SS is a 37 year old female presenting to her OB-GYN for initiation of a contraceptive agent. Her PMH includes migraines with aura. She currently takes propranolol 40mg daily for migraine prophylaxis and sumatriptan 100mg PRN for migraines. She is open to any route of administration for contraception. Select possible treatment options for SS. (Select all that apply)

A. Xulane patch

B. Depo-Provera injection

C. Kyleena IUD

D. Norethindrone oral pill

E. Nuvaring

 Answers: B,C,D

Rationale:

Because SS has a history of migraines with aura, she is not a candidate for any contraceptives with estrogens due to increased risk of stroke. Per the U.S. Medical Eligibility Criteria for Contraceptive Use, the use of combined hormonal contraception (containing estrogen and progestin) is an unacceptable health risk for women of any age experiencing migraine with aura. The package insert of estrogen products also states migraine with aura is a drug-disease contraindication. Other contraindications for estrogen containing medications include history of DVT, stroke, coronary artery disease, history of breast, ovarian or liver cancer, and uncontrolled bleeding.

 Answer A is incorrect because the Xulane patch, along with the only other FDA approved hormonal contraceptive patch Twirla, contain ethinyl estradiol. One patch is placed every week for three weeks or 21 days. Week four is a patch free week. 

 Answer B is correct because Depo-Provera, also known as medroxyprogesterone, contains only a progestin. Depo-Provera can be given subcutaneously (104mg) or intramuscularly (150mg) every 3 months. Clinical pearl: This is not a great treatment option for patients wanting to avoid further weight gain. 

 Answer C is correct because Kyleena, one of many intrauterine devices (IUD) available on the market, contains only a progestin known as levonorgestrel. The CDC ranks IUDs, along with the Nexplanon implant, and sterilization as the most effective birth control options with less than 1 pregnancy per 100 women in a year.

 Answer D is correct because norethindrone containing pills are known as progestin only pills or POPs which contain no estrogen component. It is important to counsel patients to take this pill within 3 hours of the scheduled dose. If the dose is taken outside of this time frame, the patient must use back up protection for 48 hours. This differs from estrogen containing pills which have a bit more flexibility with missed or late doses. With estrogen containing oral contraceptives, two doses may be missed before back up protection is required for 7 days along with catch up dosing. 

Answer E is incorrect because Nuvaring contains ethinyl estradiol. Nuvaring is a combined hormonal contraceptive that is inserted vaginally for three weeks followed by a one week break where menstruation occurs. A new ring is inserted one week after the last one was removed. If the Nuvaring is accidentally expelled, contraceptive efficacy is not reduced if it has been less than 3 hours. If more than three hours have passed, contraceptive efficacy may be reduced, and backup is warranted for 7 days. Refer to the package insert for more guidance on what to do if the Nuvaring is left out for more than three hours depending on what week of therapy the patient is on. 

Congrats to many of you as you close out your APPEs and will graduate very soon. Now is the time to celebrate but work hard toward passing the exam!

Dr. B