NUR 7074 Module 3 Contraception Paper: Medical Eligibility, LARC Counseling and Respecting Choice for a Teen Example

Not the Pill: Contraceptive Counseling for a Teen With Migraine With Aura

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7074: Adolescent and Early Adult Primary Care

Mentor Name

Month Day, Year

Not the Pill: Contraceptive Counseling for a Teen With Migraine With Aura

The Patient

Brianna Lewis, an invented 17-year-old high school senior, came alone asking to start "the pill." She has had one male partner for six months and uses condoms most of the time. Her periods are regular and moderately heavy. When asked about health problems, she described headaches two or three times a month that begin with zigzag flashing lights in one eye for about 20 minutes before the pain starts. She does not smoke, has normal blood pressure and has no history of blood clots. New Jersey law allows minors to consent to contraceptive care, and I explained our clinic's confidentiality practices before we talked.

Medical Eligibility

Nguyen et al. (2024) present the US Medical Eligibility Criteria, which rate each contraceptive method for people with specific conditions on a scale of 1, no restriction, to 4, unacceptable health risk. For a person with migraine with aura, any combined hormonal method falls in category 4, including pills, patch and ring, since estrogen compounds the stroke risk that aura already carries. Progestin-only pills and injections, the implant and both kinds of intrauterine device fall in category 1 or 2 for the same condition. The criteria also address age: intrauterine devices are category 2 from menarche to age 20 because of concerns about expulsion and about infection risk from sexual behavior in younger people, not because of harm to future fertility, and the implant is category 1 at any age. Brianna's aura made her requested method unsafe, but left most others available.

Effectiveness in Real Use

Winner et al. (2012) followed 7,486 women in the Contraceptive CHOICE Project, who chose freely among methods provided at no cost. Pills, the patch and the ring failed at 4.55 per 100 participant-years, against 0.27 among those using intrauterine devices or the implant. After adjustment, women using pills, patch or ring were about 20 times more likely to have an unintended pregnancy. Among women younger than 21, the risk with these methods was almost twice as high as among older women, while long-acting methods were equally effective at all ages.

Effects on Teen Pregnancy

Secura et al. (2014) looked at the 1,404 project participants who were 15 to 19 years old. Counselors described every option starting with the most effective, and no teen paid for any method. Nearly three in four of these young women picked an implant or an intrauterine device. Each year, 34 of every 1,000 became pregnant, against roughly 159 per 1,000 among sexually active teens across the country, and their birth and abortion rates were similarly far below national figures.

Counseling Without Pressure

I explained why the pill was not safe with her type of headaches and described the remaining options, from most to least effective, using a chart: the implant and intrauterine devices, the injection, progestin-only pills and condoms. I stressed that the choice was hers. Long-acting methods have been promoted in ways that some young women, particularly young women of color, have experienced as pressure, so I made clear she could choose any method or none and could have an implant or device removed whenever she wanted, with no questions. She asked about weight gain, pain and irregular bleeding.

Her Choice

Brianna chose the etonogestrel implant because it would not require daily attention and would not affect her headaches. I explained that irregular or unpredictable bleeding is the most common side effect and the most common reason for removal, and that it often settles. A urine pregnancy test was negative, and because she was more than seven days from the start of her last period, she was advised to use condoms for the next seven days. The implant was placed the same day after consent and local anesthesia.

Sexual Health

Condoms remain important for protection against sexually transmitted infections. She was screened for chlamydia and gonorrhea with a urine test, as recommended for sexually active women under 25, and offered HIV testing, which she accepted. Her HPV vaccine series was complete.

Her Migraines

Her migraine with aura deserves its own care. She was offered a follow-up visit to discuss acute treatment, and told that a new or changed aura, or aura lasting longer than an hour, needs prompt evaluation.

Paying Privately

Cost and privacy can block contraception for teens on a parent's insurance. Our clinic participates in the federal Title X family planning program, which allows confidential services on a sliding fee scale. Brianna chose to have the visit billed this way so that no statement would be sent home.

If She Changes Her Mind

I told Brianna that if she wants the implant removed for any reason, bleeding, a planned pregnancy or simply a change of mind, removal is quick and she can switch to another method the same day. Knowing this helped her feel the choice was reversible and her own.

Follow-Up

She was invited to return any time for problems with bleeding or for removal, and to come back in three months if bleeding is bothersome, when short courses of medication can help.

Documentation

The visit note recorded her eligibility category, the counseling given and her consent, kept in the confidential section of the record.

Limits

The CHOICE studies removed cost barriers, which may not reflect usual practice, and participants were volunteers. The patient is invented.

Conclusion

Nguyen and colleagues' eligibility criteria ruled out the pill Brianna requested, Winner and colleagues showed how much more reliably long-acting methods prevent pregnancy, especially in young women, and Secura and colleagues showed the effect of removing cost barriers on teen pregnancy. Safety first, honest information about effectiveness and side effects and a choice that was truly hers led to a same-day implant and a plan for her migraines.

References

Nguyen, A. T., Curtis, K. M., Tepper, N. K., Kortsmit, K., Brittain, A. W., Snyder, E. M., Cohen, M. A., Zapata, L. B., & Whiteman, M. K. (2024). U.S. medical eligibility criteria for contraceptive use, 2024. MMWR. Recommendations and Reports, 73(4), 1-126. https://doi.org/10.15585/mmwr.rr7304a1

Secura, G. M., Madden, T., McNicholas, C., Mullersman, J., Buckel, C. M., Zhao, Q., & Peipert, J. F. (2014). Provision of no-cost, long-acting contraception and teenage pregnancy. New England Journal of Medicine, 371(14), 1316-1323. https://doi.org/10.1056/NEJMoa1400506

Winner, B., Peipert, J. F., Zhao, Q., Buckel, C., Madden, T., Allsworth, J. E., & Secura, G. M. (2012). Effectiveness of long-acting reversible contraception. New England Journal of Medicine, 366(21), 1998-2007. https://doi.org/10.1056/NEJMoa1110855