Question

A 33-year-old mother of five. While she is not certain that she has all the children she wants, she does know that she in not interested in having another child for at least several years. She is frightened of injections and her husband does not like to use condoms. She has heard that COCPs are easy to use and effective; she’d like to give them a try. You conduct some basic screening and obtain the following information: BP 140/90; she was diagnosed with tuberculosis 8 months ago; she smokes 6–8 cigarettes a day, you observe mild varicosities on both lower legs.

What other information do you need to obtain in order to assess whether COCPs are the best choice for her?

The rest of the client’s history and assessment do not reveal any precautions for COCP use. Are COCPs an appropriate choice for this client? Why or why not?

Answer 1

COCP should probably not be prescribed, are:

• BMI of 35 kg/m2 or more.
• Breast-feeding up to 6 months postnatally.
• In smokers aged 35 or more.
• In those with multiple risks of cardiovascular disease (ie hypertension, obesity, smoking, diabetes, older age).
• Hypertension (systolics greater than 140 mm Hg and/or diastolics greater than 90 mm Hg, and controlled hypertension, are Category 3, whilst higher readings confer Category 4 risk).
• Vascular disease.
• History of VTE or current VTE.
• Family history of VTE in a first-degree relative under the age of 45.
• Prolonged immobility due to major surgery or disability.
• History of coronary heart disease or stroke.
• Diabetes with complications such as nephropathy, retinopathy, neuropathy or vascular disease.
• Migraine with aura.
• Cardiac valvular disease with complications.
• Breast cancer.
• Primary liver cancers.
• Gallbladder disease and cholestasis.
• Systemic lupus erythematosus (SLE) with positive antiphospholipid antibodies.
• Some types of secondary Raynaud's disease.
• Known thrombogenic mutations, such as factor V Leiden deficiency.
• Some medication which interacts, including some antiretroviral therapy, enzyme-inducing medication, and some anticonvulsants - especially lamotrigine.

other information need to obtain in order to assess whether COCPs are the best choice for her are:

• A full clinical history must be taken:
  • Current and previous medical conditions.
  • Medication use, including prescription, over-the-counter and herbal remedies.
  • Family history.
• Specifically enquire about:
  • Migraine.
  • Smoking.
  • Hypertension.
  • Thrombophilia.
  • Previous VTE and family history of VTE.
  • Hyperlipidaemia.
• Record blood pressure and BMI.
• Check any past or current conditions/medication against UKMEC.
• Exclude pregnancy by history and pregnancy test if appropriate.
• Assess competence to decide, especially in teenage girls and women with special needs.

cocps are not appropriate for her as she is a smoker and has tuberculosis