A 24-year-old woman, gravida 1 para 1, comes to the office due to not having a menstrual period for 2 months. She gave birth to a healthy boy 8 months ago. She breastfed for a month and has since been formula-feeding. Since the delivery, the patient has received 2 medroxyprogesterone injections for contraception; the last was administered 4 months ago. Over the last 2 weeks, she has begun experiencing breast soreness, weight gain, and increasing fatigue. Menarche occurred at age 14; menses were regular prior to her pregnancy but have been irregular since starting the medroxyprogesterone. The patient requests a different form of contraception due to these symptoms. Which of the following is the most appropriate next step in management of this patient?

Question

A 24-year-old woman, gravida 1 para 1, comes to the office due to not having a menstrual period for 2 months.  She gave birth to a healthy boy 8 months ago.  She breastfed for a month and has since been formula-feeding.  Since the delivery, the patient has received 2 medroxyprogesterone injections for contraception; the last was administered 4 months ago.  Over the last 2 weeks, she has begun experiencing breast soreness, weight gain, and increasing fatigue.  Menarche occurred at age 14; menses were regular prior to her pregnancy but have been irregular since starting the medroxyprogesterone.  The patient requests a different form of contraception due to these symptoms.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Depot medroxyprogesterone acetate (DMPA) is administered intramuscularly every 3 months to prevent pregnancy by inhibiting the release of gonadotropin-releasing hormone from the hypothalamus and suppressing ovulation. DMPA causes menstrual irregularities such as prolonged bleeding and/or spotting, especially during the first 6 months of use. About 50% of women have amenorrhea after 1 year of use. Less common side effects include weight gain, fatigue, nausea, and breast tenderness. Women with these symptoms typically experience them throughout DMPA use. Although the symptoms experienced by this patient could be due to DMPA side effects, they are also signs of pregnancy. Her acute onset of symptoms, absence of menses for >1 month, and mistiming of a subsequent injection raise suspicion for pregnancy. The next step to confirm this is a urine pregnancy test. (Choice B) This patient's symptoms should be evaluated with a urine pregnancy test before suggesting that they will improve. If the patient cannot tolerate contraceptive side effects, continuing the method may result in poor compliance and increase the risk of unintended pregnancy. (Choice C) TSH, FSH, and prolactin levels are measured in the evaluation of secondary amenorrhea (absence of menses >3 months). Although fatigue and weight gain can result from hypothyroidism, pregnancy must be ruled out first. (Choices D and E) If pregnancy is ruled out, an alternate method of contraception with a better side effect profile (eg, non-hormonal copper intrauterine device) should be offered. The subdermal progestin implant is not a good option for this patient as it has similar side effects of irregular menses and breast tenderness. subdermal progestin implant Educational objective: Medroxyprogesterone side effects may be similar to pregnancy symptoms (eg, breast tenderness, weight gain, fatigue). Women of childbearing age with absence of menses for >1 month should be evaluated for pregnancy. References: Depot-medroxyprogesterone acetate: an update. (http://www.ncbi.nlm.nih.gov/pubmed/18470526)

A 24-Year-Old Woman, Gravida 1 Para 1, Comes to the Office