During a routine health maintenance visit, a 34-year-old woman (G3P3) requests a reliable … — USMLE Step 2 CK

During a routine health maintenance visit, a $34$ -year-old woman (G3P3) requests a reliable method of contraception. She also reports that her menstrual periods have become increasingly burdensome over the past $8$ months. Her menses occur regularly every $28$ days but now last for $9$ to $10$ days with the passage of large clots. She must change a super-absorbency pad every $1$ to $2$ hours during the heaviest flow and complains of persistent fatigue. Her medical history is notable for a deep vein thrombosis in her right leg $3$ years ago following an international flight, for which she completed a $6$ -month course of anticoagulation. Additionally, she underwent a Roux-en-Y gastric bypass $18$ months ago; her body mass index subsequently decreased from $43 \text{ kg/m}^2$ to $27 \text{ kg/m}^2$ . Vital signs are normal. Pelvic examination reveals a normal-sized, mobile uterus with no adnexal masses.

Laboratory evaluation reveals:
Hemoglobin: $9.2 \text{ g/dL}$
Mean corpuscular volume: $74 \text{ fL}$
Thyroid-stimulating hormone: $2.1 \mu\text{U/mL}$
Urine pregnancy test: negative

Which of the following is the most appropriate next step in management for this patient?

Placement of a levonorgestrel-releasing intrauterine deviceAnswer
B
Placement of a copper-bearing intrauterine device
C
Prescription of combined oral contraceptive pills
D
Measurement of serum testosterone and dehydroepiandrosterone sulfate
E
Endometrial biopsy

Answer

The correct answer is the placement of a levonorgestrel-releasing intrauterine device.

The correct answer provides a highly effective contraceptive method that bypasses the malabsorptive environment of her gastric bypass (Category 1), contains no thrombogenic estrogen (Category 2 for deep vein thrombosis history), and acts as a first-line medical therapy to reduce her heavy menstrual bleeding and resolve her anemia.

Step-by-Step Solution

Identify the primary clinical objectives for the patient.

The patient requires a reliable contraceptive method and medical management for heavy ovulatory menstrual bleeding that has caused microcytic anemia.

Establishing the goals of care is necessary before evaluating options against her comorbidities.

Apply the US Medical Eligibility Criteria (MEC) for her history of deep vein thrombosis.

Estrogen-containing methods (like combined oral contraceptives, patches, and rings) are classified as Category 4 (unacceptable risk) and must be avoided.

A history of deep vein thrombosis, even if provoked and treated, represents a severe contraindication to exogenous estrogen due to the high risk of recurrent thrombosis.

Apply the US MEC for her history of Roux-en-Y gastric bypass.

Orally administered contraceptives (both combined and progestin-only pills) are classified as Category 3 (risks generally outweigh benefits) due to malabsorption.

Malabsorptive bariatric surgeries significantly reduce the bioavailability and efficacy of oral medications.

Select the optimal non-oral, non-estrogen method that also treats heavy menstrual bleeding.

The levonorgestrel-releasing intrauterine device is chosen over the copper intrauterine device.

While both intrauterine devices bypass the gastrointestinal tract and avoid estrogen, the copper device increases menstrual blood loss (worsening her anemia), whereas the levonorgestrel device profoundly reduces menstrual bleeding.

Key Concept

The selection of contraception must synthesize multiple US Medical Eligibility Criteria; a history of deep vein thrombosis contraindicates estrogen (Category 4), malabsorptive bariatric surgery limits the efficacy of oral contraceptives (Category 3), and concurrent heavy menstrual bleeding with anemia favors the levonorgestrel-releasing intrauterine device.

Estimated Time:2m 0s

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