# Clinical Cases: Contraception ## Case 1: IUD Counseling and Insertion in a Nulliparous Patient ### Patient Demographics - **Age:** 22 years - **Sex:** Female - **Occupation:** College senior ### Chief Complaint "I want to get an IUD. I'm tired of taking pills every day." ### History of Present Illness The patient is a 22-year-old nulliparous woman seeking long-acting reversible contraception. She has been on combined oral contraceptive pills for 3 years but frequently forgets doses, resulting in breakthrough bleeding and anxiety about contraceptive failure. She had a pregnancy scare 3 months ago after missing several pills (pregnancy test was negative). She has researched IUDs online and wants to discuss her options. ### Gynecologic History - Menarche: Age 13 - Cycles on OCPs: Regular withdrawal bleeds - Cycles off OCPs: 28-30 days, moderate flow, mild dysmenorrhea - LMP: 5 days ago - Sexually active: Yes, with one male partner x 1 year - Prior pregnancies: G0 - STI history: None - Last Pap smear: 1 year ago, normal - Last chlamydia/gonorrhea testing: 1 year ago, negative ### Past Medical History - No chronic conditions - No known drug allergies - Currently on combined OCP (ethinyl estradiol 30 mcg/levonorgestrel) ### Contraceptive Counseling **Patient Goals:** - Highly effective method - Low maintenance ("set it and forget it") - Does not want daily pills - Wants to preserve future fertility - Concerned about hormonal side effects (mood changes, acne on pills) **Options Discussed:** | Method | Effectiveness (Typical Use) | Duration | Hormones | |--------|----------------------------|----------|----------| | Copper IUD (Paragard) | >99% | 10-12 years | None | | Hormonal IUD (52mg - Mirena/Liletta) | >99% | 7 years | Levonorgestrel (local) | | Hormonal IUD (19.5mg - Kyleena) | >99% | 5 years | Levonorgestrel (local) | | Subdermal Implant (Nexplanon) | >99% | 3 years | Etonogestrel (systemic) | **Debunking IUD Myths:** - "IUDs are only for women who've had children" - FALSE. IUDs are safe and effective for nulliparous women and adolescents. - "IUDs increase infection risk" - FALSE. Infection risk is limited to first 20 days post-insertion. - "IUDs cause infertility" - FALSE. Fertility returns immediately after removal. ### Patient's Decision: Hormonal IUD (Kyleena) **Rationale:** - Highly effective, long-acting - May reduce dysmenorrhea (a concern for her) - Lower hormone dose than 52mg devices - Smaller device appropriate for nulliparous uterus - Does not require daily adherence ### Pre-Insertion Evaluation **Eligibility Screening:** - Pregnancy test: Negative (required before insertion) - Current chlamydia/gonorrhea: Tested today (results pending, will treat if positive) - No active cervicitis on exam - No contraindications: No Wilson's disease, no uterine anomaly, no current PID **Timing:** - Day 5 of menstrual cycle - Can insert any time in cycle with negative pregnancy test - Backup method not needed if within 7 days of period start ### IUD Insertion Procedure **Preparation:** - Informed consent obtained (risks: perforation 1/1000, expulsion 2-10%, infection first 20 days, cramping) - NSAID (ibuprofen 800 mg) taken 1 hour prior - Chaperone present **Procedure:** 1. Bimanual exam: Anteverted uterus, normal size 2. Speculum placed, cervix visualized 3. Cervix cleansed with antiseptic 4. Tenaculum applied to anterior lip 5. Uterine sounding: 7.5 cm (normal) 6. IUD inserted through cervix, deployed at fundus 7. Strings cut to 3 cm from external os 8. String length documented **Patient Tolerance:** - Moderate cramping during insertion - Mild vasovagal symptoms (sweating, nausea) - resolved with rest - Observed for 15 minutes, feeling well at discharge ### Post-Insertion Instructions - Cramping and spotting normal for days to weeks - Ibuprofen as needed for cramping - Irregular bleeding common for first 3-6 months, then lightens - Check strings monthly after first period - No tampons or intercourse for 24 hours - Return for: fever, severe pain, foul discharge, unable to feel strings, pregnancy symptoms ### Follow-up Visit (6 weeks) - Strings visible, appropriately positioned - Minimal spotting, cramping resolved - Satisfied with choice ### Chlamydia Result - Negative (if positive, would have treated with antibiotics; IUD does not need to be removed for uncomplicated infection) ### Teaching Points - LARC methods (IUDs and implant) are first-line recommendations for most women, including adolescents and nulliparous women - Pregnancy must be excluded before IUD insertion - Chlamydia/gonorrhea testing can be done same day; does not delay insertion - Most common reason for IUD discontinuation is irregular bleeding - Proper counseling about expected side effects improves continuation rates ### Clinical Image ![IUD Insertion](case_01_image.jpg) **Image Description:** Illustration demonstrating proper positioning of an intrauterine device within the uterine cavity. The IUD is shown deployed at the fundus with the strings extending through the cervix into the upper vagina. Correct placement ensures the device sits at the top of the uterine cavity. **Attribution:** Educational illustration. Public domain medical education resource. --- ## Case 2: Emergency Contraception Request ### Patient Demographics - **Age:** 19 years - **Sex:** Female - **Occupation:** Freshman in college ### Chief Complaint "The condom broke last night and I need the morning-after pill." ### History of Present Illness The patient presents to the student health clinic requesting emergency contraception. She reports that a condom broke during intercourse approximately 18 hours ago. Her partner did not withdraw and ejaculated inside the vagina. She is very worried about becoming pregnant and wants to know her options. ### Gynecologic History - Menarche: Age 12 - Cycles: Regular, 28-30 days - LMP: 12 days ago (mid-cycle - near ovulation) - Sexually active: Yes, one partner - Contraception: Condoms only - Prior pregnancies: None - No STI history ### Past Medical History - Asthma (uses albuterol inhaler PRN) - Weight: 165 lbs (75 kg) - Height: 5'4" - BMI: 28.3 kg/m2 ### Risk Assessment - Unprotected intercourse 18 hours ago - LMP 12 days ago (likely near ovulation - HIGH risk) - Needs emergency contraception urgently ### Emergency Contraception Options | Method | Timing | Efficacy | Weight Considerations | Access | |--------|--------|----------|----------------------|--------| | Copper IUD | Up to 120 hours | >99% | Not affected | Prescription, clinic insertion | | Ulipristal (ella) | Up to 120 hours | Best oral EC | Effective at higher weights | Prescription | | Levonorgestrel (Plan B) | Up to 72 hours (some efficacy to 120h) | 85% at 72h | May be less effective >75 kg | OTC | ### Counseling Discussion **Given Her Weight (75 kg):** - Levonorgestrel may have reduced efficacy above 75 kg - **Copper IUD** is most effective option overall - **Ulipristal acetate** maintains efficacy better than levonorgestrel at higher weights **Patient Concerns:** - "I don't want an IUD right now" - "Can I just get a pill?" - "Is this the same as the abortion pill?" (Addressed: No, EC prevents pregnancy, does not terminate existing pregnancy) ### Patient Decision: Ulipristal Acetate (ella) **Prescription:** - Ulipristal acetate 30 mg PO x 1 dose, take now - Most effective oral EC, especially for mid-cycle exposure and at her weight **Key Counseling:** - Take the pill as soon as possible - May experience nausea, headache, fatigue, menstrual irregularity - Period may come early or late - If no period within 3 weeks, take a pregnancy test - **Important:** Wait at least 5 days before starting hormonal contraception (ulipristal blocks progesterone receptors) - Use condoms or abstain in the interim ### Ongoing Contraception Discussion "Let's talk about preventing this from happening again." **Options Discussed:** - Hormonal IUD (most effective, long-acting) - Copper IUD (non-hormonal option) - Subdermal implant (most effective reversible method) - Combined OCP, patch, or ring (would need backup for first 7 days) **Patient's Plan:** - Interested in the pill but wants to think about IUD - Started on combined OCP today (will wait 5 days after ulipristal before first pill) - Given condoms for interim protection - Return visit scheduled for IUD discussion ### Follow-up (3 weeks later) - Menstrual period arrived on time - Not pregnant - Started OCPs as planned - Decided to continue with OCPs for now, may consider IUD in future ### Teaching Points - Copper IUD is the most effective emergency contraception (>99% effective up to 5 days) - Ulipristal acetate is the most effective oral EC, especially for higher-weight patients - Levonorgestrel EC is available OTC but may have reduced efficacy >75 kg - All EC should be taken as soon as possible after unprotected intercourse - EC is a bridge - always discuss ongoing contraception - Ulipristal requires a 5-day delay before starting hormonal contraception ### Clinical Image ![Emergency Contraception](case_02_image.jpg) **Image Description:** Comparison of emergency contraception options showing the copper IUD (most effective), ulipristal acetate pill, and levonorgestrel pill with their respective efficacy rates and time windows for use. **Attribution:** Educational illustration. Public domain medical education resource. --- ## 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 ![US MEC Categories](case_03_image.jpg) **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.