Contraceptive History

Reason for attendance: Problems with current contraception

Current contraception: Combined oral contraceptive pill

Details of any issue with current or previous contraception: Reports frequent missed pills on Alesse 28 and new-onset visual aura prior to headaches over the past 2 months. Desires transition to a LARC method (specifically IUS-Kyleena).

Last menstrual period: 02/05/2024

Was this a normal period for you? Yes

Longest cycle length: 28 days

Is there a risk of pregnancy? Yes

Pregnancy test done in clinic? Yes

Expiry date of test: 11/2025

Result of pregnancy test: negative

Is a repeat pregnancy test due? Yes

When? 28/05/2024 (3 weeks post-UPSI)

Is there post-coital bleeding? No

Is there intermenstrual bleeding? Yes

Comments on menorrhagia or dysmenorrhoea: Mild dysmenorrhoea on days 1–2, responsive to ibuprofen. No menorrhagia.

Any current gynaecological symptoms or diagnosis? Occasional spotting due to missed COCP doses. No abnormal vaginal discharge or pelvic pain.

Cervical screening? up to date

Obstetric history: Gravida 1, Para 1

Any history of molar pregnancies? No

Date and outcome of last pregnancy: 14/08/2021 — SVD at term, uncomplicated.

Are you currently postpartum? no

Are you currently breastfeeding? no

Medical history — any known medication or drug allergies? Penicillin (maculopapular rash)

Any history of cardiovascular disease? No

Any history of hypertension? No

Personal history of thromboembolic disease or thrombogenic mutation: None

Any history of cerebrovascular disease? No

Any history of migraine? yes — with aura

Any history of diabetes? None

Any history of symptomatic gallbladder disease? no

Any history of liver disease? no

Any history of breast cancer? no

Any history of genetic mutations associated with breast cancer? no

Any history of epilepsy? No

Any history of antiphospholipid syndrome? No

Any history or risk factors for osteoporosis? No

Past surgical history: Laparoscopic appendicectomy (2016)

Any planned operation, recent operation, or extended immobilisation? None

Current list of medications: levonorgestrel / ethinylestradiol (Alesse®) 100 mcg / 20 mcg PO daily; ibuprofen (Advil®) 400 mg PO PRN; sumatriptan (Imitrex®) 50 mg PO PRN

Current use of recreational drugs? Occasional cannabis (edibles 1x/month). Denies other substances.

Alcohol intake: 2–3 units per week

Smoker or ex-smoker: Ex-smoker

Smoking history: Quit in 2020; previously 5 cig/day for 3 years.

Family history of VTE in a first-degree relative younger than 45 years: No

Any history of STIs? Chlamydia trachomatis (2018), treated with single-dose azithromycin, TOC negative.

The patient understands that STI screening is routinely offered as part of reproductive healthcare and may be declined. The patient consents.

Have you ever felt afraid or unsafe in your relationship, or do you feel so now? No

Weight: 64 kg

Blood pressure: 116/74 mmHg

General comments: COCP discontinued immediately due to migraine with aura (UKMEC 4). Bridging contraception with desogestrel (Cerazette®) 75 mcg PO daily initiated today. Self-collected vaginal swab for C. trachomatis and N. gonorrhoeae NAAT sent. Booked for IUS-Kyleena insertion in 3 weeks following repeat urine pregnancy test.