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Difficulty: Very hardMenstrual Cycle Abnormalities and Contraception

A 26-year-old woman is evaluated in the urgent care setting after seeking postcoital contraception. She reports a single episode of unprotected vaginal intercourse approximately 90 hours prior to arrival. Her medical history is notable for a high body mass index (BMI) of 33 kg/m². During the review of systems, she mentions recent onset of lower abdominal discomfort. Pelvic examination reveals a friable cervix with mucopurulent discharge, marked cervical motion tenderness, and bilateral adnexal tenderness. A point-of-care urine pregnancy test is negative.

Arrange the following emergency contraceptive options in order from MOST appropriate to LEAST appropriate for this specific patient, taking into consideration her clinical presentation, body habitus, and time elapsed.

  1. 1Oral ulipristal acetate
  2. 2Oral levonorgestrel
  3. 3Combined oral contraceptives (Yuzpe method)
  4. 4Copper T380A intrauterine device

Answer

The correct sequence from most to least appropriate is: Oral ulipristal acetate, followed by Oral levonorgestrel, then Combined oral contraceptives (Yuzpe method), and finally the Copper T380A intrauterine device.
Appropriate emergency contraception selection requires factoring in efficacy limits and medical safety. Oral ulipristal acetate is the most appropriate choice because it retains efficacy up to 120 hours, is effective at a BMI up to 35 kg/m², and carries no infectious contraindications. Oral levonorgestrel is second; while safe from an infectious standpoint, it is poorly effective given the 90-hour delay and a BMI of 33 kg/m². The Yuzpe method is third, as it is safe but provides the lowest efficacy and the highest side-effect burden. Finally, the Copper IUD is the least appropriate—despite being the most potent emergency contraceptive overall, inserting a foreign body through an actively infected cervix (indicated by mucopurulent discharge and pelvic pain) is an absolute medical contraindication.

Step-by-Step Solution

1
Evaluate for absolute contraindications based on the physical examination.
The patient has signs of active pelvic inflammatory disease (mucopurulent cervicitis, cervical motion tenderness).
Active pelvic infection is a WHO Medical Eligibility Criteria Category 4 (absolute contraindication) for any intrauterine device insertion. Thus, the Copper IUD becomes the least appropriate method.
2
Evaluate the impact of the time elapsed since unprotected intercourse.
90 hours have elapsed.
Levonorgestrel is ideally used within 72 hours; its efficacy plummets significantly afterward. Ulipristal acetate maintains its efficacy up to 120 hours.
3
Evaluate the impact of the patient's body habitus.
The patient has a BMI of 33 kg/m².
Levonorgestrel loses significant efficacy in women with a BMI > 26 kg/m². Ulipristal acetate maintains efficacy up to a BMI of 35 kg/m².
4
Determine the final hierarchical order of the remaining safe methods.
Ulipristal > Levonorgestrel > Yuzpe method.
Ulipristal is superior due to time and weight factors. Levonorgestrel is superior to the Yuzpe method, which is the least effective oral option and causes severe nausea.

Key Concept

Selection of emergency contraception requires synthesizing three critical variables: time elapsed since intercourse, patient body mass index, and WHO Medical Eligibility Criteria regarding active infections.
Estimated Time:1m 30s
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Topics

Menstrual Cycle Abnormalities and Contraception

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