Female Reproductive System & Breast

Frame 1

It is another sunny morning, and after a vigorous jog and hearty breakfast, you are once more in the family planning clinic. Even the large heap of files in front of you fails to dent your good mood.

As you pick up the file at the top, the first patient of the day walks in.

Frame 2

Thirty-year-old Gretchen has been on the low-dose combined oral contraceptive pill for the past three and a half years.

She has a 5-year-old son, whom she delivered vaginally at term, with no complications. Her medical, surgical and gynecological histories are unremarkable. She does not smoke, drinks alcohol only occasionally, and is not on any other medications.

Gretchen has forgotten to take her pills for three consecutive days, because her son was ill, and she was busy taking care of him. Although she has not engaged in intercourse within the past 48 hours, she is sexually active, and does not desire a pregnancy. Naturally, she is worried.

Further questioning reveals that she is using biphasic pills, with 28 pills per pack, and that she is currently in the third week of the current pack.

Frame 3

Gretchen asks you if she needs a backup method of contraception.

How do you respond?

Choice Outcome Score Continues
"No, that is not necessary. Just make sure to complete the remainder of the course" Incorrect 0 → Frame 4
"Yes, you need emergency contraception" Incorrect 0 → Frame 5
"Yes, you need to use a barrier method for the next 7 days" Correct 1 → Frame 6

Frame 4

You ask Gretchen to calm down and tell her that if she takes the rest of the pills as advised, she should be safe. However, instead of calming her down, this has quite the opposite effect.

"But doctor!" she blurts out, "I just read online that I will need a backup method for a while?!"

Realizing your mistake, you hurry to correct yourself: "yes, of course! I was just coming to that." You proceed to explain about the necessity for, and use of, alternative methods of contraception.

Frame 5

You are about to tell Gretchen that she needs emergency contraception, but suddenly realize that this is unnecessary in the current context. In fact, she only needs to use an alternative method of contraception during the next week.

Frame 6

You explain that a backup method is needed and advise her regarding the available options.

Frame 7

Her concerns regarding pregnancy set to rest, Gretchen now wants to know how to continue the pack of pills.

How will you advise her regarding the missed pills?

Choice Outcome Score Continues
Take all missing pills today, and continue the rest of the pack as usual Incorrect 0 → Frame 9
Take the last pill you missed now, leave any earlier missed pills, carry on with the rest of the pack and then start a new pack without taking the inactive pills Correct 1 → Frame 10
Take today's pill, discard the previous pills, and continue the rest of the pack Incorrect 0 → Frame 8

Frame 8

You are about to advise Gretchen to take today's pill alone, and continue the rest of the pack as usual, when you realize how absurd this is. Instead, you decide to tell her to take the missed pills immediately, and start a new pack afterwards.

Frame 9

You are about to advise Gretchen to take all the missed pills today, and continue the rest of the course, when you realize that she is already on the third week of her pack. Thinking rapidly, you instead ask her to take the last pill you missed now, leave any earlier missed pills and carry on with the rest of the pack; and without taking the inactive pills, start a new pack immediately afterwards.

Frame 10

Happy with your advice, Gretchen leaves your office smiling. Just as she leaves, the next patient walks in.

Twenty-four-year-old Janis delivered her first child 5 months ago, via an uncomplicated vaginal delivery. She now wishes for advice regarding an appropriate method of contraception. As she moved to your city just two weeks earlier, she is unable to consult her previous gynecologist.

On questioning, you find out that Janis has not used any contraceptive techniques previously. Her medical, surgical and gynecological histories are unremarkable.She also does not smoke or drink alcohol. You also inquire and find out that her child is exclusively breast fed.

Frame 11

Which contraceptive technique will you recommend?

Choice Outcome Score Continues
The low-dose combined oral contraceptive pill Incorrect 0 → Frame 12
The progestin-only pill Correct 1 → Frame 14
An intrauterine contraceptive device (IUD) Correct 1 → Frame 13

Frame 12

You are about to prescribe combined oral contraceptive pills (COCPs), when you suddenly realize how stupid that sounds. Janis is breastfeeding - and COCPs should not be prescribed to lactating women!

Frame 13

You recommend a copper intrauterine contraceptive device (IUD) as a suitable option, and explain the differences and benefits of an IUD over hormonal methods.

However, after your explanation, Janis says that she would prefer a 'non-invasive' method, as opposed to inserting a device into her uterus. This makes you rethink your recommendation.

Frame 14

You inform Janis that, as a breastfeeding mother, the best option is to use the progestin-only pill (POP), if she has no objection to using a hormonal method. You also mention that an intrauterine contraceptive device (IUD) is another, non-hormonal alternative.

After listening to your explanation of the pros and cons of each technique, Janis agrees with you, and decides to start taking the pills. She leaves the office thanking you.

Frame 15

Almost before Janis exits, a woman rushes in, with a teenage girl in tow.

You find out this is Mrs. Waddell, and her 16-year-old daughter Taylor. The mother looks worried, whilst the daughter looks quite haggard. You offer Taylor the chance to interview her alone, but she insists on her mother being present.

Taylor engaged in penetrative vaginal intercourse with her boyfriend just 2 days ago. Although the couple used condoms, a breakage occurred. She was not on any form of contraception at that time.

According to Taylor, her boyfriend is a classmate. They have been in a monogamous relationship for the past 7 months. This is the first time that both have been sexually active. Her last menstrual period was 12 days ago, and her cycles are regular. She attained menarche at the age of 12.

Taylor's medical history is only significant for childhood asthma, for which she was treated with inhaled steroids. She has not been on any asthma medications for the past 5 years.

Frame 16

What will you do in Taylor's case?

Choice Outcome Score Continues
Counsel her regarding a potential pregnancy Incorrect 0 → Frame 17
Recommend the emergency contraceptive pill Correct 1 → Frame 19
Recommend implantation of a copper IUD Incorrect 0 → Frame 18

Frame 17

As you prepare to counsel the mother and daughter regarding the possibility of a pregnancy, Mrs. Waddell speaks up.

"Doctor, I have heard about the 'morning-after' pill. Will that work for my daughter?"

"Yes, Mrs. Waddell. That would actually be the best option for this situation," you answer quickly.

Frame 18

You decide that a copper IUD is the best emergency contraceptive option in this situation. However, as you explain this to the mother and daughter, your nurse gestures that she wants to have a word.

"Are you sure doctor? She's a teenager. Do you think we should go with the morning-after pill instead?" she asks. Her words make you reconsider your choice.

Frame 19

You reassure the mother and daughter, and prescribe the morning-after pill. Both look relieved, as you explain that the chance of subsequently becoming pregnant is very low.

Mrs. Waddell looks particularly satisfied when you praise them for seeking medical advice on a timely basis. Both mother and daughter leave your office happily.

Frame 20

You see several other patients after this. A couple of them need implants or injectables, but the vast majority have no significant issues. Finally, you are at the last file of the day.

Amber is a 35-year-old single mother with 3 children, who lives with her boyfriend. She had a copper T 380 intrauterine contraceptive device (IUD) inserted 3 years ago, after her last childbirth.

Amber is in your office today, because she cannot feel or see the string of the IUD. She last noticed it around a week ago, and has been sexually active since then. She did not use any other form of contraception during this time period. She is positive that the IUD was not expelled.

Her last menstrual period was 16 days ago, and her cycles are regular. Her gynecological and obstetric histories are otherwise unremarkable.

Frame 21

A speculum examination and careful probing fails to detect the strings. A urine pregnancy test is negative as well.

What will you do now?

Choice Outcome Score Continues
Order an x-ray, to find out if the IUD is still inside the uterus Incorrect 0 → Frame 22
Order an ultrasound scan, to find out if the IUD is still inside the uterus Correct 1 → Frame 24
Tell Amber to use a barrier method, and come back at the next menstrual period Incorrect 0 → Frame 23

Frame 22

You decide to order an x-ray, in order to determine if the IUD is still in place. Subsequently, you fill in the necessary forms and send Amber to the radiology department.

A few minutes later, you receive a call from the radiologist. "I think you might have made a mistake when filling out the forms. I did an ultrasound scan and can confirm that the IUD is in-situ," he says.

Feeling a bit foolish, you thank him and put down the phone. After all, why expose Taylor to ionizing radiation right away?

Frame 23

You start to reassure Amber, saying that even though the strings may not be visible right now, you might be able to visualize them during her next menstrual period, and that she should use an alternative method of contraception until her next visit.

However, you stop. This isn't the optimal approach - you're better off immediately ordering an ultrasound scan to see if the IUD is still in-situ or not.

Frame 24

You perform an ultrasound scan, which shows that the IUD is still in place. You convey the good news to Amber, who immediately perks up. She thanks you and leaves.

Frame 25

Just as you get up and prepare to go out, Taylor, whom you saw earlier today, bursts in. She is highly distressed, as she vomited up the first oral contraceptive pill less than an hour after taking it.

Frame 26

Taylor asks you what she should do now.

What will you tell her?

Choice Outcome Score Continues
She needs to repeat the first pill, and take the second pill as normal Correct 1 → Frame 29
She only needs to take the second pill at the proper time Incorrect 0 → Frame 27
Since it might be too late, counsel her regarding insertion of a copper IUD Incorrect 0 → Frame 28

Frame 27

Before you can open your mouth, the nurse walks in with Taylor's mother.

"I was just telling her that she need not worry, doctor. They just need to repeat the first pill, and take the next one as advised," she says.

"Exactly what I was about to tell your daughter, Mrs. Waddell. You really don't have to worry so much about this," you manage to mumble.

Following your reassurance, the mother and daughter leave the office quite relieved. You thank your lucky stars for the timely intervention of your nurse!

Frame 28

You start to think that it might be too late for another pill, and that insertion of an IUD might be the best option.

But almost immediately you realize that as it is still less than 72 hours since intercourse, a hormonal method would work just as well, as long as she repeats the pill which she just vomited up.

Frame 29

You reassure Taylor that she has nothing to worry about, and that all she has to do is to repeat the first pill. She is extremely happy to hear this, and thanks you over and over again.

Frame 30

Finally, you are done for the day. As a reward, the Chinese takeout is waiting for you on a table in the doctors' lounge.

"I guess you can't have a glorious ending for every single day," you think as you dig into it. But at least the food is great.

Well done!

The end