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Difficulty: MediumMenstrual Cycle Abnormalities and Contraception

A 3838-year-old woman comes to the clinic to discuss contraceptive options. She is sexually active with a new male partner and does not desire future fertility, but she explicitly declines any form of surgical sterilization. Her medical history is significant for poorly controlled hypertension and heavy menstrual bleeding. She smokes one pack of cigarettes daily. Her current medications include amlodipine. Her last menstrual period was 1414 days ago. Blood pressure is 164/102164/102 mmHg, heart rate is 7878/min, and body mass index is 2424 kg/m 2^2. Pelvic examination reveals a normal-sized, mobile uterus with no adnexal masses. Urine pregnancy test is negative. Laboratory studies show a hemoglobin level of 10.210.2 g/dL. Which of the following is the most appropriate contraceptive method for this patient?

  1. Levonorgestrel-releasing intrauterine deviceAnswer
  2. B
    Copper intrauterine device
  3. C
    Combined oral contraceptive pills
  4. D
    Subdermal etonogestrel implant
  5. E
    Bilateral tubal ligation

Answer

Levonorgestrel-releasing intrauterine device
The levonorgestrel-releasing intrauterine device is the most appropriate option because it provides highly effective, long-acting reversible contraception while simultaneously serving as a first-line medical treatment for heavy menstrual bleeding. Because it is a progestin-only method with predominantly local effects, it safely avoids the severe cardiovascular risks associated with systemic estrogen in a patient with severe hypertension and a significant smoking history.

Step-by-Step Solution

1
Analyze the patient's demographic and cardiovascular risk factors.
The patient is over 3535 years old, smokes ≥15\geq 15 cigarettes daily, and has severe hypertension (≥160/100\geq 160/100 mmHg).
These factors define the Medical Eligibility Criteria (MEC) for contraceptive safety.
2
Apply the WHO Medical Eligibility Criteria for contraceptive use.
Estrogen-containing methods are identified as a Category 4 (absolute contraindication) due to an unacceptable risk of ischemic stroke, myocardial infarction, and venous thromboembolism.
Eliminates combined oral contraceptives, patches, and vaginal rings from consideration.
3
Evaluate the patient's gynecologic symptoms alongside her remaining contraceptive options.
The patient suffers from heavy menstrual bleeding and secondary anemia (hemoglobin 10.210.2 g/dL).
Contraceptive selection must not worsen baseline morbidity and ideally should provide a therapeutic benefit.
4
Select the optimal method among safe progestin-only and non-hormonal alternatives.
The levonorgestrel-releasing intrauterine device is chosen because it safely avoids estrogen while directly thinning the endometrium, treating her menorrhagia.
The copper device worsens bleeding, the implant causes unpredictable spotting, and surgery was refused.

Key Concept

Selection of contraception based on WHO Medical Eligibility Criteria, recognizing estrogen contraindications in older smokers with severe hypertension, and utilizing the levonorgestrel IUD to simultaneously treat heavy menstrual bleeding.
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Topics

Menstrual Cycle Abnormalities and Contraception

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