Obgyn · Year 3 · from Obgyn
Case 3: Contraindications to Combined Hormonal Contraception
Patient Demographics
- Age: 38 years
- Sex: Female
- Occupation: Flight attendant
Chief Complaint
"I need birth control, but I was told I can't take regular pills anymore."
History of Present Illness
The patient was recently evaluated in the emergency department for left leg swelling and pain. She was diagnosed with a deep vein thrombosis (DVT) of the left femoral vein. She is currently on anticoagulation therapy (rivaroxaban). She was taking combined oral contraceptive pills (OCPs) at the time of her DVT and was told to stop them immediately. She is seeking alternative contraception.
Gynecologic History
- Menarche: Age 14
- Cycles (off hormones): Regular, 28 days
- LMP: 2 weeks ago
- Sexually active: Yes, married
- Prior pregnancies: G2P2 (2 vaginal deliveries)
- Prior contraception: Combined OCPs x 10 years (stopped 1 month ago due to DVT)
- No desire for future pregnancy
Past Medical History
- Deep vein thrombosis (diagnosed 1 month ago)
- On rivaroxaban (DOAC) - plan for 3-6 months of anticoagulation
- Heterozygous Factor V Leiden mutation (discovered during hypercoagulability workup)
- Obesity (BMI 32)
Family History
- Mother: DVT at age 45
- Maternal grandmother: Pulmonary embolism
US Medical Eligibility Criteria Assessment
Category 4 Contraindications (Absolute - Cannot Use):
- Current or history of VTE: YES - CATEGORY 4
- Known thrombophilia (Factor V Leiden): YES - CATEGORY 4
Methods Contraindicated for This Patient:
- Combined oral contraceptives (pills)
- Transdermal contraceptive patch
- Vaginal contraceptive ring
- Any estrogen-containing method
Safe Contraceptive Options (Progestin-Only and Non-Hormonal)
US MEC Category 1 or 2 (Safe to Use):
| Method | MEC Category | Notes |
|---|---|---|
| Copper IUD (Paragard) | 1 | No hormones, 10-12 years |
| Hormonal IUD (Mirena/Liletta) | 2 | Local progestin only |
| Progestin implant (Nexplanon) | 2 | Systemic progestin, no VTE risk |
| Progestin-only pills | 2 | Requires strict timing |
| DMPA injection | 2 | Every 13 weeks |
| Barrier methods | 1 | User-dependent |
Key Point: Progestin-only methods do NOT increase VTE risk and are safe for women with VTE history or thrombophilia.
Counseling Session
Patient's Priorities:
- Highly effective (does not want more children)
- Long-acting (travel schedule makes adherence difficult)
- Safe given her DVT history
Recommendation: Levonorgestrel IUD (Mirena or Liletta)
Rationale:
- Highly effective (>99%)
- Long-acting (7 years)
- Progestin-only with predominantly local effect
- NO increased VTE risk
- May reduce menstrual bleeding (beneficial side effect)
- Can be placed while on anticoagulation (but may have increased spotting)
Alternative Discussed: Copper IUD
- Non-hormonal option
- May increase menstrual bleeding (consideration given her anticoagulation which may also increase bleeding)
Patient's Decision: Levonorgestrel IUD (Mirena)
Pre-Insertion Considerations with Anticoagulation
- Consulted hematology - safe to proceed with IUD insertion on anticoagulation
- May have slightly increased bleeding during and after insertion
- No need to hold rivaroxaban for insertion
Insertion Procedure
- Performed without complications
- Minimal bleeding (applied pressure and Monsel's solution)
- Tolerated well
Postoperative Instructions
- Standard IUD instructions
- Continue anticoagulation as directed by hematology
- Expect some spotting (may be increased given anticoagulation)
Follow-up (6 weeks)
- IUD strings in place
- Minimal spotting
- Happy with choice
- Continuing anticoagulation
Long-term Plan
- If she desires permanent contraception, bilateral salpingectomy could be considered after anticoagulation is completed
- Salpingectomy also provides ovarian cancer risk reduction
Teaching Points
- VTE history or known thrombophilia are absolute contraindications to estrogen-containing contraception
- Progestin-only methods are safe in women with VTE risk
- IUDs can be safely placed in anticoagulated patients
- US MEC provides evidence-based guidance for contraceptive safety
- Category 4 = unacceptable health risk; Category 3 = risks usually outweigh benefits
- Always document contraindications and counseling
Clinical Image
Image Description: Chart depicting the US Medical Eligibility Criteria (US MEC) categories for contraceptive use. Category 1 indicates no restriction, Category 2 indicates benefits generally outweigh risks, Category 3 indicates risks usually outweigh benefits, and Category 4 indicates unacceptable health risk.
Attribution: Adapted from CDC US Medical Eligibility Criteria for Contraceptive Use. Public domain.