A 27-year-old woman comes to the office for advice regarding contraception. The patient has been using condoms consistently but now wants something more reliable. She has regular monthly menses, typically with 6 days of bleeding that requires wearing both a pad and a tampon simultaneously to prevent blood from getting on her clothing. Last year, the patient's mother was diagnosed with a pulmonary embolus and found to be a heterozygous factor V Leiden carrier. At that time, the patient also underwent screening and was also found to be a heterozygous factor V Leiden carrier. She has no personal history of venous thromboembolism and no other medical conditions. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 120/76 mm Hg and pulse is 70/min. BMI is 20 kg/m². Physical examination is normal. Laboratory results are as follows: Which of the following is the most appropriate contraceptive option for this patient?

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Explanation: 11ec25c8_d9b3_f847_bc81_8b63e9deeaef_MD0003_00 Contraceptive counseling should be patient-centered and take into consideration patient-specific factors (eg, medical history), the risk/benefit profiles of various contraception methods, and the patient's future fertility desires. In this patient, the most appropriate contraceptive option is the progestin-releasing intrauterine device (IUD) because it takes into consideration this patient's: increased risk of thromboembolism because she is a heterozygous factor V Leiden carrier who has a family member with inherited thrombophilia and prior thromboembolism. Estrogen-containing contraceptives are avoided in patients at increased risk of thromboembolism due to estrogen-induced hypercoagulability (Choices C and D). In contrast, the progestin-releasing IUD does not affect thromboembolic risk. heavy menstrual bleeding associated with anemia, which will not improve or may potentially worsen with the use of certain contraception methods such as the copper-containing IUD (Choice A). The progestin-releasing IUD causes endometrial atrophy, which treats heavy vaginal bleeding and anemia. desire for future fertility, which is possible with IUD removal at any time the patient desires pregnancy. In addition, the progestin-releasing IUD is one of the most effective methods of pregnancy prevention, with an efficacy of >99% and duration of use up to 5 years. (Choice B) A diaphragm with spermicide is a nonhormonal barrier method that does not affect thromboembolic risk. However, it has poor contraceptive efficacy, making it an inferior option for this patient seeking reliable contraception. Educational objective: Estrogen-containing contraception methods are contraindicated in patients at increased risk for thromboembolism. Progestin-only contraceptives (eg, levonorgestrel-releasing intrauterine device) and the copper-containing intrauterine device may be offered to these patients. References: US medical eligibility criteria for contraceptive use, 2016. (http://www.ncbi.nlm.nih.gov/pubmed/27467196) Association of venous thromboembolism with hormonal contraception and thrombophilic genotypes. (http://www.ncbi.nlm.nih.gov/pubmed/25162263) ACOG practice bulletin no. 206: use of hormonal contraception in women with coexisting medical conditions. (http://www.ncbi.nlm.nih.gov/pubmed/30681544)

A 27-Year-Old Woman Comes to the Office for Advice Regarding