A 23-year-old woman presents for her postpartum visit and contraception management. She delivered by spontaneous vaginal delivery 6 weeks ago and is breastfeeding. After reviewing her history and performing physical examination, you discuss the various methods of contraception with the patient. She opts for depot medroxyprogesterone acetate (DepoProvera).
Which of the following is a disadvantage of Depo-Provera?
DMPA, or Depo-Provera is a highly effective form of contraception. It is injectable, private, convenient, and reversible. The failure rate is less than 1%. Its mechanisms of action include ovulation suppression, cervical mucus thickening, and decidualization of endometrium, making it unfavorable for implantation. It has no impairment of lactation, and iron deficiency anemia is less likely due to amenorrhea which develops in 80% of users. Its principal disadvantages are irregular bleeding and prolonged anovulation, which results in delayed return of fertility after discontinuation of the medication. Weight gain is often attributed to depot medroxyprogesterone, but conclusive evidence is lacking. Cervical and hepatic cancers do not appear to be increased, and ovarian and endometrial cancers are decreased. Loss of bone mineral density is one concern, but this loss is reversible after discontinuation of the medication, and has not been associated with an increased risk of pathologic fracture.
A 36-year-old woman presents to your office to discuss contraception. She has had three vaginal deliveries without complications. Her medical history is significant for hypertension, well controlled with a diuretic, and a seizure disorder. Her last seizure was 12 years ago. Currently she does not take any antiepileptic medications. She also reports stress-related headaches that are relieved with an over-the-counter pain medication. She has never had any surgery. She is divorced, smokes one pack of cigarettes per day, and has three to four alcoholic drinks per week. On examination, her vital signs include weight 90 kg, blood pressure 126/80 mm Hg, pulse 68 beats per minute, respiratory rate 16 breaths per minute, and temperature 36.4°C (97.6°F). Her examination is normal except for some lower extremity nontender varicosities. She has taken birth control pills in the past and wants to restart them because they help with her cramps.
Which of the following would contradict the use of combination oral contraceptive pills in this patient?
Women with absolute contraindications should not take COCs pills. Relative contraindications to the use of COCs require clinical judgment and informed consent.
A 32-year-old woman presents to your office to discuss contraception. She has recently stopped breastfeeding her 8-month-old son, and wants to stop her progestin-only pill (mini pill) because her cycles are irregular on it. You recommend a combination pill to help regulate her cycle. You also mention that with estrogen added, the contraceptive efficacy is also higher.
In combination oral contraceptives, which of the following is the primary contraceptive effect of the estrogenic component?
Ethinyl estradiol is the estrogen used in almost all currently available COCs. The estrogenic component of oral contraceptive pills was originally added to control irregular endometrial desquamation, resulting in undesirable vaginal bleeding. However, these estrogens imposed possible risks that would not be inherent in the progestational component alone. For example, thrombosis, the most serious side effect of the pill, is directly related to the dose of estrogen. The higher the estrogen dose, the more likely there will be thrombotic complications. The combination pill prevents ovulation by inhibiting gonadotropin secretion and exerting its principal effect on pituitary and hypothalamic centers. Progesterone primarily suppresses LH secretion, while estrogen primarily suppresses FSH secretion. Progestins are responsible for endometrial changes that result in an environment not conducive to implantation, and production of cervical mucus that inhibits sperm migration.
A 22-year-old woman presents to your office for her well-woman examination and contraception. She has no medical problems or prior surgeries. She does not smoke or drink. Her vital signs and physical examination are normal. You explain the risks and benefits of combination oral contraceptive pills to the patient. She wants to know how they will keep her from getting pregnant.
Which of the following mechanisms best explains the contraceptive effect of birth control pills that contain both synthetic estrogen and progestin?
The marked effectiveness of the COC pill, which contains a synthetic estrogen and a progestin, is related to its multiple antifertility actions. The primary effect is to suppress gonadotropins at the time of the midcycle LH surge, thus inhibiting ovulation. The prolonged progestational effect also causes thickening of the cervical mucus and atrophic (not hyperplastic) changes of the endometrium, thus impairing sperm penetrability and ovum implantation, respectively. Progestational agents in oral contraceptives work by a negative feedback mechanism to inhibit the secretion of LH and, as a result, prevent ovulation. They also cause decidualization and atrophy of the endometrium, thereby inhibiting implantation. Some evidence indicates that progestational agents may change ovum and sperm migration patterns within the reproductive system. Progestins do not prevent irregular bleeding. Estrogen in birth control pills enhances the negative feedback of the progestins and stabilizes the endometrium to prevent irregular menses. Oral contraceptives have no direct effect on oocyte maturation and do not cause uterotubal obstruction.
A 34-year-old G3P3 presents to discuss options for permanent sterilization. She has read about hysteroscopic sterilization, and is interested in having this procedure.
Which of the following is a contraindication to this procedure?
Hysteroscopic sterilization is highly effective and low risk. It may be done in the office setting, without the need for general anesthesia. It should not be used if acute infection is suspected, but a history of PID or endometritis is not a contraindication. It is nonhormonal, so it is not contraindicated in women with a history of DVT. The most widely available method in the United States is the Essure, which was FDA approved in 2002. Essure involves the hysteroscopic placement of stainless steel and nickel coils into the fallopian tubes. Therefore, a nickel allergy would be a contraindication to its use. Tubal occlusion occurs by an inflammatory response, and is confirmed 12 weeks later with a hysterosalpingogram. Backup contraception must be used until tubal occlusion is documented.
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