Reliable Contraception for Smoker with Painful Menses

Mrs. G, a 35-year-old G2, P2 woman arrives at the office for an annual exam. She requests information on reliable contraception. 

HISTORY
Mrs. G is well groomed and communicative. She is married and works full time as a clerical assistant in a dental office. Mrs. G considers herself to be healthy. She is “determined to quit” smoking (1ppd X 10 years). She reported one “abnormal pap” five years ago that “cleared up” on follow-up pap tests.  Mrs. G complains that her periods, while regular, are becoming very heavy and painful.

PMH: Two spontaneous vaginal deliveries, no problems.  Tonsillectomy and adenoidectomy at age 4. 

FH: Father – Heart attack at age 55, but alive. Works full time and has discontinued smoking (1 ppd X 20 years)

       Mother – Diabetic controlled by diet; hypertension – controlled by ACE inhibitor             

EXAMINATION
On physical examination:            

HEENT:  Normal

                Chest: No adventitious sounds, clear to auscultation

                Breast exam: Normal limits (NL)

                Abdominal exam: + BS all quadrants with no tenderness

                Genitalia:

                                Vulva normal

                                Vagina: Physiologic discharge

                                Cervix: Clear, pap done

                                Uterus: AV, NT, mobile

                                Adnexa: NL, no masses

Assessment:  Normal exam; need contraception

DISCUSSION
Due to Mrs. G’s smoking status, she is not a candidate for combined hormonal (oral) contraceptive. Long-acting reversible contraceptive options were discussed and the patient was recommended a levonorgestrel intrauterine device (IUD) for contraception that will also reduce her painful menstrual symptoms.