Progestin-releasing intrauterine devices for women at increased risk for venous thromboembolism

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 19-year-old woman is seen for counseling regarding contraceptives. Medical history is unremarkable; she is nulliparous and has never taken prescription contraceptives. Her father had a pulmonary embolism at age 47 years, which was associated with arthroscopic knee surgery, and her 23-year-old sister experienced a deep venous thrombosis 3 weeks after delivering her first child. The patient does not smoke and takes no medications.

On physical examination, she appears well. Vital signs are normal; BMI is 31. The remainder of the examination is unremarkable.

She states that she does not want to use a copper intrauterine device (IUD).

Which of the following contraceptive methods would be most appropriate for this patient?

A. Estrogen-progestin vaginal ring
B. Low-dose combination estrogen-progestin pill
C. Progestin-releasing IUD
D. Transdermal estrogen-progestin patch

MKSAP Answer and Critique

The correct answer is C: Progestin-releasing IUD.

A progestin-releasing intrauterine device (IUD) would be most appropriate for this patient. Other choices include the progestin-only pill, depot injection, or implanted rod. She is at increased risk for venous thromboembolism (VTE) because of her family history of VTE in two first-degree relatives and her obesity. Progestin-releasing IUDs do not appear to increase VTE risk, so they are a good contraceptive choice for women who are at increased risk for VTE. It is uncertain if oral progestin-only contraceptives (mini-pill) lead to an increased risk of VTE; however, the risk appears to be more clearly increased if additional VTE risk factors are present (obesity, immobility, surgery). Injectable progestins do appear to increase the risk of VTE.

Oral contraceptive pills (OCPs) include combination estrogen-progestin products and progestin-only pills. Combinations with lower estrogen doses are as effective with fewer side effects. Combined products are also available as a patch and a vaginal ring. Contraindications to combination products include history or increased risk of thrombosis, liver disease, breast cancer, migraine with aura, and uncontrolled hypertension. Women older than 35 years who smoke more than 15 cigarettes per day should not be prescribed estrogen-containing preparations because of an increased risk of stroke. Because this patient is at increased risk for thrombosis, she should not use any method of contraception containing estrogen.

Key Point

Progestin-releasing intrauterine devices are the most appropriate contraceptive option for women at increased risk for venous thromboembolism (VTE) because they are not associated with increasing the VTE risk further, whereas progestin-only pills, implants, and injections may slightly increase the risk for thrombosis.

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