A 26-year-old woman comes to the office to discuss a different form of contraception. The patient recently started combination oral contraceptive pills but frequently forgot to take them every day and discontinued them 3 months ago. She has regular monthly menses with 5 days of moderate bleeding and 2 days of mild cramping. The patient typically has bloating and breast soreness 2-3 days prior to the onset of menses that resolve on the first day of her period. She has had 2 urinary tract infections in the past year and takes no daily medications. The patient is sexually active with a male partner and has no history of sexually transmitted infections. She would like to have children but not for several years. Vital signs are normal. BMI is 22 kg/m². On pelvic examination, the uterus has an irregular contour. Pelvic ultrasound reveals a divergent endometrial cavity with an indented fundus and normal ovaries bilaterally. Urine pregnancy testing is negative. Which of the following is the best contraceptive option for this patient?

Question

Quizplus · Accepted Answer

Explanation: Contraceptive counseling takes 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 depot medroxyprogesterone acetate (DMPA) because it takes the following into consideration: Preference and ease of use (eg, inability to adhere to a daily pill schedule) Uterine cavity distortion, such as this patient's bicornuate uterus (divergent endometrial cavity and indented fundus), which is a contraindication to an intrauterine device (IUD) Desire for future fertility, which is possible with DMPA cessation and return to fertility (variable from 6-18 months) when the patient desires pregnancy DMPA is an effective, injectable contraceptive that does not require daily administration. It is safe for most women, particularly those who have contraindications to intrauterine devices and/or estrogen-containing contraceptives. DMPA is given as an injection every 3 months. A common side effect is light, irregular vaginal bleeding (eg, amenorrhea). (Choice A) The copper-containing IUD is a highly effective nonhormonal, long-acting, reversible contraceptive. It is contraindicated in women with distorted uterine anatomy (eg, bicornuate uterus, large fibroids) because of the risk of malposition, perforation, and expulsion. bicornuate uterus (Choice C) Diaphragm and spermicide are placed pericoitally and have a high failure rate (12%). In addition, it is not recommended in women with frequent urinary tract infections, such as this patient. The spermicide decreases the amount of normal vaginal flora, making patients more susceptible to bacteriuria from coliform bacteria (eg, Escherichia coli). (Choice D) Hysterectomy is performed in women for medical indications (eg, uterine leiomyomata, adenomyosis) who do not desire future fertility. It is not used as contraception due to the risk of complications (eg, bleeding, urinary tract injury) and irreversibility. (Choice E) Because they are safe and have few contraindications, progestin-only contraceptive pills are commonly used in women who are breastfeeding. However, they do not consistently inhibit ovulation and have a high failure rate (eg, 6%) because of a short half-life that requires strict adherence to a daily schedule (eg, >3 hr late requires backup contraception). Educational objective: Depot medroxyprogesterone acetate is an effective, injectable contraceptive that does not require daily administration. It is a safe choice for most women, particularly those who have contraindications to intrauterine devices and/or estrogen-containing contraceptives.

A 26-Year-Old Woman Comes to the Office to Discuss a Different