A 41-year-old woman, gravida 1 para 1, comes to the office to discuss possible contraceptive options. She was recently diagnosed with hypertension and prescribed an ACE inhibitor. The patient was counseled about the risk of ACE inhibitors in pregnancy and the need for reliable contraception. She has not used contraception for the past year because she was breastfeeding until a month ago. Her husband does not think he wants more children, but the patient is unsure about future pregnancy. She has no other chronic medical conditions and takes no other daily medications. Menses are monthly, with 4 days of light bleeding and mild cramping on the first day. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 122/78 mm Hg and pulse is 70/min. BMI is 19 kg/m2. On pelvic examination, the cervix is parous and has no visible lesions. The uterus is mobile and nontender. Which of the following is the most appropriate contraceptive option for this patient?
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Contraceptive counseling should be patient-centered and take into consideration patient-specific factors (eg, medical history), the risk/benefit profiles of various contraception methods, and the patient's future fertility desires. In this patient with medication-controlled hypertension, the best option is the copper-containing intrauterine device (IUD) for several reasons, including the following:
No effect on hypertension: This is in contrast to estrogen-containing contraceptives, which can elevate blood pressure and increase the risk for stroke or acute myocardial infarction.
High efficacy (>99%) for pregnancy prevention: The effectiveness of the copper-containing IUD is due to high patient compliance (ie, ease and duration of use, with reinsertion every 10 years) and its multiple mechanisms of action (ie, impaired sperm function, fertilization, and implantation). Contraceptive efficacy is particularly important for patients taking teratogenic medications (eg, ACE inhibitors).
No effect on future fertility: The copper-containing IUD can be removed at any time the patient desires pregnancy, with immediate return of fertility.
Although the copper-containing IUD does not help (and may worsen) menstrual bleeding, patients, such as this one, with light bleeding and mild cramping are ideal candidates because they typically experience minimal adverse effects.
(Choices A and E) Bilateral tubal ligation and vasectomy are surgical procedures that induce permanent sterility and should not be undertaken by those considering future fertility. Although reversal of tubal ligation and vasectomy is possible, it involves an additional surgery and is not always successful; success rates are between 50% and 70% and decline with increased time between procedures.
(Choices B and D) Combined estrogen/progestin oral contraceptive pills and the estrogen/progestin vaginal ring can worsen preexisting hypertension due to estrogen-induced angiotensinogen synthesis. Therefore, estrogen-containing contraceptives are an absolute contraindication in patients with severe hypertension and a relative contraindication in patients with mild or medication-controlled hypertension, such as this patient.
Educational objective:
Long-acting, reversible contraceptives (eg, copper-containing intrauterine devices) are highly effective for pregnancy prevention and can be used in patients with contraindications to estrogen-containing contraceptives (eg, hypertension).