Pediatric Primary Care Case Studies, 1st Ed.

Chapter 28. The 15-Year-Old Girl Who Wants Birth Control

Deborah Stiffler

Prescribing contraception to adolescent females can be a difficult and time-consuming task. Assisting the adolescent to choose a contraceptive that is right for her, and also finding one that she can use consistently and correctly to prevent pregnancy and help her to prevent any sexually transmitted infections, can be challenging.

Educational Objectives

1.  Differentiate among the types of contraceptives currently available.

2.  Compare the risks and benefits of each contraceptive.

3.  Choose a safe and effective contraceptive method for a patient.

4.  Formulate an individualized management plan for a patient.

  Case Presentation and Discussion

Jaime Hoskins, a 15-year-old African American young woman, presents to your office requesting birth control. Jaime relates to you that she has been sexually active for about a year. She has had two different partners in that year, but she was only having sex with one at a time. She has been with her current boyfriend, Blair, for almost 3 months. Blair is 18 years old. As far as she knows, he is only having sex with her. She does not know how many partners he has had previously. They usually use a condom when they have sex, but sometimes Blair isn’t in the mood, so they don’t use one. Jaime tells you the reason she has come in today is that she and Blair recently had a scare. They were using a condom, but it slipped off during sex. When her period was a few days late, she was sure she was pregnant. Jaime’s mom is waiting for her in the waiting room; she brought Jaime in today thinking that Jaime had a yeast infection. Jaime does not want her mom to know that she is here for birth control because “she would just freak” if she knew that Jaime was sexually active.

What questions would you ask Jaime to expand on the above information? image

Jaime’s immunizations are current, she has had no surgeries, has no allergies, and is taking no medications.

Jaime’s family is fairly healthy. Her mother is 33 years old and somewhat overweight, but otherwise, she is healthy. Her maternal grandmother is deceased from a stroke at age 61. Jaime’s maternal grandfather is currently 68 years old and has adult onset diabetes. Her sisters are healthy. Jaime does not know anything about her father’s side of the family.

Jaime started her periods at age 11. They have always been regular, about 26–28 days apart, and they last for 5 days. Jaime relates moderate to heavy flow for the first 3 days, saturating three or four maxi pads each day. She also has moderate cramping with her periods. The cramping does not cause her to stay home from school, but she is “not worth much” on those days. Other than occasional condom use, she has never used any methods of birth control nor has she had a pap smear. Her last menstrual period was 2 weeks ago, and she and Blair have had unprotected intercourse since then.

Social history: Jaime is a sophomore at the local high school. She is on the cheerleading squad and plays volleyball on the school team. She lives at home with her mother and two younger sisters, ages 14 and 11. Her parents are divorced. She sees her father occasionally. She denies using street drugs and occasionally drinks alcohol, mostly beer on the weekends. She admits to being drunk twice, and doesn’t smoke.

What findings are important on the physical examination? image

You chart her examination as follows: Vital signs: temperature 98.2°F, oral; blood pressure 110/58; pulse 82; respirations 16; height 64 inches; weight 137 pounds; body mass index (BMI) 23.5.

Physical examination: EENT WNL; thyroid not enlarged; heart RRR without murmurs; lungs clear to P&A; back no CVA tenderness; abdomen soft, nontender, no splenohepatomegaly. She has a negative Homan’s sign, bilaterally. Pelvic: escutcheon, normal female; vulva without lesions; vagina moist, normal leukorrhea; cervix small, nulliparous; uterus anteverted, small, no tenderness on palpation; adnexa without cysts or masses, no tenderness to palpation.

What testing should be done? image

In this case, the following laboratory testing should be done:

•  Urine human chorionic gonadotropin: An easy test for pregnancy that can be done quickly in the office.

•  Pap smear: The newest guidelines from the American Cancer Society (ACS) state the first pap smear should be done by 3 years of initiation of intercourse or by the age of 21, whichever comes first (ACS, 2008).

•  Gonorrhea/chlamydia cultures: Jaime is already sexually active and does not always use condoms, so she is at risk for currently having or acquiring a sexually transmitted infection in the future.

•  Hemoglobin/hematocrit count (H&H): This will check for anemia due to Jaime’s heavy menstrual periods.

You collect the specimens and send them off for laboratory studies.

After completing the history and physical, what information should you consider? image

Jaime is in her adolescent years. This is a period of time when adolescents start to take risks. Risk-taking is a way for an adolescent to define and develop his or her identity. Healthy risk-taking, such as playing sports, seeking out new friends, or starting a job is a valuable experience (Ponton, 1997); however, adolescents frequently make unhealthy choices. Adolescents are at risk for behaviors such as drinking, smoking, drug use, reckless driving, unsafe sexual activity, disordered eating, self-mutilation, running away, stealing, and gang activity. Jaime does engage in occasional binge drinking. Alcohol decreases inhibitions, and this could put Jaime at risk for unintended sexual activity, decrease the potential for using a condom, or affect her use of other contraceptives. Adolescents under the influence of alcohol or drugs may take chances with their personal safety (U.S. Department of Health and Human Services, 2008). Currently, Jaime is engaging in another unhealthy 'margin-top:2.4pt;margin-right:0cm;margin-bottom:2.4pt; margin-left:0cm;text-align:justify;text-indent:18.0pt;line-height:normal'>It is important to have Jaime start some method of contraception. However, adolescents tend to be inconsistent users of contraception (Frost, Singh, & Finer, 2007). They can be forgetful, not taking their oral contraceptive pills or not keeping a condom with them when there is the potential for intercourse (Frost et al., 2007). Adolescents who have initiated sexual activity early in their teen years have the potential for multiple sexual partners. Jaime has stated that she is only having intercourse with Blair right now, but she has been sexually active with someone previously. Plus, there is no way to know how many partners Blair has had. When Jaime has sexual intercourse with Blair, she is essentially having intercourse with every other person he has had sex with (Stiffler, Sims, & Stern, 2007). She is at risk for HIV/AIDS along with other sexually transmitted infections (STIs). Adolescent females are biologically more at risk for STIs than adolescent males (Chambers & Rew, 2003). During the adolescent years, the transformation zone of the cervix is lower in the cervical canal. This is the area where the cells are changing from squamous epithelium to columnar epithelium, and it is especially vulnerable to infection and disease (Moore et al., 2005).

Jaime is very active, playing on her school volleyball and cheer teams. She travels with her teams frequently, which could cause her schedule to be erratic. Any contraceptive that would need a strict schedule could be affected.

Another risk that you must consider for Jaime is that of partner violence. Blair refuses to use condoms at times; this could potentially cause discord in the relationship. Women who do not feel that they have power in their relationships are less likely to use condoms with each sexual act (Harvey, Bird, Galavotti, Duncan, & Greenberg, 2002). Although Jaime has not said anything today that warrants concern, it would be advisable to consider this possibility for her.

Jaime is not communicating with her mother throughout this situation. Although this is not unusual for adolescents, Jaime might find her mother’s insights helpful because Jaime’s mother was an adolescent when Jaime was born. When adolescents do talk with their parents about contraceptive use, they are more likely to consistently use contraceptives (Manlove, Ryan, & Franzetta, 2003).

Jaime suffers from menorrhagia and dysmenorrhea with her monthly menses. Some contraceptive methods could potentially decrease her symptoms. It would be important to discuss these with Jaime and assist her to choose a contraceptive that could decrease her flow of blood and alleviate some, if not all, of her cramping.

Jaime would like to prevent a pregnancy without jeopardizing her future ability to have children. Her contraceptive needs should be effective, reversible, not linked to coitus, and assist in preventing sexually transmitted infections. Adolescents at this stage have the cognitive ability to make good decisions; however, they do not always make the most appropriate decisions in light of future consequences (Commendador, 2003). When adolescents have higher self-esteem, they tend to make decisions that are better for them (Commendador). Jaime, however, tends to allow Blair to decide whether or not he wants to use a condom when they have sex. This is not uncommon because Blair is older than Jaime; however, this means the chances that they will use contraception with intercourse decreases. Older partners tend to have a greater influence on the adolescent (Manlove et al., 2003).

What contraceptive options should you consider? What are the advantages and disadvantages of each option? Which would be reasonable options for Jaime? image

A list of possible contraceptives is provided in Table 28-1, and discussed here:

•  Abstinence

image  Advantages: Nonhormonal, no need to remember to take a pill every day.

image  Disadvantages: There are no risks to abstinence. except that it requires self control under all circumstances. This is the only 100% effective and safe method of contraception, if followed (Caufield, 2004; Kowal, 2007). Once an adolescent has become sexually active, it is unlikely that he or she will cease having intercourse, especially if he or she continues in the same relationship (Chambers & Rew, 2003).

image  Option for Jaime: Although a good option for any adolescent, this is not likely an option Jaime will choose.

•  Combined estrogen/progesterone (oral, transdermal, transvaginal)

image  Advantages: Highly effective in preventing pregnancy when taken correctly; not related to coitus; rapid return to fertility after discontinuation; very safe when prescribed for appropriate users; can be used throughout the reproductive years; decreased maternal deaths; reduction in risk of ectopic pregnancy; decrease in dysmenorrhea; decrease in menorrhagia; reduction in premenstrual syndrome (PMS) symptoms; reduction in endometrial and ovarian cancer risks; decrease in benign breast conditions; improvement of androgen-sensitivity or androgen-excess conditions (such as PCOS).

image  Disadvantages: Must be taken consistently and correctly to be effective; storage, access, lack of privacy; no protection against STIs. Common side effects include nausea, vomiting, weight gain, decrease in libido, headaches, breast tenderness, and skin hyperpigmentation. The transdermal form may be linked to an increased risk of thromboembolic disease because of higher concentrations of estrogen in the system.

image  Contraindications: Personal history of thrombosis, known clotting disorder, personal history of stroke or MI, labile hypertension, estrogen-sensitive malignancy, active liver disease, migraines with focal neurologic symptoms.

image  Complications: Venous thromboembolism, myocardial infarction, stroke, hypertension, liver disease (Caufield, 2004; Nelson, 2007).

image  Option for Jaime: Any one of these methods could be an option for Jaime, but not alone. These methods do not protect against STIs, so it would be essential for Jaime to also use condoms to decrease transmission of STIs.

Table 28–1 Types of Contraception

• Abstinence

• Combined estrogen/progesterone

image Combined oral contraceptive pills (oral)

image Ortho Evra patch (transdermal)

image Vaginal ring (transvaginal)

• Progesterone only

image Depo-Provera (injectable)

image Progestin-only pills (oral)

• Barrier methods/spermicidal

image Condoms (male or female)

image Diaphragm

image Sponge

image Various spermicides

• Intrauterine devices

image Paraguard (nonhormonal)

image Mirena (progestin)

• Fertility awareness/natural family planning

image Sympto-Thermal

image Calendar

• Permanent contraception

image Bilateral tubal ligation

• Emergency contraception

•  Progesterone only

image  Advantages: No estrogen; reversible; amenorrhea or scanty bleeding after prolonged use; improvement in dysmenorrhea, menorrhagia, premenstrual dysphoric disorder (PMDD), premenstrual symptoms, and endometriosis symptoms; decreased risk of endometrial or ovarian cancer; decreased risk of PID; compatible with breastfeeding. Depo Provera–specific: highly effective, discreet and private, not linked to coitus, requires user to remember only four times a year.

image  Disadvantages: Menstrual cycle irregularities; weight gain; depression; headaches; no protection against STIs. When taking progestin-only pills, they must be taken at almost the exact same time every day. Progestin-only pills are not as effective as combined oral contraceptive pills. Depo-Provera–specific: weight gain, prolonged return to fertility, adverse effect on lipids, decreased bone mineral density with prolonged use (Caufield, 2004; Raymond, 2007).

image  Option for Jaime: The progestin-only pills need to be taken precisely on time. Being an adolescent, this might not be the best option, plus Jaime is looking for an effective means of birth control. Depo-Provera, in contrast, is very effective; however, with decreased calcium absorption at the time when the most bone mass is being laid down, and the recommendation of not being on this method for more than 2 years, this might not be the optimal method for Jaime.

•  Barrier methods/spermicides

image  Advantages: Male participation, no prescription needed, very inexpensive, effective in preventing pregnancy if used correctly with every intercourse, minimal side effects, provides some STI protection, no hormones.

image  Disadvantages: Reduces sensitivity, reduces spontaneity, male erection problems, lack of cooperation from the male, embarrassment about purchasing, not very effective with “typical use,” latex allergy, some methods (diaphragm) need professional fitting (Cates & Raymond, 2007; Caufield, 2004; Warner & Steiner, 2007).

image  Option for Jaime: This is certainly an option for Jaime, along with another method. At the very least, she would need to use a condom with spermicide with every act of intercourse. Blair has been resistant to this at times. With whatever method Jaime chooses, she needs to use condoms in addition to help prevent STIs.

•  Intrauterine device (Paraguard and Mirena)

image  Advantages: Highly effective, no user error, convenient, long-lasting (10 years for Paraguard, 5 years for Mirena), reversible, discreet, cost-effective with prolonged use, low incidence of side effects, independent of coitus.

-  Paraguard: Can remain in place for up to 10 years, nonhormonal, normal menstrual pattern continues.

-  Mirena: Can remain in place for up to 5 years, protective against endometrial cancer, reduces menstrual bleeding by 90%, 20% of users become amenorrheic, low incidence of progestin side effects.

image  Disadvantages: Menstrual problems, discomfort with insertion, expulsion of the device, perforation of the uterus, requires office visit with trained professional, high initial cost, no protection against STIs.

-  Paraguard: Can cause heavier menses with more severe cramping, especially the first few cycles.

-  Mirena: Irregular bleeding, especially during the first 6 months (Grimes, 2007; Caufield, 2004).

image  Option for Jaime: Although not necessary, most providers would prefer to place an IUD in someone who has previously borne a child because the uterus has been stretched. The Paraguard can cause increased bleeding and cramping. This is something that Jaime is already concerned with, so the Paraguard would not be recommended. The Mirena, which decreases bleeding, could possibly be an option, but the irregular bleeding early in use might be a deterrent.

•  Fertility awareness/natural family planning

image  Advantages: No hormones, no side effects, enables a woman to understand her body’s cycles, promotes cooperation between partners, can also be used to achieve pregnancy or to identify fertility problems, only method approved by the Catholic church.

image  Disadvantages: Methods require varying amounts of training and cost, which detracts from spontaneity; causes friction between partners if not in agreement; difficult to use if recent childbirth, breastfeeding, recent menarche, approaching menopause, recent discontinuation of a hormonal method, irregular cycles, or unable to interpret fertility signs (Caufield, 2004; Jennings & Arevalo, 2007).

image  Option for Jaime: This method takes training, enthusiasm for the method, and support from the partner. At Jaime’s time of life, this is probably not a good method for her.

•  Permanent sterilization

image  Advantages: Permanent, highly effective, safe, quick recovery, lack of significant long-term side effects, cost-effective, partner cooperation not required, not coitus linked.

image  Disadvantages: Possibility of patient regret, difficult to reverse in the future, achieving pregnancy could require assistive reproductive techniques (Caufield, 2004).

image  Option for Jaime: This is a permanent method, so it would not be an option for a 15-year-old girl.

•  Emergency contraception

image  Advantages: To be used for contraceptive failure, error in withdrawal or periodic abstinence, rape, any unintended sperm exposure.

image  Disadvantages: Not to be considered ongoing contraception (Caufield, 2004; Stewart, Trussel, & Van Look, 2007).

image  Option for Jaime: In the incidence of method failure, emergency contraception could be an option, but not as an ongoing method of contraception.

Making the Diagnosis

Given her history and physical information, it is helpful to identify Jaime’s risk factors. In this case, Jaime is at risk for unhealthy lifestyle choices such as unprotected sexual intercourse, STIs, partner violence, and binge drinking. These risks must be addressed. Also, due to her menorrhagia, Jaime is at risk of becoming anemic. Jaime should be encouraged to discuss these issues with her mother. Her mother could be a tremendous help for her in dealing with them.

Although her maternal grandmother had a stroke and her maternal grandfather has adult onset diabetes, these do not significantly alter Jaime’s choices of contraception.

Management

After much discussion, Jaime decides she would like to try combined oral contraceptive pills (COCs).

You explain to Jaime what she needs to know regarding taking COCs, including how to take the pills, when to start the pills, risks and benefits, and warning signs of problems (Box 28-1). Providing accurate and understandable information relating to using the method of choice increases the chance that the contraception will be used properly and consistently, thus decreasing unwanted pregnancies (Frost et al., 2007). Explain that Jaime may also experience less bleeding during her period and less cramping. You could give her a nonsteroidal anti-inflammatory medication (such as Anaprox DS or ibuprofen) to decrease her pain from the cramping. A prescription for no more than 3 months of COCs should be given at this visit.

You explain to Jaime that her partner must also use a condom every time she has intercourse, even though she is taking COCs. This is to help prevent the transmission of STIs. You explain that using condoms every time does not prevent the transmission of all STIs, but it does decrease her risk. The only way to be 100% sure of no risk of STIs is with abstinence.

Box 28–1  Instructions for Taking Combined Oral Contraceptive (COC) Pills

When you get home after having your prescription filled, make sure you read the package insert. There is a lot of information in there that is very helpful. It has directions for how to take the pills, what to do if you miss a pill, and warning signs of problems. Always keep a copy of the package insert tucked away in a drawer.

Most combined oral contraceptive pills come in a package with 28 pills in them. The first 21–24 pills are “active” pills, which means they have the estrogen and progesterone in them that prevent pregnancy. The 4–7 pills at the end of the package are “inert,” meaning there is no medicine in them. They are there to remind you to keep taking a pill once every day. The last 4–7 pills are a different color from the “active” pills.

Starting Your Pills

There are three different ways to start taking COCs:

•  Sunday start method: This means you take the very first pill in the package on the Sunday following the start of your period. If your period starts on Sunday, take your first pill that same day. Most pill packages are set up for a Sunday start. The theory behind this is that you will always start your pill packages on a Sunday and finish taking the last pill on a Saturday. You will probably start your period on the Tuesday or Wednesday following the last “active” pill in the pack. For most women, their period will finish before the weekend. If you choose this start method, you should use a backup method of contraception (condom and/or spermicide) until you have taken at least seven consecutive active pills. I encourage my patients to use a back-up method for the entire first month they are taking their pills.

•  First day start: This method has you start your first active pill on the first day of your menstrual period no matter what day of the week it is. Even though the majority of pill packages are set up for a Sunday start, they will usually have stickers with the days of the week on them that you can place on the package to remind you what day you are on. Start with the very first pill in the package. When using the first day start, you should not need a back-up method, but I still encourage my patients to use condoms for the first month they are on the pills.

•  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? image

You want to discuss the following with Jaime:

image  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.

image  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.

image  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? image

Since Jaime is just starting COCs for the first time, she should return to the office within 1–2 months. At this visit, her blood pressure can be taken to rule out any hypertension as a result of starting the COCs. Information on how to take COCs can be reviewed and further instructions can be given if Jaime is having any problems. If Jaime is doing well at that time and does not have any questions or concerns, she should receive a prescription for up to 9 months (1 year total).

Jaime returns to your office a little more than a month after her first visit. Her blood pressure is 116/54, pulse 78, and respirations 12. She tells you that she is doing well remembering to take her pills every day. She has had some slight nausea and breast tenderness, but this seems to be improving. She has had one period since beginning her COCs. She was very happy that her cramping wasn’t bad, and she didn’t seem to flood as much. She relates that she still hasn’t talked to her mother, but she does want to. She and Blair are doing well together and he is doing better about wearing condoms, though he still doesn’t like it much. Jaime has thought about the HPV vaccine and would like to start it today. You review with Jaime how to take COCs and the warning signs to watch for, and give her a prescription for 9 months of COCs. You administer her first HPV immunization injection and remind her to return at 2 and 6 months for the other shots. Jaime states that she doesn’t have any other questions and that she will come back for the rest of the injections.

Other than for the vaccinations, she should return to the office in 1 year unless she has any concerns prior to that time.

Key Points from the Case

1. It is important to look at the whole person when providing contraceptive counseling and prescribing. Assisting the patient to choose the appropriate type of contraception will increase her ability to take/use it effectively.

2. The hormones estrogen and progesterone, although safe, do have side effects associated with their use. Careful explanation of the potential risks is crucial along with warning signs to watch for.

3. Although in this case Jaime came to the office for contraception, there were other very important issues that needed to be addressed. Be watchful for these other issues.

4. Try to help the adolescent to feel comfortable with the care being provided. Make the office a safe place where she feels comfortable discussing anything with you.

REFERENCES

American Cancer Society. (2008). Cervical cancer: prevention and early detection. Retrieved December 18, 2009, from http://www.cancer.org/docroot/CRI/content/CRI_2_6x_cervical_cancer_

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Cates, Jr., W., & Raymond, E. G. (2007). Vaginal barriers and spermicides. In R. A. Hatcher, J. Trussel, T. L. Nelson, W. Cates Jr., & F. Stewart (Eds.), Contraceptive technology (19th ed., pp. 317–336). New York: Ardent Media.

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