WHO Numeric Classification for the use of 10 contraceptives in over 120 diseases:7 1 = Use method without restrictions 2 = Advantages of method generally > risk 3 = Risks of method usually > advantages 4 = Avoid since method presents unacceptable health risks
HPI: 20 yo WF G0 with LMP 2 wks ago, presents with acute pelvic pain, dizziness, and vomiting. No
GI sxs, fevers, unusual vaginal discharge. Sexually active. Long history of menorrhagia. PMHx: SLE with DVT x 2 (diagnosed at age 16) on Coumadin 7.5 mg q day Exam: Ht 5’3’’ Wt 200 lbs BP 80/40 P 120
Marked abdominal distension with rebound. Pelvic exam normal except severe pain on bimanual. Labs: BHCG negative PCV 20
What is your diagnosis? Acute hemoperitoneum probably due to ovulation and anticoagulation. What is the best long-term contraceptive option for this patient? Why? There are some studies to suggest that E+P hormonal contraceptives doesn’t ↑ risk of recurrent thrombosis if INR is therapeutic.5,6 Baseline risk of VTE of 1/10,000 per year: 1 to 2 fold increase risk with HRT, 3 to 4 fold increase risk with COCs, 5 fold increase risk with pregnancy. Protein C and S, Antithrombin III deficiencies, Factor V Leiden mutations are associated with an even greater ↑ VTE risks. However, with other effective contraceptive options available in the U.S., most clinicians would not prescribe estrogen containing contraception for women who require anticoagulation. In this patient who requires life-long anticoagulation, contraception as well as consistent ovulation suppression is important to prevent intra-abdominal bleeding as a result of ovulation. DepoProvera is probably the best option. Levonorgestrel IUD and progesterone-only pills are reasonable options for contraception but will not consistently suppress ovulation. Avoid OCPs and copper IUD if possible.
HPI: 38yo single BF smoker P1001 divorced banking executive who needs contraception. She has
heavy and painful periods and desires future fertility. PMHx: PIH with pregnancy at age 30, HTN diagnosed 2 years ago but well controlled with HCTZ Exam: normal BP 138 / 88 Ht 5’8” Wt 160 lbs Labs: FBP normal Chol 220 mg/dl LDL 140 mg/dl TG 420 mg/dl
What is the data on OCP use in patients with a history of PIH? Although h/o PIH increases a woman’s risk for developing future Htn, it is not a contraindication for the use of OCPs as long as BP has returned to normal ranges postpartum.
Current Htn? Progesterone-only method is preferable but estrogen use is safe if Hypertension is well-controlled. 8% of users will have a idiosyncratic ↑BP with OCP use. Hypertension + smoking + OCPs =
↑CHD risk. Patients should be counseled that risk of cerebral thromboembolism is ↑ by 3-fold in hypertensive women, irrespective of OCP use. 3 Dyslipidemia? Consider the use of newer 3rd generation progestins in these patients (theoretically
less androgenic effects on lipids although clinical significance is less clear). OCPs containing estrogen will increase triglycerides and should be avoided if patients with marked hypertriglyceridemia, such as in this patient. NCEP recommends avoiding the use of OCPs if LDL>160 mg/dL or if multiple CAD risk factors are present.
What is the data on smoking and OCP use? Data suggests that there are ↑ CV events in smokers>35 yrs old using > 50 mcg EE OCPs. However, for OCPs containing <50 mcg EE, no data to suggest that there is an increase risk of MI and CVAs as the number of smokers over 35 years of age were small in the original studies. 1,2 Therefore, current recommendations are to weigh risk of contraceptive method against risk of unplanned pregnancy, and that Estrogen-containing contraceptives are safe in smokers age < 35 but should be avoided in smokers age >35. Healthy non-smokers can use OCPs until menopause.
What is the best contraceptive option for this patient? Why? The best contraceptive options for
this patient would be LNG IUD or mini-pill because it would provide contraception as well as decrease
menstrual blood loss and improve dysmenorrhea. DepoProvera would be a good option as well except
it may further delay fertility in this 38 y.o. woman. If she stops smoking and had her
hypertriglyceridemia controlled, she might be a reasonable candidate for OCPs.
HPI: 33 yo married nonsmoker P1001 who is 8 wks s/p SVD. She plans to breastfeed for 4 months then return to work. Prior to pregnancy, she suffered from menorrhagia with anemia and severe dysmenorrhea. Her symptoms improved on OCPs but she was switched to barrier methods due to worsening migraines. She plans a second pregnancy in 24 months.
PMHx: Classic migraines FHx: negative
Exam: normal Ht 5’5” Wt 145 lbs BP 120/65
What is the best contraceptive option for this patient with classic migraines? Why? European case-control study of risk for ischemic stroke suggests a 4 fold increase of stroke (OR=4) in patient with migraine with aura and this risks is exponentially increase in patients who have migraines and smoker (OR 34.4). Therefore, the recommendation is that OCP acceptable in nonsmoker, <35 y.o., with migraine without aura.4 Progestin-only method or levonorgestrel IUD is preferrable in this patient.
HPI: 23 yo single, nonsmoker, BF P0010 with Sickle cell disease and chronic anemia is referred by her hematologist for contraceptive counseling. She recently had a SAB and has been using condoms for birth control. She has a long history of oligomenorrhea. No dysmenorrhea. She does not desire pregnancy for at least 5 years.
Exam: normal Ht: 5’1” Wt 101 lbs BP 128/68 P78 Hct 28 Cr. 0.9
What is the best contraceptive option(s) for this patient? Why? Since chronic anemia is a concern in sickle cell patients, the use of DMPA or levonorgestrel IUD may be ideal since they both ↓ menstrual blood loss. Additionally, DMPA may also decrease the incidence of painful crises. OCPs will also ↓ menstrual blood loss and estrogen affects clotting via the extrinsic pathway and does not affect sickling, which is the cause of thromboembolic events in these patients. 8,9Copper IUDs may ↑ menorrhagia and ↑ risk of PID in at risk women, precipitating a crises. However, the risk of pregnancy in these patients greatly outweighs risk associated with contraception, even COCs. References: