A 27-year-old woman, gravida 0 para 0, comes to the office for contraceptive management. The patient recently started a new relationship and would like a more reliable form of contraception than barrier contraception. Her menstrual cycles occur every 4-5 weeks with 3-6 days of heavy bleeding. The patient has occasional migraines that are associated with visual disturbances. She had low-grade cervical dysplasia a year ago and was treated for Chlamydia trachomatis cervicitis 3 months ago. Vital signs are normal. BMI is 31 kg/m². Physical examination, including pelvic examination, is normal. Urine pregnancy test is negative. Which of the following is a contraindication for combined estrogen/progestin oral contraceptive pills in this patient?

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11ec160b_3bc6_ad07_9249_670bb4160a38_MD0001_00 Combined estrogen/progestin oral contraceptive pills (OCPs) are a reliable (91% efficacy) and reversible female contraceptive method. The estrogen component suppresses ovulation by acting on the hypothalamic-pituitary-ovarian (HPO) axis to inhibit GnRH, FSH, and the midcycle LH surge; it also stabilizes the endometrium to control bleeding. The progestin component also inhibits the HPO axis and further enhances contraceptive efficacy by thickening cervical mucus. However, estrogen is prothrombotic and can increase the risk for severe complications, such as thrombosis, ischemic vascular disease, and stroke, particularly in patients with an elevated baseline risk. Patients with migraine with aura (ie, visual disturbances or sensory [eg, paresthesia, numbness], auditory, or motor [eg, tremors, weakness] dysfunction) have a baseline increased risk for ischemic stroke, likely due to underlying endothelial dysfunction. In these patients, exogenous estrogen use can further compound the risk for stroke; therefore, estrogen-containing OCPs are contraindicated. (Choice A) Elevated BMI is not a contraindication to the use of OCPs because they have similar efficacy in overweight/obese patients and do not cause significant weight gain. (Choice B) Because OCPs are a reversible form of contraception, a patient's gravidity and parity are not contraindications to their use. In contrast, some gynecologic procedures (eg, endometrial ablation, uterine artery embolization) are contraindicated in patients who desire future fertility because the procedures can increase the risk for obstetric complications (eg, placenta accreta) in future pregnancies. (Choice D) Because of the risk for undiagnosed endometrial cancer, unexplained, abnormal uterine bleeding can be a contraindication to the initiation of hormonal contraception until further evaluation (eg, ultrasound, endometrial biopsy) is performed. However, this patient's menstrual pattern is normal (eg, every 4-5 weeks, lasting 3-6 days); OCPs will likely improve her heavy bleeding. (Choice E) Unlike barrier method contraception, OCPs do not protect against human papillomavirus infection, which increases the risk for cervical cancer. However, prior abnormal Pap testing is not a contraindication. (Choice F) Although a current pelvic infection is a contraindication to intrauterine device insertion, a recent or current sexually transmitted infection is not a contraindication to initiating OCPs. Educational objective: Estrogen-containing contraceptive pills (eg, combined estrogen/progestin oral contraceptive pills) are contraindicated in patients with migraine with aura due to the increased risk for ischemic stroke. __________ References: Migraine in women: the role of hormones and their impact on vascular diseases. (http://www.ncbi.nlm.nih.gov/pubmed/22367631)

A 27-Year-Old Woman, Gravida 0 Para 0, Comes to the Office