Saturday, October 11, 2014

The Truth Turned Someone Away from an IUD

This post conforms to the blog rules.Because of my conversation with a patient, she chose not to have a hormonal IUD implanted, a form of long-acting contraception that can end a zygote's life. All I had to do was tell her how it worked.

I was on an audition rotation in a pretty pro-birth control clinic. A young patient with extremely severe menorrhagia was failing oral management (i.e. NSAIDs and high-dose birth control pills weren't helping). Her compliance with daily pills was in question and at the last visit my attending, Dr. L, had discussed mirena with her. I would have been comfortable giving her a mirena, except that she was sexually active. And I know that the mirena can cause damage to a zygote ("fertilized egg" to some, but a person nonetheless). So I told her that the attending would be speaking with her about that prescription, but that there were nonhormonal options, too (lysteda or amicar). I counseled her about the nonhormonal options and about mirena and nexplanon. She couldn't decide what she wanted to do.

"What would you do?" she asked. My heart sang.

"HA! She ASKED," I thought victoriously. "I told myself that I wouldn't make my own recommendations in opposition to the attending unless explicitly asked. AND SHE ASKED!"

"Actually," I said aloud to the patient, "I don't recommend mirena." I explained how it affects the endometrium and can cause loss of the cells that forms after sperm and egg fuse. "And when that embryo is lost, that's an early miscarriage. And I don't want that--"

"I don't want that either," broke in the patient.

"--so I won't in conscience recommend mirena to my patients. But Dr. L does prescribe it, so..."

"No," the patient said. "I guess I'll try the other things."

I left the room promising to bring back a pamphlets on those meds. I returned to the charting room and faced the pamphlet rack. As I pulled out a lysteda brochure, Dr. L said, "Tell me about your lady."

I presented her. "This is your 14-year-old African American patient with a two year history of disabling dysmenorrhea. She hasn't had relief with ibuprofen, orthocyclen, or ogestrel; we talked about mirena and nexplanon but she's interested in something non-hormonal. I counseled on lysteda and she wants more information. Physical exam is benign, she's had guardasil, and HEADS survey is unchanged since last visit; same male partner, 100% condom use. No tobacco, alcohol, or drugs."

My attending was pleased with my presentation, but not pleased that the patient didn't want a mirena. Dr. L joined me at the pamphlet rack and began to pull out brochures for nuvaring, nexplanon, and skyla. She stuffed the sheaf into my hands and sent me back into the patient's room.

(Skyla, btw, has the a disturbingly and tragically accurate advertising campaign, featuring sexually-active women explicitly prioritizing activities over children. How can people ignore the identical mindset behind contraception and abortion?)

I showed the patient the whole stack, but emphasized that everything that has hormones works like mirena. I gave her the pamphlet she wanted, and went back to my attending. "She's still going with lysteda," I said.

Then my attending went in with me. I was a little afraid that she might dissuade the patient from her decision. But this attending actually walks the walk when she supports "patient autonomy," so my patient was allowed a limited trial of lysteda. I have no idea what happened after that, but at least for now, that patient is aware of what hormonal contraceptives can do.

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