A 37-year-old woman is evaluated for contraceptive advice. She is married and has a 1-year-old child. The patient describes the conception of this child as an “accident” because she often missed taking her previous oral contraceptive. Her menstrual periods have resumed and are regular but heavy and, in that regard, bothersome to her. Medical history is unremarkable. She drinks a glass of wine every night and smokes a pack of cigarettes daily. She has no other health issues and takes no medications.
The result of a pregnancy test performed today is negative.
The patient is provided with a brief smoking cessation intervention. She is not ready to stop smoking but will consider it again at a later time.
Which of the following is the most appropriate female contraceptive option for this patient?
A. Estrogen-progestin oral contraceptive
B. Estrogen-progestin vaginal ring
C. Progesterone-containing intrauterine device
D. Progesterone-only “mini pill”
MKSAP Answer and Critique
The correct answer is C. Progesterone-containing intrauterine device. This content is available to MKSAP 18 subscribers as Question 37 in the General Internal Medicine section. More information about MKSAP is available online.
The most appropriate contraceptive option for this patient is a progesterone-containing intrauterine device (IUD). Hormonal contraception options include oral contraceptive pills, a transdermal patch, a vaginal ring, and long-acting reversible contraceptives. Long-acting reversible contraceptives are progestin-only forms of contraception that include depot medroxyprogesterone acetate injections, subcutaneous implants, and progestin-containing IUDs. These preparations are less reliant on user adherence than oral contraceptive pills, are highly effective, and may be ideal for this patient who has proven difficulty with adhering to a daily pill routine. Return of fertility may be delayed with these methods, with a median time to conception of 10 months after cessation of use. As with other progestin-only methods, irregular bleeding and amenorrhea are prevalent, and weight gain is a common side effect. The levonorgestrel IUD is available in two dosage formulations: one that releases 14 µg/d and is effective for 3 years and one that releases 20 µg/d and is effective for 5 years. The levonorgestrel-containing IUD releases a low dose of progestin, which causes endometrial atrophy and generally leads to decreased or absent menstrual flow. The progesterone-containing IUD may be ideal for this patient who is bothered by heavy menstrual flow, and it will simultaneously eliminate the need for daily adherence to a pill.
Oral contraceptive pills are the most common form of contraception. These include combination estrogen-progestin pills and progestin-only pills (“mini-pill”). Combination preparations differ based on the strength of estrogen and the type of progestin component. All preparations are therapeutically equivalent in preventing pregnancy. Contraindications to estrogen-containing preparations (including oral contraceptives and estrogen-progestin vaginal rings) include breast cancer, liver disease, migraine with aura, uncontrolled hypertension, and venous thromboembolism. They are also contraindicated in women older than age 35 years who smoke more than 15 cigarettes per day, such as this patient, because of an increased risk for venous thromboembolism. When estrogen-containing products are contraindicated, a progesterone-only contraceptive could safely be used. In this patient, a progestin-only pill is less preferable to a progesterone-containing IUD because a pill would require daily adherence.
- Estrogen-containing hormonal contraceptives are contraindicated in women older than 35 years who smoke more than 15 cigarettes a day because of an increased risk for venous thromboembolism.