Patient JC walks on in, the first visit of the day,
she wants to discuss contraception and how to keep babies away.
She’s just turned 18 and started college at State,
and found a nice man with whom she’d like to be intimate.
I start to discuss some methods she may act on,
emphasizing hormone or copper IUD, or maybe the Nexplanon.
We also browse through the ring, the patch or the shot,
and the wide array of pills she can take daily on the dot.
She’s overwhelmed with the options, can’t even remember what they were,
so we decide to move on and talk about what family problems bother her.
Her mom just turned 52 and has been in menopause for a while,
she just recently started bleeding again, hampering her active lifestyle.
Mom’s mind was a whirl, the internet suggested uterine cancer,
but follow-up scans show a fibroid as the answer.
My patient asks about treatments before a final decision is made,
and we begin by drawing out all the options to be weighed.
Mom can do nothing if she wants, or take an array of pills every day,
Some just block estrogen, while some block the whole hormonal pathway.
She can also choose surgery to just scoop it right out,
or opt for the big gun and remove the uterus to leave no doubt.
My patient remembers that her mother also had a breast tumor,
because diagnosed before 50 increases her own risk, goes the rumor.
Browsing her chart shows a flag under genetic screening,
she’s BRCA 1 positive but was unsure of its meaning.
She already looked up basic info but was scared of the terms,
so we discuss all of the various types of risk it confirms.
We start by addressing advanced screening via mammogram and MRI,
ultrasound, as we found out, has no added value to supply.
She can choose routine screening or get prophylactic mastectomy,
and then the discussion shifts to possible preventative oophorectomy.
Next we turn to Grandma, recently 82, celebrating with a surprise,
a lump in her breast found out to be cancer in disguise.
She was just recently referred to the big cancer center around,
and my patient wants to know what possible treatment can be found.
She’s metastasis-free and has a manageable stage,
so she’s free to get whatever treatment is right for her age.
Chemotherapy, immunotherapy or radiation, each with its own upside,
or a lumpectomy versus a mastectomy, either bilateral or just one side.
She can instead try special meds to block her estrogen from working,
SERMs are an option, maybe aromatase inhibitors, with even newer ones lurking.
It’s five years later, her mom treated and her grandmother cured,
my patient comes back to clinic pregnant, a recent urine test assured.
She’s happily married, secure, and excited to start a new phase of life,
but is now overwhelmed with questions and feeling the strife.
We discuss prenatal vitamins, her diet, mood, support and exercise,
at the end, she calmly notes, “it burns when I pee, what do you advise?”
A urinalysis is cloudy, a culture finds many pathogens,
sensitive to all different treatments, and she’s negative for allergens.
So we offer her pills to fix what discomfort she’s in,
but now she has to choose from Nitro, Bactrim, Erythromycin, Keflex or Augmentin.
She returns 12 weeks later and notes she is well all-around,
her baby is healthy, says the first-trimester ultrasound.
We sit to discuss what else is needed to be done,
genetic screening she brings up, she has currently had none.
She can choose to not know and remain in the dark,
or check for abnormal chromosomes at this gestational age benchmark.
From triple screen to quad screen, nuchal translucency to N.I.P.T.,
really the choice is hers to decide how confident in the results she wants to be.
I warn her that they are screening tests, and if they note something wrong,
she’ll have to choose between amniocentesis or CVS to go along.
She delivers a happy baby boy and later produces another healthy two,
the family she’s always wanted, grateful after all she’s been through.
The choices patients make can be quite difficult and daunting,
but with trust in the provider, the conversations are less haunting.
They appreciate calm patience with making each and every decision,
and the simple or detailed pamphlets that are routinely given.
JC is now 45 and has read extensively about the ability,
for permanent sterilization aimed to eliminate her fertility.
She comes to me already decided that a tubal ligation’s the way to go,
we discuss various options but our routine discussions she chooses to forgo.
Now all that’s left to do is decide the date for her surgery…
Image credit: I heart Hailey (CC BY-NC-ND 2.0) by Phae
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Former Managing Editor and Contributing Writer
University of South Florida Morsani College of Medicine
Currently, Brian is a fourth-year medical student at the University of South Florida Morsani College of Medicine. He was born in Westchester County, NY, and moved to Laguna Beach, CA in 2007. He graduated with a Bachelor of Science in Pharmacology and a Bachelor of Science in Biopsychology from the University of California, Santa Barbara in 2017. Brian is planning on becoming an OB/GYN and is currently interested in Surgical Oncology. Outside of the classroom, Brian enjoys playing racquetball, reading on personal finance and nutrition, and enjoying outdoor activities at the beach and hiking.