Examkin

Question

Difficulty: Very hardMenstrual Cycle Abnormalities and Contraception

For her annual well-woman examination, a twenty-seven-year-old female is evaluated in the ambulatory care center. She is seeking advice on initiating a highly reliable form of birth control, having recently entered a new sexual relationship. Her medical background is notable for polycystic ovary syndrome (PCOS), currently managed solely through lifestyle modifications, with menses occurring unpredictably every 6 to 8 weeks. Additionally, eight weeks ago, she developed an unprovoked right lower extremity deep vein thrombosis (DVT) and is presently anticoagulated with oral apixaban. Her vital signs are within normal limits, though her body mass index is 31.5 kg/m². A bimanual pelvic exam demonstrates a normal-sized, mobile uterus with no adnexal masses. A urine pregnancy test is negative. In light of her complex medical history, which of the following represents the optimal choice for preventing pregnancy in this individual?

  1. Levonorgestrel-releasing intrauterine deviceAnswer
  2. B
    Combined oral contraceptive pill
  3. C
    Copper intrauterine device
  4. D
    Subdermal etonogestrel implant
  5. E
    Depot medroxyprogesterone acetate

Answer

The correct answer is the levonorgestrel-releasing intrauterine device.
The levonorgestrel-releasing intrauterine device is the optimal choice because it safely provides highly effective contraception (MEC Category 2 for DVT), delivers local progestin to protect the endometrium from hyperplasia (crucial for PCOS), and significantly decreases menstrual blood loss, mitigating the bleeding risks associated with active apixaban therapy.

Step-by-Step Solution

1
Assess the absolute contraindications based on the patient's acute DVT.
Estrogen-containing methods (Combined OCPs) are US MEC Category 4 and must be excluded.
Estrogen increases the synthesis of clotting factors, unacceptably raising the risk of recurrent VTE.
2
Identify the patient's need for endometrial protection due to PCOS.
The patient requires a progestin-containing method to prevent endometrial hyperplasia from chronic anovulation.
The copper IUD is non-hormonal and does not protect the endometrium against unopposed estrogen, making it inappropriate for this patient.
3
Evaluate the remaining progestin-only options in the context of active apixaban use and obesity.
The levonorgestrel-releasing IUD is selected over the subdermal implant and depot medroxyprogesterone acetate (DMPA).
The LNG-IUD reliably decreases menstrual bleeding (offsetting the bleeding risk of apixaban) and avoids the metabolic derangements and weight gain heavily associated with DMPA, making it the most optimal choice.

Key Concept

Selection of contraception requires synthesizing multiple medical conditions using the US Medical Eligibility Criteria (MEC); in patients with a history of DVT, estrogen is contraindicated, while concurrent PCOS mandates endometrial protection with a progestin.
Rate this question

Topics

Menstrual Cycle Abnormalities and Contraception

More questions from this topic