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A 26-year-old woman comes to the physician to be fitted for a new diaphragm. She had an elective abortion for an unplanned and unwanted pregnancy 2 months ago. She and her husband have been using a diaphragm and contraceptive jelly as their only means of contraception. They have a pattern of drinking heavily on weekends and having unprotected intercourse. Which of the following is the most appropriate next step?

A) Evaluate her for a sexually transmitted disease
B) Fit her with a diaphragm as requested
C) Help her to deal with her feelings about the abortion
D) Refer her to Alcoholics Anonymous
E) Talk to her about a non-barrier method of contraception

my choice was B ( wrong) according to NBME
 

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E. Talk to her about a nonbarrier method of contraception

I would definitely choose E.

Let's analyze the answers:
  • Evaluate her for a sexually transmitted disease
    There is no reason to assume that she has sex with anyone but her husband.
  • Fit her with a diaphragm as requested
    A diaphragm requires forethought and planning. Her history of getting drunk and having unprotected sex with her husband, underscored by the elective abortion, shows that she lacks the forethought that a barrier method like condoms or a diaphragm requires to be effective.
  • Help her to deal with her feelings about the abortion
    Well, secondarily - but your first concern is the reason for her visit today. This is not the best answer, even though it's not inappropriate.
  • Refer her to Alcoholics Anonymous
    You do not have enough information to diagnose her with alcoholism. You may wish to investigate or address her binge drinking at some point, but this is not the reason for her visit, which is contraception.
  • Talk to her about a nonbarrier method of contraception
    This is the best answer. As long as her abortion was uncomplicated (no endometritis post-abortion), she is an excellent candidate for an IUD. If an IUD is contraindicated, then injectable or implantable hormonal contraception would be good options. Even an OCP would have better compliance than a diaphragm in this patient.
 

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I'll go with E.

history of unwanted,unplanned abortion,
unprotected sex following alcohol binging,

these are signs of noncompliance with barrier method of contraception, the best thing is to advice the couple on another method to prevent another unplanned pregnancy.
Choice B is wrong, they will still be uncompliant with diapragm, because of their habit of unplanned intercourse.
 
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