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A 19-year-old girl is seen for counseling relating to contraceptives. Medical historical past is unremarkable; she is nulliparous and has by no means taken prescription contraceptives. Her father had a pulmonary embolism at age 47 years, which was related to arthroscopic knee surgical procedure, and her 23-year-old sister skilled a deep venous thrombosis three weeks after delivering her first youngster. The affected person doesn’t smoke and takes no medicines.

On bodily examination, she seems effectively. Important indicators are regular; BMI is 31. The rest of the examination is unremarkable.

She states that she doesn’t need to use a copper intrauterine gadget (IUD).

Which of the next contraceptive strategies could be most acceptable for this affected person?

A. Estrogen-progestin vaginal ring
B. Low-dose mixture estrogen-progestin tablet
C. Progestin-releasing IUD
D. Transdermal estrogen-progestin patch

MKSAP Reply and Critique

The right reply is C: Progestin-releasing IUD.

A progestin-releasing intrauterine gadget (IUD) could be most acceptable for this affected person. Different selections embrace the progestin-only tablet, depot injection, or implanted rod. She is at elevated danger for venous thromboembolism (VTE) due to her household historical past of VTE in two first-degree kinfolk and her weight problems. Progestin-releasing IUDs don’t seem to extend VTE danger, so they’re a very good contraceptive alternative for ladies who’re at elevated danger for VTE. It’s unsure if oral progestin-only contraceptives (mini-pill) result in an elevated danger of VTE; nonetheless, the chance seems to be extra clearly elevated if extra VTE danger elements are current (weight problems, immobility, surgical procedure). Injectable progestins do seem to extend the chance of VTE.

Oral contraceptive drugs (OCPs) embrace mixture estrogen-progestin merchandise and progestin-only drugs. Combos with decrease estrogen doses are as efficient with fewer unintended effects. Mixed merchandise are additionally obtainable as a patch and a vaginal ring. Contraindications to mixture merchandise embrace historical past or elevated danger of thrombosis, liver illness, breast most cancers, migraine with aura, and uncontrolled hypertension. Girls older than 35 years who smoke greater than 15 cigarettes per day shouldn’t be prescribed estrogen-containing preparations due to an elevated danger of stroke. As a result of this affected person is at elevated danger for thrombosis, she mustn’t use any technique of contraception containing estrogen.

Key Level

  • Progestin-releasing intrauterine gadgets are essentially the most acceptable contraceptive possibility for ladies at elevated danger for venous thromboembolism (VTE) as a result of they don’t seem to be related to growing the VTE danger additional, whereas progestin-only drugs, implants, and injections could barely improve the chance for thrombosis.

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