A 32-year-old woman, gravida 5 para 4, comes to the office for follow-up of breast biopsy that confirmed high-grade malignant features. Nine weeks ago, the patient was incidentally found to have a breast mass during a pregnancy visit. The pregnancy ended in a miscarriage. She is coping with the new diagnosis and otherwise has been feeling well with no vaginal bleeding or abdominal pain. Family history is significant for ovarian cancer in her mother, who died at age 50. Genetic testing reveals a mutation in the BRCA2 gene. The patient is scheduled to begin chemotherapy and is advised to avoid pregnancy. She took oral contraceptives during adolescence with no side effects. Breast examination shows a well-healing biopsy scar. Which of the following is the best contraceptive option for this patient?

Question

A 32-year-old woman, gravida 5 para 4, comes to the office for follow-up of breast biopsy that confirmed high-grade malignant features.  Nine weeks ago, the patient was incidentally found to have a breast mass during a pregnancy visit.  The pregnancy ended in a miscarriage.  She is coping with the new diagnosis and otherwise has been feeling well with no vaginal bleeding or abdominal pain.  Family history is significant for ovarian cancer in her mother, who died at age 50.  Genetic testing reveals a mutation in the BRCA2 gene.  The patient is scheduled to begin chemotherapy and is advised to avoid pregnancy.  She took oral contraceptives during adolescence with no side effects.  Breast examination shows a well-healing biopsy scar.  Which of the following is the best contraceptive option for this patient?

Quizplus · Accepted Answer

11ec25c8_d9b2_71a3_bc81_e34fc62874b8_MD0003_00 Pregnancy is contraindicated during breast cancer treatment due to teratogenic agents such as chemotherapy and radiation. Hormone-containing methods of contraception are avoided in patients with breast cancer, as estrogen and progesterone may have a proliferative effect on breast tissue. This is particularly concerning with hormonal receptor-positive breast cancer, and BRCA2 carriers tend to have estrogen receptor-positive breast cancer. A copper intrauterine device (IUD) is a safe, long-term, hormone-free method of contraception. It is 99% effective and prevents pregnancy by creating a chronic cytotoxic inflammatory response. A copper IUD can be placed for a maximum of 10 years. copper intrauterine device (IUD) (Choices A, C, and F) Combined oral contraceptives contain both estrogen and progesterone. Combined oral contraceptives decrease the risk for ovarian cancer in the general population as well as BRCA mutation carriers. However, due to their hormonal content, they are contraindicated in patients with current breast cancer. The patch and ring are other delivery modes of estrogen-progesterone contraceptives and should also be avoided. (Choice B) Typical condom use is only 80% effective in preventing pregnancy, and this patient requires more reliable contraception, such as an IUD. (Choice E) The progesterone IUD is a highly effective contraceptive and can be placed for 5 years. It is also contraindicated in the setting of current breast cancer due to potential systemic absorption of progesterone. progesterone IUD Educational objective: All hormone-containing contraception is absolutely contraindicated in patients with breast cancer. A copper intrauterine device is a safe, effective, hormone-free, long-term method of contraception. References: U.S. Selected Practice Recommendations for Contraceptive Use, 2013: Adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edition. (http://www.ncbi.nlm.nih.gov/pubmed/23784109)

A 32-Year-Old Woman, Gravida 5 Para 4, Comes to the Office