A 19-year-old nulligravid woman comes to the office for a routine checkup. She is concerned about having gained 4.5 kg (10 lb) over the last year and believes it is related to her oral contraceptive pills. The patient takes low-dose ethinyl estradiol/norethindrone daily. Prior to starting the pills, she had regular, heavy periods lasting 4-5 days. The patient missed school every month due to severe cramping on the first day of her period. Her pain symptoms resolved after 3 months on the pills. She takes no other medications. Coitarche was at age 18 and she has had 2 partners since then. The patient and her current partner use condoms inconsistently. Vital signs are normal. Her BMI is 27 kg/m². Physical examination is unremarkable. Which of the following is the most appropriate advice for this patient?

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11ec25c8_d9b1_fc72_bc81_cff9955c1e0f_MD0003_00 This patient describes symptoms of primary dysmenorrhea, defined as recurrent lower abdominal pain associated with menstruation. First-line treatment in sexually active patients is combination estrogen-progestin oral contraceptive pills (OCPs). OCPs decrease pain symptoms by thinning the endometrial lining, reducing prostaglandin release, and decreasing uterine contractions. Early side effects of OCPs include nausea, bloating, and breast tenderness, which usually improve with continued use. Breakthrough bleeding is the most common side effect and is usually associated with lower estrogen doses. Adverse effects include hypertension, increased risk of cervical cancer, and venous thromboembolism. Although weight gain as a side effect is a common perception, several studies have shown no significant weight gain, particularly with low-dose formulations. As a result, this patient can be reassured that weight gain is not associated with continued OCP use. (Choice A) Nonsteroidal anti-inflammatory drugs are the first-line treatment in primary dysmenorrhea in non-sexually active patients. Stopping contraception in this patient increases her risk of unintended pregnancy. (Choice C) Switching the patient to the copper intrauterine device (IUD) will decrease systemic side effects. However, a copper IUD is not recommended for patients with dysmenorrhea as its inflammatory reaction in the uterus may increase pain symptoms. (Choice D) Medroxyprogesterone is not a good option for this patient as it may increase body fat, decrease lean muscle mass, and cause weight gain. Medroxyprogesterone is not recommended for adolescents or young women due to risk of significant loss of bone mineral density and should be used in this age group only if no other options are acceptable. (Choice E) Side effects of combination OCPs are due largely to the estrogen component. Progesterone-only pills have relatively fewer side effects but are less effective for dysmenorrhea treatment and contraception as they do not inhibit ovulation. Educational objective: Combination oral contraceptive pills are the first-line therapy for primary dysmenorrhea in sexually active patients. Side effects include breakthrough bleeding, hypertension, and increased risk of venous thromboembolism. Weight gain is usually not an adverse effect. References: Weight and body composition changes during oral contraceptive use in obese and normal weight women. (http://www.ncbi.nlm.nih.gov/pubmed/24156617) The long-term influence of combined oral contraceptives on body weight. (http://www.ncbi.nlm.nih.gov/pubmed/21507999)

A 19-Year-Old Nulligravid Woman Comes to the Office for a Routine