contraception
Doctor Information
Geraldine Adams, age 48
No recent consultations
Past history:
Hayfever, takes prn cetirizine
No regular medication
Allergic to penicillin
No recent consultations
Past history:
Hayfever, takes prn cetirizine
No regular medication
Allergic to penicillin
Patient Information
Geraldine Adams, age 48
Opening line: This is a bit embarrassing Doctor but I’m wondering if I need to go back on my pill?
History: You have been in a new relationship for 6 months, following a messy divorce and custody battle for your daughter, now 15. You and your new partner James are sexually active but just using condoms. Your periods are scanty, maybe every 2-3 months. You looked up ‘menopause’ on google and dont have any of the other symptoms mentioned, but you wonder if you are going through it anyway. You are a bit confused with what you read - do you still need contraception or is it now not possible to get pregnant?
If asked only:
You definitely do not want another child and are happy to take anything that would stop this. You used to take Microgynon for years but stopped during the divorce. Your partner also has children from his first marriage and does not want more. You do regularly use condoms and have no symptoms of sexually transmitted infections. You are currently menstruating. You have not had any intermenstrual or postcoital, and no abnormal discharge.
Social History:
You got divorced last year when you found out your ex-husband was having an affair. You met James through a dating agency and are very happy in your relationship. You daughter Jasmine and his daughters Laura and Jenny all live with you and are supportive of the relationship.
You smoke 20 cigarettes per day - you know its a bad habit, you had stopped but the stress of the last year made you start up again. You will try and book in with the nurse if asked about stopping.
No alcohol consumption. You don't drink any alcohol.
PMH: no history of DVT/breast cancer/migraine/liver disease
No regular medication
Allergic to penicillin
Ideas: I am probably going through the menopause so I doubt that I can get pregnant anyway
Concerns: Actually I never really like taking pills as I am quite forgetful. If there was another option I would definitely be interested.
Expectations: The doctor is going to tell me I don't need any contraception as I am too old to get pregnant anyway
Opening line: This is a bit embarrassing Doctor but I’m wondering if I need to go back on my pill?
History: You have been in a new relationship for 6 months, following a messy divorce and custody battle for your daughter, now 15. You and your new partner James are sexually active but just using condoms. Your periods are scanty, maybe every 2-3 months. You looked up ‘menopause’ on google and dont have any of the other symptoms mentioned, but you wonder if you are going through it anyway. You are a bit confused with what you read - do you still need contraception or is it now not possible to get pregnant?
If asked only:
You definitely do not want another child and are happy to take anything that would stop this. You used to take Microgynon for years but stopped during the divorce. Your partner also has children from his first marriage and does not want more. You do regularly use condoms and have no symptoms of sexually transmitted infections. You are currently menstruating. You have not had any intermenstrual or postcoital, and no abnormal discharge.
Social History:
You got divorced last year when you found out your ex-husband was having an affair. You met James through a dating agency and are very happy in your relationship. You daughter Jasmine and his daughters Laura and Jenny all live with you and are supportive of the relationship.
You smoke 20 cigarettes per day - you know its a bad habit, you had stopped but the stress of the last year made you start up again. You will try and book in with the nurse if asked about stopping.
No alcohol consumption. You don't drink any alcohol.
PMH: no history of DVT/breast cancer/migraine/liver disease
No regular medication
Allergic to penicillin
Ideas: I am probably going through the menopause so I doubt that I can get pregnant anyway
Concerns: Actually I never really like taking pills as I am quite forgetful. If there was another option I would definitely be interested.
Expectations: The doctor is going to tell me I don't need any contraception as I am too old to get pregnant anyway
Examination Findings
Pulse 76 regular
Blood pressure 138/81
BMI 28
Blood pressure 138/81
BMI 28
Mark scheme
Data Gathering
|
Positive Indicators
Takes full menstrual and gynaecological history Asks about potential contraindications to combined contraceptives (UKMEC) Examines BMI and blood pressure |
Negative Indicators
Fails to take menstrual or gynaecological history Fails to asks about contraindications to treatments No examination |
Clinical Management Skills
|
Positive indicators
Makes an appropriate diagnosis, correctly identifies the need for continued contraception Appropriate management plan with shared contraceptive options Manages risk and arranges follow-up |
Positive indicators
Incorrect about diagnosis or does not give accurate advice about contraception Incorrect management plan Fails to share options No follow-up arrangements made |
Inter Personal Skills
|
Positive Indicators
Identifies agenda and health beliefs Sympathetic to situation and good rapport Avoids jargon and uses simple explanations |
Negative Indicators
Does not identify agenda or health beliefs Poor rapport, fails to connect with patient Poor explanation with jargon |
Management
A few facts about menopause:
During the menopausal period, women are less likely to ovulate, but effective contraception is still required to prevent unplanned pregnancy.
Patients on non-hormonal contraception can stop using them one year after periods have stopped if age > 50, or two years after periods have stopped if < 50. However for those taking hormonal contraception, periods are not a reliable of assessing fertility.
Decisions about choice of contraceptive should take into account patient preference, benefits and risks.
The combined pill: can be safely taken over the age of 40 if there are no medical problems. However the usual risk factors need to be considered (DVT/breast cancer/liver disease/migraine) and it should not be used in women over 35 who smoke 15+ cigarettes per day. The combined pill should be stopped at age 50.
The progesterone only pill: a good option if the combined pill is unsuitable (i.e. can be used in smokers, those with migraine, history of stoke/MI). Can be safely used up to 55 years. After 55 most women can safely stop using contraceptives, however a serum FSH can be done if there is uncertainty.
The contraception injection: can be used up to the age of 50. Bear in mind it causes reduction in bone mineral density (reversible on stopping).
The contraceptive implant: can be used up to the age of 55.
Intrauterine contraceptive device: if inserted over age 40, it can be kept in until the patient has gone through menopause.
If your patient wants something permanent there is always sterilisation (male or female). This is discussed in detail through other cases.
During the menopausal period, women are less likely to ovulate, but effective contraception is still required to prevent unplanned pregnancy.
Patients on non-hormonal contraception can stop using them one year after periods have stopped if age > 50, or two years after periods have stopped if < 50. However for those taking hormonal contraception, periods are not a reliable of assessing fertility.
Decisions about choice of contraceptive should take into account patient preference, benefits and risks.
The combined pill: can be safely taken over the age of 40 if there are no medical problems. However the usual risk factors need to be considered (DVT/breast cancer/liver disease/migraine) and it should not be used in women over 35 who smoke 15+ cigarettes per day. The combined pill should be stopped at age 50.
The progesterone only pill: a good option if the combined pill is unsuitable (i.e. can be used in smokers, those with migraine, history of stoke/MI). Can be safely used up to 55 years. After 55 most women can safely stop using contraceptives, however a serum FSH can be done if there is uncertainty.
The contraception injection: can be used up to the age of 50. Bear in mind it causes reduction in bone mineral density (reversible on stopping).
The contraceptive implant: can be used up to the age of 55.
Intrauterine contraceptive device: if inserted over age 40, it can be kept in until the patient has gone through menopause.
If your patient wants something permanent there is always sterilisation (male or female). This is discussed in detail through other cases.