Marquez, Caren Joy B.

Case Study 122

SCENARIO
You are working in a busy OB/GYN office, and the last patient of the day is P.B., a 36-year-old who is
planning to get married soon. She wants to use birth control but is not sure what to choose. Her fiancé
is in law school, and they do not have health insurance, so she is anxious not to get pregnant right
away. She asks you to review the various methods and help her explore what is best for her.

1. What past medical information will you need to ask P.B. about?
 Vital signs
 Reproductive and Contraceptive History (history of birth control use, history of sexually transmitted
diseases, methods of birth control used)
 Medical history (including any long-term conditions or surgeries)
 Pap smear (to detect abnormal cells around the cervix, test for cervical cancer)
 Nucleic Acid Amplification Tests (for STD testing)
 Urine Test (to test for luteinizing hormone that shows up in high levels just before a woman
ovulates)

2. Are there any other conditions that would influence the choice of a contraceptive method?
 Relationship factors (including marital status, number of sexual partners, how often you have sex
and partner preferences)
 Religious beliefs (Certain types of birth control are considered to be in violation of religious or
cultural customs. Weigh the risks and benefits of a birth control method in light of the patient’s
personal beliefs.)
 Differences in birth control techniques (such as their effectiveness in preventing pregnancy, side
effects, cost, and whether they prevent sexually transmitted infections)

3. Is P.B. currently at risk for sexually transmitted infections (STIs)?

Anyone who has sexual contact with another person is at risk of contracting a sexually transmitted
infection (STI). To know more information about this, we can do a screening or laboratory tests. It
includes blood test to confirm the diagnosis of HIV or later stages of syphilis, urine sample, and fluid
sample if the patient has open genital sores to diagnose the type of infection.

4. What lifestyle information will help you assist P.B. in choosing an appropriate method for her?
It is critical to pick a birth control method that works for a person. For some people, the most
comfortable method of birth control is one that is simple to use, has no unpleasant side effects, and
does not interfere with daily activities. Check for the patient’s everyday routine and lifestyle. Consider
her willingness to plan ahead or stick to a strict schedule when picking a birth control technique.

5. P.B. asks you about the effectiveness rating of available birth control methods. Categorize your
response according to the following efficacy ratings: most effective (more than 99%), highly
effective (97% to 99%), and moderately effective (less than 90%).
Most effective (more than 99%)
 Abstinence (refraining from sexual relationships, most effective way)
 Oral contraceptives (includes a combination of an estrogen and a progestogen)
 Vaginal Estrogen/Progesterone Rings (stopping your ovaries from releasing an egg each month)
 Estrogen/Progesterone Transdermal Patch (patch that attaches to your skin and contains
medication)
 Subdermal Hormone Implants (small flexible plastic rod that's placed under the skin in your upper
arm, releases the hormone progestogen into your bloodstream to prevent pregnancy and lasts for 3
years)
 Intrauterine Devices (T-shaped birth control device that is inserted into the uterus to prevent
pregnancy)
Highly effective (97% to 99%)
 Withdrawal (coitus interruptus) (the man completely removes his penis from the vagina, and away
from the external genitalia of the female partner before he ejaculates)
 Basal Body Temperature Method (tool to determine if ovulation has occurred or not)
 Two-Day Method (fertility awareness method of family planning that uses cervical secretions to
indicate fertility)
 Symptothermal Method (used to predict when a woman might be fertile. The method uses body
temperature and other signs and symptoms of ovulation.)
 Standard Days Method: CycleBeads (Woman tracks her menstrual cycle and avoids unprotected sex
on the fertile days.)
 Ovulation Detection (detects a rise in luteinizing hormone (LH) in the urine)
 Spermicide (contraceptive substance that destroys sperm, inserted vaginally prior to intercourse to
prevent pregnancy)
 Male and Female Condoms (sheath-shaped barrier device used during sexual intercourse to reduce
the probability of pregnancy or a sexually transmitted infection)
Moderately effective (less than 90%)
 Diaphragm (circular dome made of thin, soft silicone that's inserted into the vagina before sex)
 Sponge (prevents sperm from entering the uterus)
 Cervical Cap (fits over the cervix and blocks sperm from entering the uterus through the external
orifice of the uterus, called the os)

6. P.B. asks you to explain the main advantages and disadvantages of the most effective methods
Abstinence: acceptable to all religious groups; requires high motivation and periods of abstinence
Oral contraceptives: coitus independent; continual cost and possible side effects of thrombophlebitis
Vaginal Estrogen/Progesterone Rings: easy to insert; may need reminder to insert
Estrogen/Progesterone Transdermal Patch: easy to apply; irritation at local site
Subdermal Hormone Implants: coitus independent, dependable for 5 years; initial cost, appearance on
arm
Intrauterine Devices: no memory or motivation needed; cramping, bleeding, expulsion possible

7. What are the main advantages and disadvantages of the contraceptive methods in the highly
effective category?
Withdrawal: a male-controlled method; sperm may be present in pre-ejaculatory fluid
Basal Body Temperature Method: cost of thermometer; requires motivation and cooperation by male
partner
Two-Day Method: no cost; requires motivation and cooperation by male partner
Symptothermal Method: no cost; requires motivation and cooperation by male partner
Standard Days Method: CycleBeads: visual aid can improve compliance, available as iPhone app; initial
cost, may need to make on a calendar they have moved a bead rather than rely on memory
Ovulation Detection: no cost; requires motivation and cooperation by male partner
Spermicide: easy to use, sold over the counter; may leave an annoying vaginal discharge
Male Condom: protects against STIs, male responsibility, no prescription necessary; requires
interruption of sexual activity
Female Condom: protection against STIs; insertion may be difficult

8. What about the moderately effective birth control methods? What are the main advantages and
disadvantages?
Diaphragm: easy to insert; prescription needed, necessary to take measures to avoid toxic shock
syndrome
Sponge: easy to insert, no prescription; may cause leakage, necessary to take measures to avoid TSS
Cervical Cap: can leave in place for several days if desired; may be difficult to insert, can irritate cervix,
necessary to take measures to avoid TSS

9. She wants to know about cost with each method because she will be on a tight budget, with
limited insurance coverage.
Some methods are free (abstinence, two-day method, symptothermal method, and ovulation
detection), while others such as spermicide, sponge, male and female condoms can be purchased
without a prescription (over-the-counter) and doesn’t require much money.
Oral contraceptives, hormone implants, vaginal ring, diaphragm, and IUDs, are by far the most expensive
of the reversible methods because they require medical supervision, but supplies alone are also more
expensive.

10. She asks you which method you would pick. What do you tell her?
Birth control pills, in my opinion, are the most effective for women. You can have one that solely uses
progestin or one that uses both estrogen and progestin. The failure rate can be as low as 1% if you pop
the pill perfectly. Combination birth control pills can also help you have less unpleasant menstrual
cramps, shorter periods, and less premenstrual syndrome symptoms. Pelvic inflammatory illness,
endometrial cancer, and ovarian cancer may all be prevented by using the pill. Women with a history of
blood clots or uncontrolled high blood pressure should take progestin-only pills (sometimes known as
"minipills"). Both kinds of contraception aid in the regulation of your periods.

CASE STUDY PROGRESS

P.B. comes back in a week and tells you that she can get a low-cost oral contraceptive through a local
store. You convey this information to the nurse practitioner, who examines P.B. and writes a
prescription for a biphasic pill containing ethinyl estradiol and norethindrone. You are asked to
discuss the use of the pill with P.B.
11. What key factors should you address with P.B.?
Human-made estrogen and progestin hormones are present in all hormonal contraceptives.
Combination pills (combined oral contraceptives/COCs) and progestin-only pills are the two types of
birth control pills (mini pills). The birth control pill prevents sperm from forming a bond with an egg.
Ovulation is safely stopped by the hormones in the pill. Forgetting pills, misplacing the pack, and failing
to refill their prescription on time are the main reasons why people get pregnant while taking the pill.
Some reminders to help you remember to take your pills on a daily basis are: set an alarm to remind you
to take the pill, and put the pills in your bag so you always have them with you.

It's preferable if the pills are taken at the same time each day. You can take these at any time during the
day, but it will be easier to remember if you take them before breakfast or before sleep. If you forgot to
take a birth control pill, remember to do it as soon as possible. Also, have another method of birth
control on available, such as spermicidal foam or condoms. Call your doctor if you miss more than two
pills. You can be told to take one pill per day until Sunday and then start a new pill pack. You should get
a pregnancy test if you miss two periods despite taking all of your medicines on time.

Antibiotics and anti-seizure medications, for example, can reduce the effectiveness of birth control pills.
Tell your doctor about all of your prescription and over-the-counter medications, herbal supplements,
and recreational substances. They'll be able to tell you if the medication has any side effects.

12. A few months later, K.B. calls the clinic because she realized she missed a dose of her oral
contraceptive. What will you tell her? (Select all that apply.)
a. “Take the missed pill now, along with today's pill, then resume the pack.”
If you forget to take a birth control pill, remember to do it as soon as possible. Take two pills the next day
if you don't recall until the next day. Take two pills the day you remember and two pills the next day if
you forget to take your medicines for two days. You'll then be back on track.
b. “It is okay, you are still protected from pregnancy if you take two now.”
c. “Just throw that pill away; restart taking your pills tomorrow.”
d. “Please make an appointment so we can insert a temporary IUD.”
e. “Wait until the start of your next menses, then begin a new pack of pills.”
f. “You should use a backup form of contraception until you start your menses.
References:
American College of Obstetricians and Gynecologists. How to Prevent Sexually Transmitted Infections
(STIs). Retrieved from https://www.acog.org/womens-health/faqs/how-to-prevent-stis
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Mayo Clinic. Birth control options: Things to consider. Retrieved from
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Suszynki, M. (2017). What Are the Best and Worst Birth Control Options? Retrieved from
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