Contraception case study for a 38-year-old G5 P5

The case supplies a large amount of history and one deliberately unanswered question, and noticing which is which is the exercise. The vignette gives you age, parity, medical and surgical history, social history, allergies, medications, a full family history and a physical examination — and then asks what other information you need. That framing tells you the given data is not sufficient, and the assignment is partly a test of whether you can identify the gap rather than proceed on what is in front of you. The prompt even seeds the answer with its own list of further questions: past methods and why they were stopped, number of partners in twelve months, current cycles, last gynaecological examination and results, whether the migraines have aura, and which method she has considered. Use those, and add the ones it omits. Contraceptive risk depends on things a physical examination cannot show, which is why a normal examination here settles very little.

The migraine question is the single most consequential item in the case and it is left open on purpose. Migraine with aura in a woman using combined hormonal contraception carries an increased risk of ischaemic stroke, and it is a contraindication to combined methods in standard eligibility criteria. Migraine without aura is treated differently and, in a woman aged thirty-five or over, still generally counts against combined methods. Her age of thirty-eight therefore matters twice over. Your answer should make clear that you cannot recommend a combined method until this is resolved, and should explain what aura actually is, since patients frequently describe photophobia or nausea as aura and equally often do not report a visual aura they have had for years. Ask about visual changes preceding the headache specifically, rather than asking whether she gets aura, because the word means little to most patients and the answer you get to the plain question is unreliable.

The relationship detail is the other item the case plants deliberately. She is certain she wants no more children, but her new partner has never fathered a child. That is a counselling problem rather than a clinical one and it belongs in the patient teaching section. It bears on whether permanent methods are appropriate now, on whose decision the method is, and on the regret literature, which associates younger age and relationship change with later regret after sterilisation. It also raises the question of male sterilisation, which is simpler, safer and cheaper than tubal occlusion and is almost never mentioned in student answers to this case. Raising it is not a recommendation; it is completing the range of options for a couple whose stated goal is no further pregnancies. Asking whether he has children of his own, and what he wants, is a legitimate part of counselling a couple about a permanent method.

Her other history each narrows the field slightly and should be handled precisely rather than treated as a list of comorbidities. Exercise-induced asthma is not a contraindication to hormonal contraception. Irritable bowel syndrome matters mainly because severe diarrhoea can affect absorption of oral methods, which is a counselling point rather than an exclusion. There is no thrombotic history, no smoking, no hypertension on today's reading, and a normal body mass index, which keeps most options open. Say what each finding does and does not rule out, since a good answer distinguishes the things that change the recommendation from the things that merely appear in the history. Her blood pressure today is normal, which keeps combined methods theoretically open, but a single reading is not a substitute for a documented history and should be repeated. Say what each finding does and does not rule out. A good answer separates the constraints from the noise.

The methods section should be organised by effectiveness and reversibility rather than presented as a list. Long-acting reversible methods — the levonorgestrel intrauterine system, the copper intrauterine device and the etonogestrel implant — are the most effective reversible options, are unaffected by the migraine question, and suit a woman who wants no more children but may not want an irreversible decision while a relationship is new. The copper device is the option with no hormone at all. Progestogen-only pills and the injection are alternatives with their own trade-offs. Combined methods are on hold pending the aura history and are questionable at thirty-eight regardless. Permanent methods are reasonable to discuss given her stated certainty, with the counselling caveats above. Say which you would recommend and why, because the question asks which methods are appropriate for Elaine, not which methods exist. Reversibility matters here in a way it usually does not, because her certainty about family size is firm while her relationship is new.

On execution, answer the three questions in the order given and keep the structure visible. Next steps should include the missing history, the aura clarification, a blood pressure recheck if she is to be considered for any combined method, cervical screening according to schedule if she is due, and a discussion of sexually transmitted infection risk given the new partner, which the case invites and most answers omit. Support the recommendations with current eligibility criteria rather than with recollection, since these guidelines are specific, categorical and updated, and cite them properly. Say which method you would offer first, which you would offer if she declined it, and what would have to change for a combined method to come back into consideration at all. Cite the eligibility category for each method you name, since these guidelines are categorical and a recommendation that does not match its category is the error a marker will find first.