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Difficulty: HardMenstrual Cycle Abnormalities and Contraception

Review the following patient scenarios involving complex medical histories. Select the most appropriate contraceptive method for each patient based on the World Health Organization Medical Eligibility Criteria (WHO MEC) and clinical efficacy.

  • A 34-year-old G2P2 with systemic lupus erythematosus and a positive lupus anticoagulant. Vital signs are normal. She desires long-term, reversible contraception but has a history of an unprovoked deep vein thrombosis.Copper intrauterine device
  • A 26-year-old nulligravida with a BMI of 31 kg/m², prior Roux-en-Y gastric bypass surgery, and a known bicornuate uterus. Pelvic exam confirms normal adnexa. She seeks highly effective, maintenance-free contraception.Etonogestrel subdermal implant
  • A 38-year-old G3P3 who smokes one pack of cigarettes daily. Blood pressure is 128/82 mmHg. She reports debilitating monthly pelvic pain during menses and seeks reliable pregnancy prevention.Levonorgestrel-releasing intrauterine device
  • A 29-year-old nulligravida presenting 72 hours after unprotected intercourse. Exam reveals mucopurulent cervical discharge and cervical motion tenderness. Vital signs: T 37.8°C, HR 90. She urgently requests emergency pregnancy prevention.Oral ulipristal acetate

Answer

The copper IUD is matched to the patient with SLE and antiphospholipid antibodies. The etonogestrel implant is matched to the patient with gastric bypass and a bicornuate uterus. The LNG-IUD is matched to the smoker over 35 with dysmenorrhea. Oral ulipristal acetate is matched to the patient needing emergency contraception with active cervicitis.
Each clinical scenario contains specific medical conditions that dictate the safety and efficacy of contraceptive methods according to the WHO Medical Eligibility Criteria. Matching requires identifying the absolute contraindications (MEC 4) or relative contraindications (MEC 3) in each vignette to isolate the single most appropriate method.

Step-by-Step Solution

1
Evaluate the patient with SLE, positive lupus anticoagulant, and history of DVT.
Identify that both estrogen and progestin-containing methods present unacceptable thromboembolic risks in this highly hypercoagulable state.
This rules out implants, oral pills, and hormone-releasing IUDs, leaving the non-hormonal Copper IUD as the safest choice.
2
Evaluate the patient with a Roux-en-Y gastric bypass and a bicornuate uterus.
Identify that oral absorption is compromised and the uterine cavity is structurally abnormal.
This rules out oral contraceptive pills (due to malabsorption) and all intrauterine devices (due to cavity distortion), leaving the Etonogestrel subdermal implant.
3
Evaluate the 38-year-old smoker with severe dysmenorrhea.
Identify that combined hormonal contraceptives are contraindicated due to age over 35 and heavy smoking.
The Levonorgestrel-releasing IUD provides excellent contraception without cardiovascular risk and directly treats the heavy bleeding and pain associated with dysmenorrhea.
4
Evaluate the patient requiring emergency contraception who has signs of acute pelvic inflammatory disease (PID).
Identify that intrauterine device insertion is contraindicated during an active pelvic infection.
Because it has been 72 hours, Oral ulipristal acetate is chosen over levonorgestrel as it maintains higher efficacy up to 120 hours.

Key Concept

Application of the WHO Medical Eligibility Criteria (MEC) for Contraceptive Use in complex medical scenarios
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Topics

Menstrual Cycle Abnormalities and Contraception

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