A 32-year-old woman, gravida 4 para 4, comes to the office for a routine checkup 6 weeks after an uncomplicated vaginal delivery of a healthy boy. The patient has no concerns and would like to discuss contraception options. She heard from a friend that some options can make losing weight challenging. Prior to this pregnancy, the patient had a history of increasingly heavy menses and was found to be mildly anemic. Iron was prescribed, but she often forgot to take it; she often forgot her prenatal vitamins too. The patient is breastfeeding exclusively. Pelvic examination shows a small, mobile uterus with no abnormalities. Breast examination shows no masses, tenderness, or nipple injury. Which of the following is the preferred method of contraception for this patient?

Question

A 32-year-old woman, gravida 4 para 4, comes to the office for a routine checkup 6 weeks after an uncomplicated vaginal delivery of a healthy boy.  The patient has no concerns and would like to discuss contraception options.  She heard from a friend that some options can make losing weight challenging.  Prior to this pregnancy, the patient had a history of increasingly heavy menses and was found to be mildly anemic.  Iron was prescribed, but she often forgot to take it; she often forgot her prenatal vitamins too.  The patient is breastfeeding exclusively.  Pelvic examination shows a small, mobile uterus with no abnormalities.  Breast examination shows no masses, tenderness, or nipple injury.  Which of the following is the preferred method of contraception for this patient?

Quizplus · Accepted Answer

11ec25c8_d9b1_8741_bc81_fbebcbe38105_MD0003_00 The levonorgestrel-containing intrauterine device (IUD) is a long-acting, reversible contraceptive that prevents pregnancy by releasing levonorgestrel (a progestin), which creates a physical barrier by thickening cervical mucus and impairing implantation through decidualization of the endometrium. It has an efficacy of >99% and is approved for use in the United States for up to 5 years. A common side effect is amenorrhea, which can be used to improve anemia and abnormal uterine bleeding. A small percentage of women experience systemic side effects (eg, mood changes, breast tenderness, headaches). Weight gain is not a side effect. (Choice A) Combined oral contraceptives can be used for contraception in patients >6 weeks postpartum while breastfeeding. They are an effective contraceptive method that can improve hypermenorrhea but should be reserved for patients who reliably take daily medications. (Choice B) The copper IUD, another long-acting, reversible contraceptive option, is approved in the United States for up to 10 years. The copper IUD can cause heavy menstrual bleeding and should not be placed in women with hypermenorrhea or anemia as it may exacerbate these conditions. (Choice D) Medroxyprogesterone is an option for long-term contraception, with patients receiving injections every 3 months. Because weight gain is a common side effect, medroxyprogesterone is not optimal for this patient, who is concerned about difficulties with postpartum weight loss. (Choice E) Lactation can cause anovulation and therefore some degree of contraception as high prolactin levels inhibit the release of gonadotropin-releasing hormone from the hypothalamus. Lactation, however, is not considered a reliable form of birth control because ovulation can resume while a mother is still breastfeeding. Educational objective: The levonorgestrel intrauterine device (IUD) provides highly efficacious, long-acting, reversible contraception that works by thickening cervical mucus and impairing implantation. Progestin-containing IUDs have the added benefit of amenorrhea and minimal systemic side effects. References: Levonorgestrel intrauterine system (Mirena): an emerging tool for conservative treatment of abnormal uterine bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/25861205)

A 32-Year-Old Woman, Gravida 4 Para 4, Comes to the Office