# Clinical Cases: Contraception

## Case 1: IUD Placement and Counseling

### Clinical Image
![Intrauterine Device](case_01_image.jpg)
*Source: [Wikipedia - Intrauterine device](https://en.wikipedia.org/wiki/Intrauterine_device) - CC BY-SA 4.0*

### Case Presentation
A 22-year-old nulligravid woman presents for contraception counseling. She has been using combined oral contraceptives but reports frequently missing pills and had a pregnancy scare 3 months ago. She desires highly effective, long-acting contraception and does not plan to become pregnant for at least 5 years. She has no significant medical history. Her menstrual periods are regular but heavy, causing her to miss school or work monthly. Physical examination is unremarkable. She is counseled about long-acting reversible contraception (LARC) options. Given her heavy menstrual bleeding, she is particularly interested in the levonorgestrel IUD (Mirena), which may reduce menstrual blood loss. After counseling about the insertion procedure, potential side effects (irregular bleeding initially, possibility of expulsion), and the lack of STI protection, she opts for Mirena placement. A urine pregnancy test is negative. The IUD is inserted successfully with mild cramping. She is counseled that the IUD is effective immediately and provides contraception for up to 8 years, though heavy bleeding typically improves within 3-6 months. At her follow-up visit, the IUD strings are visualized. At 6 months, she reports minimal menstrual bleeding and is very satisfied.

### Key Learning Points
- LARC methods (IUDs and implants) have the lowest failure rates (<1%) and are recommended as first-line contraception by ACOG, including for nulliparous women and adolescents
- The levonorgestrel IUD (Mirena) provides contraception for up to 8 years and has non-contraceptive benefits including reduced menstrual blood loss (20-50% of users become amenorrheic)
- Common myths should be dispelled: IUDs do not cause infertility, are safe in nulliparous women, and PID risk is limited to the first 20 days after insertion
- Effectiveness is not user-dependent, making LARC superior to methods like pills, patches, or rings that require consistent correct use

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## Case 2: Contraindications to Combined Hormonal Contraceptives

### Clinical Image
![Migraine with Aura](case_02_image.jpg)
*Source: [Wikipedia - Aura (symptom)](https://en.wikipedia.org/wiki/Aura_%28symptom%29) - CC BY-SA 3.0*

### Case Presentation
A 35-year-old G2P2 woman presents requesting oral contraceptives. She has been using condoms but wants more reliable contraception. Her medical history includes migraine headaches that began 10 years ago. On further questioning, she reports that her migraines are preceded by visual disturbances including flashing lights and zigzag lines that last about 20 minutes before the headache begins. She smokes half a pack of cigarettes daily and has been trying to quit. She has no history of blood clots, stroke, or heart disease. BMI is 26. The provider explains that she has two Category 4 contraindications to combined hormonal contraceptives (CHCs) per the US Medical Eligibility Criteria: migraine with aura (at any age) and smoking more than 15 cigarettes daily at age 35 or older. Migraine with aura increases ischemic stroke risk, and CHCs further elevate this risk. Alternative contraceptive options are discussed. She is counseled about progestin-only methods, which are safe for women with migraine with aura. She chooses the etonogestrel implant (Nexplanon), which is placed at the same visit. She is also provided with smoking cessation resources. At follow-up, she reports no change in her migraine pattern and is satisfied with the implant.

### Key Learning Points
- Combined hormonal contraceptives are contraindicated (US MEC Category 4) in women with migraine with aura at any age due to significantly increased ischemic stroke risk
- Other Category 4 contraindications include history of VTE/PE, thrombogenic mutations, current or recent breast cancer, severe hypertension, and smoking 15+ cigarettes daily at age 35 or older
- Progestin-only methods (implant, injection, IUD, progestin-only pills) are safe alternatives for women with CHC contraindications
- The US Medical Eligibility Criteria (MEC) provides guidance on contraceptive safety based on medical conditions

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## Case 3: Emergency Contraception

### Clinical Image
![Emergency Contraception](case_03_image.jpg)
*Source: [Wikipedia - Emergency contraception](https://en.wikipedia.org/wiki/Emergency_contraception) - CC BY-SA 4.0*

### Case Presentation
A 24-year-old woman presents to the clinic 36 hours after unprotected intercourse. The condom broke during sex, and she is not using any other contraception. Her last menstrual period was 12 days ago, and she has regular 28-day cycles. She is concerned about pregnancy and requests emergency contraception. Her BMI is 32. Physical examination is unremarkable. A urine pregnancy test is negative. The provider discusses emergency contraception options. Given that she is likely in her fertile window (around day 12-14 of her cycle) and her elevated BMI may reduce levonorgestrel effectiveness, the copper IUD is recommended as the most effective option. The copper IUD is effective as emergency contraception for up to 5 days after unprotected intercourse and is the most effective method regardless of BMI, with a pregnancy rate of less than 0.1%. Additionally, it provides ongoing highly effective contraception. The patient agrees. A copper IUD is inserted the same day. She is counseled that her next period may be heavier than usual. At follow-up, she confirms she had a normal menstrual period and the IUD is in good position. She decides to continue using the copper IUD for ongoing contraception.

### Key Learning Points
- The copper IUD is the most effective form of emergency contraception (pregnancy rate <0.1%) and can be inserted up to 5 days after unprotected intercourse or 5 days after expected ovulation
- Levonorgestrel EC (Plan B) is most effective within 72 hours but has reduced efficacy in women with BMI >25-30 kg/m2; ulipristal acetate maintains efficacy at higher weights
- Emergency contraception works primarily by delaying or inhibiting ovulation; it does not disrupt an established pregnancy
- The copper IUD provides the added benefit of ongoing highly effective contraception for up to 10 years