A 34-year-old woman comes to the office to discuss the progestin-releasing intrauterine device. The patient previously used condoms for contraception but is interested in starting a more reliable method. Her menses occur every 8 to 12 weeks, with heavy vaginal bleeding and passage of clots, and she has intermittent light spotting in between. The patient's last menstrual period was 1 week ago. She has no chronic medical conditions and takes no daily medications. The patient was treated for Trichomonas vaginitis at age 16. Her maternal grandmother had metastatic breast cancer in her 70s. Blood pressure is 118/64 mm Hg and pulse is 80/min. BMI is 44 kg/m². Pelvic examination shows a nulliparous cervix with scant physiologic discharge and a small, nontender uterus. Urine pregnancy test is negative. Which of the following is this patient's contraindication to a progestin-releasing intrauterine device?

Question

A 34-year-old woman comes to the office to discuss the progestin-releasing intrauterine device.  The patient previously used condoms for contraception but is interested in starting a more reliable method.  Her menses occur every 8 to 12 weeks, with heavy vaginal bleeding and passage of clots, and she has intermittent light spotting in between.  The patient's last menstrual period was 1 week ago.  She has no chronic medical conditions and takes no daily medications.  The patient was treated for Trichomonas vaginitis at age 16.  Her maternal grandmother had metastatic breast cancer in her 70s.  Blood pressure is 118/64 mm Hg and pulse is 80/min.  BMI is 44 kg/m².  Pelvic examination shows a nulliparous cervix with scant physiologic discharge and a small, nontender uterus.  Urine pregnancy test is negative.  Which of the following is this patient's contraindication to a progestin-releasing intrauterine device?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9b3_8315_bc81_3338ca55d2ae_MD0003_00 Long-acting, reversible contraceptives such as an intrauterine device (IUD) are highly effective for pregnancy prevention, easy to use, and rapidly reversible. IUDs may be used in patients of all ages and parity (Choices A and D). However, one contraindication to IUD insertion (both copper-containing and progestin-releasing) is unexplained, abnormal vaginal bleeding, such as this patient's irregular menstrual bleeding pattern. Abnormal bleeding is often a symptom of an underlying condition that requires further evaluation before IUD insertion, such as: Infection (eg, cervicitis, pelvic inflammatory disease) Endometrial polyp, which often causes intermenstrual bleeding Endometrial hyperplasia or cancer, particularly in patients with multiple risk factors for unopposed estrogen exposure (eg, obesity, chronic anovulation [as evidenced by this patient's irregular menses]) IUD placement in patients with unexplained, abnormal vaginal bleeding can mask symptoms and delay diagnosis. Therefore, these patients require further evaluation prior to IUD insertion, which typically includes sexually transmitted infection testing, endometrial biopsy, and pelvic ultrasound. (Choice B) Progestin-releasing IUDs are contraindicated in patients with active breast cancer because breast cancers are often progesterone-sensitive. However, a family history of breast cancer, particularly in a second-degree relative, is not a contraindication. (Choice E) IUD insertion and removal is contraindicated during an active pelvic infection, which typically presents with pelvic pain, uterine tenderness, and abnormal vaginal discharge (not seen in this patient). A prior sexually transmitted infection, such as this patient's remote history of Trichomonas vaginitis, is not a contraindication. Educational objective: Unexplained, abnormal vaginal bleeding is a contraindication to intrauterine device insertion because it may indicate an underlying condition (eg, endometrial cancer). Patients with unexplained vaginal bleeding require further evaluation (eg, endometrial biopsy). References: U.S. medical eligibility criteria for contraceptive use, 2016 (http://www.ncbi.nlm.nih.gov/pubmed/27467196) ACOG practice bulletin no. 206: use of hormonal contraception in women with coexisting medical conditions. (http://www.ncbi.nlm.nih.gov/pubmed/30681544) U.S. selected practice recommendations for contraceptive use, 2016. (http://www.ncbi.nlm.nih.gov/pubmed/27467319)

A 34-Year-Old Woman Comes to the Office to Discuss the Progestin-Releasing