A 24-year-old woman comes to the clinic to discuss contraceptive options. She is sexually active with a new male partner and does not desire pregnancy. The patient has a history of severe, throbbing headaches that occur once a month. Before the onset of the headache, she typically sees a "flashing zigzag line" that slowly moves across her field of vision. She has no other medical conditions and takes no daily medications. Her blood pressure is 118/76 mm Hg, and body mass index is 22 kg/m². Which of the following contraceptive methods is absolutely contraindicated in this patient?
- AProgestin-only pill
- BLevonorgestrel-releasing intrauterine device
- Combined estrogen-progestin oral contraceptive pillAnswer
- DCopper intrauterine device
- EEtonogestrel subdermal implant
Answer
The combined estrogen-progestin oral contraceptive pill is absolutely contraindicated in this patient due to her history of migraine with aura.
The correct answer is the combined estrogen-progestin oral contraceptive pill. This patient's description of a 'flashing zigzag line' preceding her severe headaches is classic for a visual aura. According to the World Health Organization (WHO) Medical Eligibility Criteria, all estrogen-containing contraceptives are absolutely contraindicated (Category 4) in women of any age who have migraine with aura. The use of exogenous estrogen in these patients synergistically elevates the risk of ischemic stroke to an unacceptable level. Safe alternatives include all progestin-only methods (pills, implants, injections, IUDs) and the non-hormonal copper IUD.
Step-by-Step Solution
Key Concept
Estrogen-containing contraceptives (such as the combined oral contraceptive pill, patch, and vaginal ring) are absolutely contraindicated in women of any age who experience migraine with aura due to an elevated risk of ischemic stroke.