This patient is interested in birth control but not a permanent option at this time. I would inquire about her periods, are regular, does she get premenstrual symptoms, what is her flow like? Does she have breakthrough bleeding or spotting in between her periods? There are several birth control options that will lighten the cycle and or completely stop bleeding all together. I would like to know about when her last pap was and if she has ever had any abnormals in her lifetime?At the age of 38 she should have a pap smear every 5 years if normal with cytology and high-risk HPV testing (Hsieh et al., 2017). I would also inquire about her sexually transmitted infection (STI) history and if she has ever been diagnosed or treated for an STI. Is the patient experiencing any vaginal discharge, odor, itching, or burning? Does the patient have issues with painful intercourse? What has the patient used for birth control methods before and did it work well for the patient? I would like to know what she did and didn’t like about the previous birth control she has used to narrow down options for her. Is this patient in a monogamous relationship with her current boyfriend? I would address this patient’s migraine history. There is a six-fold increase for stroke in women who have migraines and take combined hormonal contraception (Tanos et al., 2019). Are the migraines controlled with medications and if so, what medications are you taking? How often are you getting migraines? How often do you use medications to alleviate your migraine? This would be a very important part of deciding which kind of birth control in order to reduce the risk of cerebrovascular risks for this patient (Tanos et al., 2019). Migraines with aura have also been associated with increased risk of ischemic stroke with patients that use combination hormonal contraceptives (Champaloux et al., 2017). Finding out if this patient does have auras would be necessary. Her assessment did report a 1st degree cystocele. A cystocele is where the bladder herniates into the vagina and can cause issues with urination and put women at a higher risk for bladder infections (Ni et al., 2017). Symptoms can include urgency, incontinence, voiding disorder, the feeling of a foreign body, or dyspareunia (Cadenbach-Blome et al., 2019). Being that hers is only 1st degree it is not likely she would require any interventions but asking her if she has any of these symptoms would be helpful to rule out any issues she may be having. With her father having a history of basal cell carcinoma, I would want to assess her skin and ask her if there are any spots she is concerned about. Basal cell cancer is not hereditary but fair skin, freckles, skin that is easily burned rather than tanned are traits that do run in families that make the patient more susceptible to developing basal cell skin cancer (Verkouteren et al., 2017). The patient should have a pap smear today if she has not had one in the last 5 years or cannot recall when. Per guidelines, the patient should also be testing for STI’s since she has a new partner (Parekh et al., 2018). The options for birth control for this patient would be depending on her migraines but there are options for oral contraception (mini pill- progesterone only), Depo-Provera injection, Nexplanon, and an IUD either hormonal or non-hormonal. In the case that she does have bad migraines with aura I would steer clear of combination options such as oral contraceptives, the patch, or NuvaRing. She can choose based on her preferences. References Cadenbach-Blome, T., Grebe, M., Mengel, M., Pauli, F., Greser, A., & Fünfgeld, C. (2019). Significant improvement in quality of life, positive effect on sexuality, lasting reconstructive result and low rate of complications following cystocele correction using a lightweight, large-pore, titanised polypropylene mesh: final results of a national, multicentre observational study. Geburtshilfe und Frauenheilkunde, 79(9), 959. DOI: 10.1055/a-0984-6614 Champaloux, S. W., Tepper, N. K., Monsour, M., Curtis, K. M., Whiteman, M. K., Marchbanks, P. A., & Jamieson, D. J. (2017). Use of combined hormonal contraceptives among women with migraines and risk of ischemic stroke. American journal of obstetrics and gynecology, 216(5), 489-e1. DOI:https://doi.org/10.1016/j.ajog.2016.12.019 Hsieh, H. L., Huppert, J., Patel, C. G., & Tao, G. (2017). The impact of the American College of Obstetricians and Gynecologists guideline changes in Pap tests on annual chlamydia test rates. Journal of Adolescent Health, 61(4), 440-445. DOI:https://doi.org/10.1016/j.jadohealth.2017.05.012 Ni, D., Ji, X., Wu, M., Wang, W., Deng, X., Hu, Z., … & Wang, H. (2017). Automatic cystocele severity grading in transperineal ultrasound by random forest regression. Pattern Recognition, 63, 551-560. Retrieved from https://doi.org/10.1016/j.patcog.2016.09.033 Parekh, N., Donohue, J. M., Corbelli, J., Men, A., Kelley, D., & Jarlenski, M. (2018). Screening for Sexually Transmitted Infections After Cervical Cancer Screening Guideline and Medicaid Policy Changes. Medical Care, 56(7), 561-568. DOI: https://doi.org/10.1097/MLR.0000000000000925 Tanos, V., Abi Raad, E., Berry, K. E., & Toney, Z. A. (2019). Review of migraine incidence and management in obstetrics and gynecology. European Journal of Obstetrics & Gynecology and Reproductive Biology, 240, 248-255. Retrieved from https://doi.org/10.1016/j.ejogrb.2019.07.021 Verkouteren, J. A. C., Ramdas, K. H. R., Wakkee, M., & Nijsten, T. (2017). Epidemiology of basal cell carcinoma: scholarly review. British Journal of Dermatology, 177(2), 359-372. Retrieved from https://doi.org/10.1111/bjd.15321
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