Unwillingness to change contraception
Make sure the patient's symptoms are secondary to her birth-control use.
The question of how to switch women from their contraceptive of choice once you've determined that it is medically unwise to continue it arises commonly among clinicians providing contraceptive care. With regard to this specific patient, I have a few suggestions.
First, make sure your patient's headaches are secondary to her birth-control use. I have many patients who blame side effects (e.g., weight gain, depression) on the Pill that sometimes are the result of other, often alterable, circumstances. Other changes in your patient's life or health (e.g., increased stress, allergies) could be the cause of the headaches.
Second, are your patient's headaches migraine-type headaches? Are they accompanied by aura? If the headaches are migraines with aura, the increased risk of ischemic stroke associated with oral contraceptive use warrants discontinuation, regardless of the patient's objections. For an excellent review article, see Contraception. 2006;73:189-194. The conversation about other birth-control methods can be difficult, but the advantages of safer alternatives should be stressed.
If the patient's headaches are severe in intensity but not migraines with aura, changing the dosing pattern (night rather than morning often works well) or lowering the dose of estrogen may help. Of course, various modes of headache management are also useful. For a more detailed discussion of this topic, see Contraception. 2009;80:417-421.
Finally, have you offered the patient progesterone-only birth-control pills (also referred to as "the minipill")? Women with a history of migraines can take the minipill safely. If your patient relies on the Pill for cycle control, the minipill may be less efficacious, but it acts as effective birth control and has many of the same noncontraceptive benefits as the Pill. Other progesterone-only methods like medroxyprogesterone (Depo-Provera), etonogestrel (Implanon), or levonorgestrel (Mirena) could also be used (as well as any nonhormonal method, of course).—Lisa Stern, APRN (142-4)