Family planning and contraceptive advice

Reason for Visit

• Primary Concern: Contraception Advice

Patient History

• Age: 28 years

• Menstrual History: Regular 28-day cycle, menses last 5 days, moderate flow, mild dysmenorrhoea Day 1. LMP 05/03/2026. No IMB or PCB.

• Current Contraceptive Method: Male condoms

• Previous Contraceptive Methods: Combined oral contraceptive pill (ethinylestradiol/levonorgestrel (Microgynon 30®)) – stopped 1 year ago due to newly developed migraine with aura.

• Reproductive Goals: Wishes to delay pregnancy for at least 3–4 years; desires reliable long-acting reversible contraception (LARC).

Medical History

• Chronic Conditions: Migraine with aura (diagnosed 2025). No personal or family history of VTE, stroke, or ischaemic heart disease.

• Gynaecological History: Up to date with cervical screening (last smear 2024, HPV negative). Negative STI screen 6 months ago.

• Obstetric History: G0 P0

• Medications: sumatriptan 50 mg PO PRN for acute migraine. No regular enzyme-inducing medications. NKDA.

Lifestyle Factors

• Sexual History: In a mutually monogamous relationship with a male partner for 18 months.

• Lifestyle: Non-smoker. Alcohol: ~6 units/week. Works shifts as a nurse, making daily pill-taking difficult.

• Weight and Nutrition: Weight 64 kg, Height 168 cm, BMI 22.7 kg/m². BP today 116/72 mmHg.

Consultation Details

1. Contraceptive Options Discussed:

   • Hormonal Methods:

     • Oral Contraceptives: CHC contraindicated (UKMEC 4) due to migraine with aura. Progestogen-only pill (desogestrel 75 mcg PO OD) discussed as a safe option, though patient prefers non-daily method due to shift work.

     • Contraceptive Patch: Contraindicated (UKMEC 4) due to history of migraine with aura.

     • Hormonal Injections: medroxyprogesterone acetate (Depo-Provera®) 150 mg IM every 12 weeks discussed; patient declined due to potential delay in return to fertility.

     • Implants: etonogestrel (Nexplanon®) 68 mg subdermal implant discussed; 3-year duration, >99% effective, rapid return to fertility upon removal.

   • Intrauterine Devices (IUDs):

     • Copper IUD: Discussed 5–10 year hormone-free device; patient declined due to potential for heavier, more painful periods.

     • Hormonal IUD: levonorgestrel (Mirena®) 52 mg IUS discussed; licensed for 8 years for contraception, reduces menstrual flow/pain, local hormone action.

   • Barrier Methods:

     • Condoms: Currently using; advised to continue for STI protection and until new LARC method is effective.

     • Diaphragms and Cervical Caps: Briefly mentioned; patient not interested due to lower efficacy compared to LARC.

   • Permanent Methods:

     • Tubal Ligation: Not appropriate as patient wishes to conceive in the future.

     • Vasectomy: Not appropriate given future fertility desires.

   • Fertility Awareness Methods: Discussed; deemed unsuitable due to irregular shift work affecting basal body temperature tracking and high failure rate with typical use.

   • Emergency Contraception:

     • Emergency Contraceptive Pills: Discussed levonorgestrel 1.5 mg PO and ulipristal acetate (ellaOne®) 30 mg PO in the event of condom failure prior to LARC fitting.

     • Copper IUD: Highlighted as the most effective form of emergency contraception (can be fitted up to 5 days after UPSI or 5 days after earliest estimated ovulation).

2. Considerations for Choice:

   • Effectiveness: Emphasised superior efficacy of LARC methods (implant and IUS >99% effective) over user-dependent methods.

   • Side Effects: Discussed irregular/unscheduled bleeding pattern with Nexplanon® and Mirena®, especially in the first 3–6 months. Mentioned small risks of IUS insertion (infection, perforation ~1–2/1000, expulsion ~1/20).

   • Patient Preferences: Strongly prefers a "fit and forget" method that may also reduce menstrual bleeding and dysmenorrhoea; keen on hormonal IUS.

   • Health Conditions: Migraine with aura strictly contraindicates all estrogen-containing methods (UKMEC 4). Progestogen-only methods are safe (UKMEC 2).

3. Current Plan:

   • Selected Method: levonorgestrel (Mirena®) 52 mg intrauterine system (IUS).

   • Next Steps: Self-swab for NAAT chlamydia/gonorrhoea screen performed today prior to insertion. Booked into GP LARC clinic for Mirena® fitting next week. Advised to continue rigorous condom use or abstain from UPSI prior to fitting.

   • Education Provided: Provided FPA leaflet on IUS. Advised to take ibuprofen 400 mg PO 1 hour prior to fitting appointment. Explained thread-checking technique and post-insertion red flags (severe lower abdominal pain, fever, offensive discharge, non-palpable threads).

Follow-Up

• Appointment: Booked into LARC clinic on 24/03/2026 at 10:30 for IUS insertion. Routine IUS check PRN 6 weeks post-insertion.

• Contact Information: Elmwood Medical Practice: 0161 496 0123 (Mon–Fri 08:00–18:30) or NHS 111 out of hours.

Signature

Dr Sarah Jenkins

General Practitioner (GMC: 7129483)

Elmwood Medical Practice, 42 High Street, Manchester, M14 5TQ | Tel: 0161 496 0123

Date: 16/03/2026