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Difficulty: EasyMenstrual Cycle Abnormalities and Contraception

Presenting for a family planning consultation, a 38-year-old gravida 2 para 2 is seeking a reliable method of birth control. She is currently sexually active with a new male partner. Review of her medical chart shows no chronic medical conditions, and she takes no daily medications. Social history is significant for a 20-pack-year smoking habit; she currently smokes approximately one and a half packs of cigarettes per day. She consumes alcohol occasionally on weekends. Today, her blood pressure is 116/74 mmHg, pulse is 76/min, and BMI is 24 kg/m². Cardiopulmonary and abdominal examinations are within normal limits. A pelvic exam shows a normal-appearing cervix without discharge, and a point-of-care urine beta-hCG test is negative. Which of the following contraceptive options is absolutely contraindicated for this patient?

  1. Ethinyl estradiol and norgestimate oral tabletAnswer
  2. B
    Copper intrauterine device
  3. C
    Levonorgestrel-releasing intrauterine device
  4. D
    Etonogestrel subdermal implant
  5. E
    Depot medroxyprogesterone acetate injection

Answer

Ethinyl estradiol and norgestimate oral tablet
Combined hormonal contraceptives, such as the ethinyl estradiol and norgestimate oral tablet, are absolutely contraindicated in patients who are 35 years of age or older and smoke 15 or more cigarettes daily. The combination of estrogen and heavy smoking at this age synergistically increases the risk of arterial thrombosis, potentially leading to myocardial infarction or ischemic stroke.

Step-by-Step Solution

1
Identify the patient's age and relevant social history.
The patient is 38 years old and smokes 1.5 packs (30 cigarettes) per day.
Age and smoking status are critical variables in determining the safety profile of hormonal contraceptives.
2
Apply the WHO Medical Eligibility Criteria (MEC) for contraceptive use.
Age 35 or older combined with smoking 15 or more cigarettes per day is a Category 4 (absolute) contraindication for estrogen-containing contraceptives.
The synergistic effect of age, smoking, and exogenous estrogen significantly elevates the risk of severe cardiovascular events (e.g., myocardial infarction, stroke, thromboembolism).
3
Evaluate the given contraceptive options for estrogen content.
Only the ethinyl estradiol and norgestimate oral tablet contains estrogen. The others are either progestin-only or non-hormonal.
Progestin-only and non-hormonal methods are generally safe for smokers over the age of 35.

Key Concept

WHO Medical Eligibility Criteria for Combined Hormonal Contraceptives
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Topics

Menstrual Cycle Abnormalities and Contraception

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