Complex Patient Case 1: Women’s Health & Contraception

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Case Author
Elizabeth Salisbury, PharmD

Expert Guests
Ashley Meredith, PharmD, MPH, BCACP, BCPS, CDCES
Rebecca Stone, PharmD, BCPS, BCACP
Sally Rafie, PharmD, BCPS, APh

Elizabeth Salisbury PGY2 Ambulatory Care Resident Lifespan, Rhode Island Hospital

Ashley Meredith Professor Purdue University

Rebecca Stone Clinical Associate Profesor University of Georgia

Sally Rafie Pharmacist Specialist UC San Diego Health

The Case!

Setting:  

Family medicine clinic located in an urban area. Most patients served by this clinic have limited financial means. 

Patient Demographics (Initials, age, sex/gender, and race, only if relevant)

Appointment Date | Time | Provider: TODAY | 10:30 am 

JS is a 23-year-old female^✦, presenting to the clinic for an initial pharmacy consultation. 

^✦Unless otherwise noted, the patient’s sex assigned at birth and current gender identity are congruent.

Reason for Visit:

JS was referred to discuss initiating contraceptive therapy. 

ICD-10 Code: Z30 – Encounter for contraceptive management

History of Present Illness and Presenting Symptoms

Chief Complaint: “I think I’m leaning more towards the pill, but I’m really open to anything. It’s also itchy again down there, probably another yeast infection.”  

JS was referred by her PCP to the ambulatory care pharmacist for contraceptive counseling. At her most recent visit with the PCP (three weeks ago), the patient requested a pregnancy test and reported two new sexual partners. Furthermore, symptoms at that time indicated she had a vaginal yeast infection, confirmed by wet prep. Fluconazole and ulipristal acetate were prescribed. 

JS has a complex gynecologic history, including an uncomplicated, spontaneous abortion, earlier this year. JS requires thorough evaluation for the appropriateness of initiating hormonal contraceptive therapy. She has not previously been prescribed hormonal contraception and admits that she does not consistently use condoms. However, the patient reports she took “a blue pack” of her friend’s oral contraceptive pills in 8^th grade. She does not recall the product name but abruptly stopped taking it when her parents discovered the pack. Since then, the patient has not taken any form of hormonal contraceptive.

Her first pap smear was completed in 2020 in accordance with screening recommendations. 

Social History including Health Insurance Coverage

Cultural/Ethnic Background: Hispanic            

Language Spoken: Bilingual (English, Spanish)

Religious Practices: Catholic 

Education: General Education, high school graduate 

Occupation: Teacher assistant for children ages 4-6 years 

Marital Status: Single

Sexual History: 

            Sexually Active: Yes w/ males and females 

            Classification of Sexual Activity: Genital, Oral 

            Condom Use: Occasionally w/ genital intercourse only 

            Number of Partners in Last Month: 2 

Smoking Status: 6 pack years, current smoker 

            Smokeless Tobacco: No, never 

            Vaping Use: No, never 

Alcohol Use: Yes (wine or mixed drinks)

            Alcohol/Week: ~ 6-7 drinks/week 

Recreational Drug Use: No, never 

Health Insurance Coverage: Commercial 

Significant Past Medical History

Vaginal Candidiasis, unspecified (3 weeks ago)

Spontaneous abortion without complication (7 months ago)

Tobacco dependence

Acne, unspecified

Generalized Anxiety Disorder

Eczema

Obesity since childhood         

Immunization History 

Influenza –administered (3 weeks ago)

HPV Quadrivalent – declined

COVID-19 Bivalent Pfizer – (4 months ago) (initial series completed) 

TdAP – administered (10 years ago)

Current Medications

Medication	Directions for Use	Dispense	Remaining Refills
Sertraline 100 mg tablets	Take 1 tablet daily	30	5
Women’s multivitamin	Take 1 tablet daily	90	5
Dicyclomine 10 mg capsules	Take 1-2 capsules up to 3-4 times daily	120	2
Triamcinolone acetonide 1% cream	Apply to affected area once daily after bathing as needed	454 g	3
Ulipristal acetate 30 mg tablet	Take 1 tablet up to 5 days after unprotected sex as needed	5	0
Fluconazole 150 mg tablet	Take 1 tablet once, repeat in 3 days if still symptomatic	2	0

Physical Exam Findings / Vital Signs (TODAY)

Weight	103.3 kg (227 lb 12.8 oz)
Height	168.6 cm (66.38”)
Blood Pressure	120/72 mmHg
Temperature	98.7 ˚F
Pulse Rate	84 bpm

Pertinent Laboratory Findings

Basic Metabolic Panel 

Component	Reference Range & Units	3 weeks ago
Glucose	67 – 99 MG/DL	132
BUN	6 – 24 MG/DL	19
Creatinine	0.44 – 1.03 MG/DL	0.5
Sodium	135 – 145 MEQ/L	130
Potassium	3.6 – 5.1 MEQ/L	3.8
Chloride	98 – 110 MEQ/L	106
CO2	22 – 32 MEQ/L	22
Anion Gap	3 – 13	8
Calcium	8.5 – 10.5 MG/DL	10.2
eGFR	Abnormal <60 ML/MIN/1.73M	>90

Component	Reference Range & Units	3 weeks ago
Hemoglobin, A1c	4.3 – 5.8%	6.2

Urinalysis 

Component	Reference Range & Units	3 weeks ago
Color, Ur	Yellow	Yellow
Appearance, Ur	Slightly cloudy	Clear
Glucose, Ur	Negative	Negative
Ketones, Ur	Negative	Negative
Blood, Ur	Negative	2+
pH, Ur	5.0 – 8.0	5.4
Protein, Ur	< 10 mg/dL	UTQ
Nitrite Level, Ur	Negative	Negative
Leukocytes, Ur	Negative	Trace

Component	Reference Range & Units	3 weeks ago
Chlamydia trachomatis	Neg – Chlamydia PCR	Negative
Neisseria gonorrhoeae	Neg – GC PCR	Negative

Component	Reference Range & Units	3 weeks ago	9 months ago
hCG Qualitative, Serum	negative	negative	positive

Gynecologic Cytology Report 

Collected: 3 weeks ago

Source of Specimen: Cervix 

Interpretation: Satisfactory for evaluation. Endocervical component present. 

ThinPrep Pap Test – Negative for intraepithelial lesion or malignancy. 

Continuing Education Credit

Click on this link to obtain continuing education credit for reading and listening to this Complex Patient Case – Women’s Health + Contraception. The University of Mississippi is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program is approved for 1 hour of continuing education credit. UAN: 0032-0000-22-041-H01-P In order to claim CE you’ll need to read the patient case, listen to the podcast episode in its entirety, and correctly answer 4 out of 5 self-assessment questions. The questions go beyond the information in the case and you may need to consult the resources provided at the end of the case below. Cost = Free

References and Resources

1. Birth Control Pharmacist. Birth Control Pharmacist provides education and training, implementation assistance, resources, and clinical updates to pharmacists prescribing contraception and key stakeholders, as well as leading and stimulating advocacy, research, and policy efforts to expand the role and realize the potential of pharmacists in reproductive health and justice.
2. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-4):1–66.
3. Curtis KM, Nguyen A, Reeves JA, Clark EA, Folger SG, Whiteman MK. Update to U.S. Selected Practice Recommendations for Contraceptive Use: Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate. MMWR Morb Mortal Wkly Rep 2021;70:739–743.
4. CDC – Recommended Adult Immunization Schedule.
5. Moyer VA, U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;156:880-891.