A 31-year-old woman, gravida 5 para 3, comes to the office to discuss contraception methods. The patient has 3 children delivered vaginally at term and 2 elective first-trimester pregnancy terminations. Her last delivery was a year ago and she does not currently use contraception. She has just finished breastfeeding. The patient is worried about unintended pregnancy and says that she has completed childbearing. She has no history of thromboembolism, migraines, or liver disease. Her regular monthly menses typically have 4-5 days of moderate bleeding. The last menstrual period was a week ago. Her last Pap test was a year ago, and all testing has been normal. The patient had acute cervicitis at age 19 with negative sexually transmitted infection screening since then. Her maternal aunt was diagnosed with breast cancer at age 54 and died from complications of pulmonary embolism. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 128/70 mm Hg and pulse is 70/min. BMI is 27 kg/m². Physical examination is normal. Which of the following is the best contraception option for this patient?

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Explanation: 11ec2b69_c142_49e8_8f63_656451edf8e8_MD0005_00 The effectiveness of contraception is categorized by perfect use and typical use. Perfect use refers to contraceptive use in a research setting ensuring patients' consistent and correct use. Typical use of contraception refers to efficacy rates that occur due to patient error and inconsistent administration in the general population. Methods that rely on the user for proper and consistent administration have a discrepancy between perfect and typical use, with higher rates of pregnancy with typical use. The progestin subdermal implant, which is long-acting and reversible, is the most effective contraceptive method with a >99% efficacy rate with typical use. The progestin subdermal implant has a high pregnancy prevention rate because once inserted it is effective for 3 years and is not user dependent. It is even more effective than the intrauterine device (0.2%-0.8% failure rate) and female sterilization (0.5% failure rate). Contraception is achieved by progesterone-induced changes that result in cervical mucus thickening and decreased tubal motility, which inhibit sperm migration. In addition, progestin causes ovulation suppression via decreased FSH and LH secretion. Side effects include unscheduled bleeding (most common), weight gain, and headache. A contraindication to use is progesterone receptor-positive breast cancer. Ovulation and fertility return within a month after removal. progestin subdermal implant intrauterine device (Choices A and D) Combination oral contraceptives and the hormonal contraceptive patch are less efficacious (91%) than the progestin implant. (Choice B) Male condoms protect against sexually transmitted infections but are only 82% effective in preventing pregnancy with typical use. The addition of spermicide can cause genital irritation and increase HIV transmission rates. (Choice C) Depo-medroxyprogesterone acetate injection has a mechanism of action similar to that of the progestin implant, but it requires an injection every 90 days and is less efficacious (94%). Educational objective: The progestin subdermal implant, which is long-acting and reversible, is the most effective contraceptive, with a >99% efficacy rate with typical use. 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) Efficacy and safety of long-acting reversible contraception. (http://www.ncbi.nlm.nih.gov/pubmed/21668037)

A 31-Year-Old Woman, Gravida 5 Para 3, Comes to the Office