A 33-year-old woman comes to the office for a contraception prescription. The patient previously used oral contraceptive pills for menstrual regulation and acne treatment, but she frequently forgot to take them, resulting in an unintended pregnancy 2 years ago. During her pregnancy, she gained 36.3 kg (80 lb) and has been unable to return to her prepregnancy weight. Her postpartum course was complicated by severe postpartum depression requiring a brief hospitalization, and she does not want to become pregnant again. The patient has not been sexually active since the delivery but recently started a new relationship. She has no other chronic medical conditions and no previous surgeries. The patient has had normal routine Pap testing. Her menses occur every 45-90 days with 5-6 days of heavy bleeding and passage of large clots. The patient's mother has type 2 diabetes mellitus and her paternal grandmother had ovarian cancer. She does not use tobacco, alcohol, or illicit drugs. BMI is 33 kg/m². Physical examination is normal. Serum chemistries, prolactin, and TSH levels are normal. Urine pregnancy test is negative. Pelvic ultrasound reveals a small anteverted uterus and multifollicular ovaries bilaterally. Which of the following is the best contraceptive option for this patient?

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Explanation: 11ec2b69_bf0f_1586_8f63_590cb8455e41_MD0005_00 Patients with polycystic ovary syndrome often have menstrual irregularities (eg, anovulation), signs of androgen excess (eg, acne), and polycystic ovaries on ultrasound. Chronic anovulation can lead to unopposed estrogen, resulting in uncontrolled endometrial proliferation and increased risk for endometrial hyperplasia and cancer. Typically, combined oral contraceptive pills (OCPs) are first-line therapy for women with irregular menses who do not desire pregnancy. OCP use provides both a predictable menstrual cycle and regular progestin exposure to counteract the effects of endometrial estrogen stimulation. However, women who are not candidates for OCPs (eg, forgetfulness, contraindications to estrogen) are offered alternate treatments (Choice D). A progestin-containing intrauterine device (IUD) is a long-acting contraceptive option that provides endometrial protection by thinning the endometrium and reversing hyperplasia. (Choice A) Copper-containing IUDs do not protect the endometrium. Furthermore, they typically increase menstrual bleeding and cramping, traits undesirable in patients who already have heavy menstrual bleeding. (Choice B) Cyclic progestin-only pills are taken for 10-14 days each month and provide endometrial protection by inducing monthly withdrawal bleeding. However, cyclic progestins are not an effective contraceptive as the alteration of the cervical mucus and impairment of sperm mobility caused by each pill last for approximately 24 hours. Therefore, patients using cyclic progestin-only pills lack contraception for a portion of each cycle. (Choice C) This patient does not desire future fertility, but surgical sterilization does not provide endometrial protection against hyperplasia or cancer. Educational objective: Patients with polycystic ovary syndrome typically have irregular menses, androgen excess, and polycystic ovaries on ultrasound. The unopposed estrogen excess caused by anovulation results in an increased risk for endometrial hyperplasia or cancer. The endometrium can be protected by use of a progestin-containing intrauterine device, which simultaneously provides contraception. References: Cancer risk and PCOS. (http://www.ncbi.nlm.nih.gov/pubmed/23624028)

A 33-Year-Old Woman Comes to the Office for a Contraception