Mrs. A, a 35-year-old G2P2 reports for an annual exam and contraceptive counseling as a new patient to your practice. She states that her menstrual cycles are “regular,” occurring monthly, but reports heavier bleeding, often passing clots. She also is experiencing increased cramping with her periods.

Mrs. A has a history of CIN III (cervical intra-epithelial neoplasia) with a subsequent LEEP procedure in her 20s. Her subsequent pap tests have been normal. She is currently married to her husband of ten years, and reports a total of five sexual partners. Mrs. A currently takes a combination low-dose oral contraceptive pill that was prescribed by her provider in a different state. 

Mrs. A’s review of systems is negative with the exception of migraine headache which she has had “since I was a teenager.” When asked about these, she admits that “occasionally” she experiences nausea and has a “blind spot” in her field of vision which she describes as “annoying”.

Mrs. A is 5’2″ tall and weighs 170lbs. Her vital signs show that she is hypertensive: BP 140/90mm Hg; pulse 88bpm.

On physical examination:
HEENT: Normal, no adenopathy
Chest: Heart RRR, Lung sounds normal
Breasts: Pendulous, no masses/adenopathy on clinical breast exam
Abdomen: Obese, + BS all 4 quadrants
External genitalia: Normal pubic hair distribution, no masses/lesions
Vagina: Physiologic discharge
Cervix: Parous, clear
Uterus: Anteverted, non-tender, mobile
Adnexa: No masses, ovaries normal, palpable
Rectal: Deferred

Heavy menstrual bleeding; increased cramping. Obesity.  Stage 1 hypertension. Classic migraine.

Based on the clinical picture, it is recommended that Mrs. A discontinue her combined low-dose oral contraceptive which may aggravate her hypertension and migraines. She is recommended to switch to a levonorgestrel IUD which will help alleviate the heavy menstrual bleeding and cramping. Weight loss strategies such as fiber supplementation, increased water intake, and a protein-based diet are also recommended.

Mrs. A is told to return to the clinic for the IUD insertion and to reevaluate her blood pressure. If BP is still elevated at 140/90mm Hg, consider initiating a trial of hydrochlorothiazide 12.5mg once daily or refer her to her PCP.