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Zorluk: Çok zorMenstrual Cycle Abnormalities and Contraception

A 26-year-old woman presents to the clinic requesting emergency contraception. She reports having condomless vaginal intercourse 115 hours ago. Her last menstrual period began 16 days ago, and she usually has regular 28-day cycles. Her past medical history is significant for Wilson disease, which is well-controlled on oral D-penicillamine. She takes no other medications. She states she would also like to initiate a highly effective, long-acting reversible contraceptive method today to prevent future unintended pregnancies.

Vital signs include a blood pressure of 118/76 mmHg, a heart rate of 78/min, and a respiratory rate of 14/min. Her body mass index (BMI) is 34 kg/m234 \text{ kg/m}^2. Physical examination reveals a normal thyroid gland, clear lungs, and a soft, non-tender abdomen. Neurologic examination is unremarkable, with no resting tremor or ataxia. A urine pregnancy test obtained in the clinic is negative.

Which of the following is the most appropriate emergency contraceptive method for this patient?

  1. A
    Copper intrauterine device
  2. 52-mg levonorgestrel-releasing intrauterine deviceCevap
  3. C
    Oral ulipristal acetate
  4. D
    Oral levonorgestrel
  5. E
    Oral combined ethinyl estradiol and levonorgestrel

Cevap

The 52-mg levonorgestrel-releasing intrauterine device is the most appropriate choice.
The patient requires emergency contraception (EC) 115 hours after unprotected intercourse. She has a BMI of 34 kg/m234 \text{ kg/m}^2, is likely post-ovulation (Day 16 of a 28-day cycle), has Wilson disease, and desires long-acting reversible contraception (LARC). The 52-mg levonorgestrel-releasing intrauterine device (LNG-IUD) is highly effective for EC if placed within 120 hours (5 days) of unprotected intercourse. Unlike oral EC methods, the efficacy of the LNG-IUD is not reduced in patients with obesity, and it remains effective even if ovulation has already occurred. Furthermore, the patient has Wilson disease, which is a disorder of copper metabolism and represents an absolute contraindication (Category 4) to the Copper IUD. The 52-mg LNG-IUD perfectly meets all clinical constraints and immediately initiates her desired LARC.

Adım Adım Çözüm

1
Evaluate the timeframe from unprotected intercourse to presentation.
115 hours have elapsed.
To determine which emergency contraception methods remain effective; levonorgestrel pills are best within 72 hours, while ulipristal and intrauterine devices (IUDs) are effective up to 120 hours.
2
Assess the impact of the patient's BMI on contraceptive efficacy.
The patient has a BMI of 34 kg/m234 \text{ kg/m}^2.
Obesity significantly decreases the efficacy of oral emergency contraceptives (ulipristal and levonorgestrel), making IUDs the preferred choice for reliable pregnancy prevention.
3
Consider the patient's cycle timing.
Presentation is on Day 16 of a regular 28-day cycle.
Oral emergency contraceptives act primarily by delaying ovulation and are ineffective if ovulation has already occurred. IUDs prevent fertilization and implantation, remaining highly effective.
4
Cross-reference chosen methods with patient's medical history using Medical Eligibility Criteria.
Wilson disease is present.
Wilson disease is a Category 4 absolute contraindication to the Copper IUD, leaving the 52-mg levonorgestrel-releasing IUD as the optimal choice that also provides her requested long-acting reversible contraception.

Anahtar Kavram

Selection of emergency contraception based on timeframe, BMI, cycle timing, and medical contraindications (WHO Medical Eligibility Criteria).
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Menstrual Cycle Abnormalities and Contraception

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