Contraception Counselling

Patient Name: Chloe Mitchell Date of Birth: 14/08/1995 Date of Visit: 24/10/2023 Medical Record Number: MRN-8492014

Visit Type: Contraception Counselling

History and Background

Presenting Complaint: Requests discussion of long-acting reversible contraception (LARC) options; struggling with daily adherence to current oral contraceptive pill and experiencing worsening menorrhagia.

Medical History

• Chronic Conditions: Migraine with aura (diagnosed 2019), mild asthma.
• Previous Contraceptive Methods Used: Combined oral contraceptive pill (levonorgestrel/ethinylestradiol) ceased in 2019 due to migraine with aura. Currently taking progesterone-only pill (norethisterone (Noriday®) 350 mcg PO daily), but reports frequent missed pills and erratic bleeding. Male condoms used intermittently.
• Allergies: Nil known drug allergies (NKDA).
• Medications: Norethisterone (Noriday®) 350 mcg PO daily, salbutamol (Ventolin®) 100 mcg INH PRN, sumatriptan (Imigran®) 50 mg PO PRN. No relevant interactions with planned LARC.

Gynaecological History

• Menstrual History: Menarche age 13. Prior to POP, cycles were regular (28–30 days) with heavy flow lasting 6 days and moderate dysmenorrhoea. On POP, experiences unpredictable spotting. LNMP 10/10/2023. CST up to date and negative (2022).
• Sexual Activity: Sexually active with one regular male partner for 2 years. No dyspareunia or post-coital bleeding. STI screen negative 6 months ago.
• Pregnancy History: G0P0.

Family History

• Reproductive Health: Mother had uterine fibroids; no family history of breast, ovarian, or endometrial malignancy.
• Chronic Diseases: Father has hypertension and T2DM. No family history of VTE.

Lifestyle Factors

• Smoking Status: Non-smoker (never smoked).
• Alcohol Use: Social drinker, approximately 2–4 standard drinks per week.
• Physical Activity: Runs 3 times per week, pilates once weekly.

Patient's Preferences and Concerns: Prefers a "set and forget" method lasting at least 3 years. Wants to reduce menstrual bleeding and cramping if possible, and avoid systemic oestrogen due to migraine history.

Contraceptive Options Discussed

1. Hormonal Contraceptives:

• Birth Control Pills: Discussed transitioning to drospirenone (Slinda®) 4 mg PO daily, which offers a wider 24-hour missed pill window compared to norethisterone, though still requires daily adherence.
• Depo-Provera Injection: Discussed medroxyprogesterone acetate (Depo-Provera®) 150 mg IM every 12 weeks. Noted > 99% efficacy, potential for amenorrhoea, but highlighted possible weight gain and delayed return to fertility.

2. Barrier Methods:

• Condoms: Reinforced ongoing use for STI protection, noting higher typical-use failure rate (approx. 18%) when used as sole contraception.

3. Intrauterine Devices (IUDs):

• Copper IUD: Discussed non-hormonal nature, > 99% efficacy for 5–10 years, and immediate return to fertility. Noted potential to increase menstrual blood loss and dysmenorrhoea, making it less ideal given her baseline heavy periods.
• Hormonal IUD: Discussed levonorgestrel 52 mg IUD (Mirena®). Explained local progestogenic effect, > 99% efficacy for up to 8 years, and significant reduction in menstrual flow and dysmenorrhoea. Discussed irregular spotting in the first 3–6 months and procedural risks (perforation ~1–2/1000, expulsion ~5%, pelvic infection in first 20 days).

5. Emergency Contraception:

• Options Available: Discussed levonorgestrel 1.5 mg PO (up to 72 hours post-UPSI) and ulipristal acetate 30 mg PO (up to 120 hours post-UPSI), both available over the counter at pharmacies, as well as copper IUD insertion within 5 days as the most effective option.

Advice Given

• Method Selection: Patient elected to proceed with the hormonal IUD (Mirena®) as it best aligns with her preference for a high-efficacy, low-maintenance method that reduces menstrual bleeding and is safe with migraine with aura (UKMEC 2).
• Usage Instructions: Provided prescription for levonorgestrel 52 mg IUD (Mirena®). Advised to continue norethisterone 350 mcg PO daily strictly at the same time each day, plus barrier protection, until the IUD is inserted to exclude pregnancy risk. Advised taking ibuprofen 400 mg PO and paracetamol 1,000 mg PO 1 hour prior to the insertion appointment.
• Follow-Up: Booked for IUD insertion at the clinic next week. Advised to schedule a follow-up review 4–6 weeks post-insertion for a string check, or return sooner if experiencing severe pelvic pain, fever, offensive discharge, or suspected expulsion.
• Emergency Contraception: Advised to access oral emergency contraception (levonorgestrel or ulipristal acetate) if any norethisterone pill is delayed by > 3 hours alongside unprotected intercourse prior to IUD placement.

Patient Education Materials Provided: Family Planning Victoria fact sheets on Hormonal IUD (Mirena) and Emergency Contraception.

Signature

Dr Sarah Jenkins General Practitioner Melbourne Central Medical Clinic, (03) 9555 0192

Date: 24/10/2023