Friday, July 23, 2010
Rhythm Method = Motherhood
One interesting patient I saw was a 35 year old black female G0P0 with a history of fibroids, metrorrhagia, and pelvic pain associated with her menses. The patient’s last pap smear and well woman exam by a civilian provider was in 2009 with normal results/findings (per patient). It was noted that this patient’s menstrual cycle ranged anywhere from 16 to 26 days with spotting in between periods. The patient had no medical records (to include labs, previous abdominal U/S) available to look at as she was typically followed off base by her primary care provider. The patient stated that she was told 2 years ago she had a fibroid the size of a grapefruit on the right side of her uterus. No other information was known (i.e. fibroid characteristics, or even possible surgical plan that fell through). Also, the patient stated that she was married and has not been using any form of birth control for the past 5 years other than the rhythm method. The patient stated that she had been previously worked up for fertility several years ago and was told that she should be able to conceive children. The patient denied having any knowledge pertaining to her husband’s fertility status. The patient vehemently denied wanting to have children at this time. The patient was alert and in no acute distress. The patient had an athletic build and noted that she works out 4-5 times weekly. The physical exam and ROS was unremarkable except for metrorrhagia, pelvic pain, and the rubbery 4-5 cm mass evidenced with a bimanual exam to the right uterine adnexa. Also, of note was a slightly enlarged liver 2cm below the right costal margins with exhalation and even greater excursion with inhalation. The patient was counseled regarding birth control and informed that there was a strong possibility that the fibroid(s) may be keeping her from getting pregnant, or that her husband may suffer from infertility. The patient was offered a monophasic COC (LoOvral) to help with her metrorrhagia and spotting in between menses as well as to provide a form of contraception. The patient was extensively counseled as to her risks of getting pregnant if she was only using the rhythm method. No risk factors other than age were identified with regards to OCP’s. The patient was instructed to have a CMP drawn. Also, she was given a referral for a repeat abdominal U/S as well as a consult surgery. Lastly, the patient was instructed to f/u with her pcm regarding her liver function test, U/S results, and a BP check in 4 weeks time.
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I saw a similar pt in clinic yesterday. 40 WF, G2P1. Always has used natural family planning, has had no "surprises". Previous pregnancy and this one were planned. Spent the past year trying to conceive, with success. So this couple were motivated and educated, and had managed their fertility successfully. This was a huge contrast to what I've been seeing more of in the clinic so far. I was impressed.
ReplyDeleteWow...interesting comments/cases from both of you. I find it VERY difficult to believe that rhythm method would be successful in a woman with they cycles you describe above, John. Fibroids are not going to keep her from getting pregnant either (the fact that she's 35 might, though!).
ReplyDeleteI wonder what was going on with her liver? Did that make you stop to re-consider the OCP's?
I was wondering about the fibroids as well. That was per the NP precepting me. However, I did do a little research on my own. One of the articles I found is listed below.
ReplyDelete"Fibroids and reproductive outcomes: a systematic literature review from conception to delivery." Published in the April 2008 issue of American Journal of Obstetrics and Gynecology. Authored by Klatsky, Tran, Caughey & Fujimoto.
There are several other recent articles pointing to a correlation with fibroids and infertility. However, other literature disputes this or discounts the effect they might have.
Next, keep in mind that this patient has not had protected sex in five years, and her insight into the correct application of the rhythm method was not very encouraging as she seemed ignorant of timing intercourse around her cycle (sorry if I did not explain that in my initial comment).
As to the patient's enlarged liver. This finding did cause us to delve a little deeper into this patient's history. The patient denied any drug/ETOH abuse or any signs of obstructive cholestasis. A previous Hepatitis screen was negative. Other "red flag" symptoms were not present. She had a physical exam to include a normal CBC by her PCM within the past 6 mo. However, we did order an LFT test via a CMP and instructed this patient to follow up with her PCM. I had wanted to dig a little deeper, but I was unable to do so.
As to the use of birth control affecting the liver function and size. I was only able to find a possible correlation with focal nodular hyperplasia and worsening cholestasis or even a specific drug induced canicular cholestasis. I noted nothing having to do with worsening/affecting a malignancy. It did not affect my preceptor prescribing the COC. The patient was counseled as to the side effects and symptoms that would necessitate a follow up visit and discontinuation of the medication.
As to Elena's comment. The patient said she was in a happy/wonderful marriage, and she was pretty adamant about not wanting to ever have any children. The rapport gained by me and my preceptor during the 30 minute visit wasn't sufficient to delve into why she felt differently than many other childless women her age.