires a more reliable method of birth control. For this reason, I would recommend an implant to Karen. Either the IUD or the hormonal implant that goes in the arm. Both these methods are extremely effective and do not require ongoing maintenance of care once inserted. Contrarily, shots, barrier methods and oral contraceptives require perfect and exact use for them to be effective (Schuiling & Likis, 2016). 

· Are there any methods that you would not recommend for Karen? Why?

I may not recommend tubal ligation (female sterilization) for Karen, as she is still young and may choose to become pregnant in the future. Even though tubal ligation is reversible, the likelihood of becoming pregnant afterwards decreases as women get older. The pregnancy success rate in women under 35 after tubal ligation reversal is approximately between 70-80%. However, the success rate of pregnancy for women over 40 is more between 30-40%. So, if there is any chance Karen would like to become pregnant at some point again, this is likely not the best option as she is 33 years of age (Jayakrishnan & Baheti, 2011). 

Discussion #2

Karen has a history of migraines, heavy and painful periods, is a current smoker with family history of cardiac disease and cervical cancer, and her blood pressure today in the office is slightly elevated. She is currently using condoms but wants something more reliable. Based on her history and risk factors, I would want to discuss options that are progestin-only, as the cardiac risk, smoking and history of migraines makes estrogen contraindicated for her.  Progestin only options typically cause more breakthrough bleeding than combined birth control options. Progestin only pills may not be as effective as COCs, but rely more on the contraceptive effect of thickened cervical mucus. Because these pills rely heavily on timing of medication to cause cervical mucus thickening, even taking the pill a few hours late significantly decreases the efficacy of the pill. Another option would be the Depo-Provera shot. The medication is administered via injection once every 13 weeks by a nurse or healthcare provider, so they will require more frequent appointments. As with all other hormonal contraceptives, the Dep shot has shown to help in reducing the effects of menorrhagia and dysmenorrhea, which this client has complained of. The progestin implant is one of the most effective forms of birth control available and is effective for contraception for three years. The copper IUD is another option for this patient that does not have hormones that put her at increased cardiac risk. The IUD is inserted in the office and is effective for up to ten years. The most common side effects of the copper IUD however, are increased bleeding and dysmenorrhea, as well as headaches, which are already complaints the patient is having (Schuiling & Likis, 2017). 

Because the patient has complaints of dysmenorrhea and heavy menses, I would also discuss the option for an endometrial ablation. I would discuss the risks and benefits of this procedure with the patient, as it will cause infertility. The patient also has a mother with a history of cervical cancer, and the ablation can cause screenings for endometrial cancer more challenging in the future. Prior to having the procedure done, because she has irregular bleeding, she should undergo a hysteroscopy to ensure there is no underlying endometrial disease (Schuiling & Likis 2017). 

Typically, in a patient who complains of dysmenorrhea, the first line treatment would be combined oral contraceptives. This patient, however, is not a good candidate for COCs because of the risk of cardiac disease. The patient is a smoker which will increase her likelihood of getting a DVT while on the medication, and she has direct relatives with cardiac disease and DVTs. Because of this, and her migraines that she has, I would not recommend any COCs (Schooling & Likis, 2017).