What method is best for my 48 year-old patient who is sexually active and has not had a period in over 2 years? #422/13

Just attended the meeting in Washington DC  and loved it!

I saw a 48 year-old woman today who for over 2 years did not have a period. She had been on Depo some time prior to that.  In February she had a  very heavy period, and now in April, she had some spotting. She is sexually active and is not using birth control. Her past medical history is: diabetes mellitus (DM), HTN (hypertension and obesity. I am getting a TV ultrasound to rule out pathology. She needs contraception, but doesn’t want a intrauterine contraceptive (IUC).

What would be my best option? Also getting FSH (as suggested by the GYN that I work with). Suggestions please!

 

Liz Dietrich

Peachhealth



Thanks for the nice words about our Contraceptive Technology Conference in Washington last week, Liz.

 

You may remember Dr. Michael Policar’s comment that a woman age 50 had a risk of becoming pregnant from unprotected sex of about 1 in 250,000.  It is slightly higher, but still very low at age 48. 

 

She has several options: condoms used perfectly every single time would certainly be adequate. 

 

Mirena could do double duty, lowering her bleeding and her risk of endometrial hyperplasia as well as providing a contraceptive effect for 5 to 7 years.

 

Progestin-only pills for several years are another option (as are combined pills if she has no reason to avoid an estrogenic contraceptive).

 

Dr. Michael Policar, would you like to add to my answer?   Please send your answer to Liz and me both.  Have a nice day, both of you.

 

On April 29 Dr. Policar wrote: Hi Liz and Bob

 

  1. I believe that the major priority for this patient is evaluating what sounds like post-menopausal bleeding. I agree with the FSH to determine if she is indeed menopausal. I would have done an EMB(endometrial biopsy), but if she is menopausal based on FSH level (>30 mIU/mL) and her stripe is <5mm, her work-up is done. Obviously, if this is the case, there is no need for any contraception.
  2. If she is not menopausal, I’m with Bob that her best choice is a barrier.
    If unwilling, then POPs would be a reasonable choice. Given her long history of what sounds like anovulation + her age, her pregnancy risk is probably
    even lower than 4/million.
  3. I’m not enthusiastic about any combined hormonal method because she is 48+obese+HTN (hypertension)+DM (diabetes mellitus)…excessive risk for both arterial and venous complications. 

Hope that helps.

 

From Liz Dietrich on 4-29: “You guys are amazing!  It is so nice to have you experts at my fingertips.  Thank you very much for your advice.  I am waiting for ultrasound results.” 

 

From Liz Dietrich on 4-30: “Her ultrasound came back showing a small fibroid (15mm) endometrial stripe 8mm, and her FSH is 47.  I think I should do an EMB, but don’t think she needs birth control.  Do you agree?”

 

To learn more about the advantages and disadvantages of progestin-only pills, combined birth control pills, condoms and the Mirena IUD, go to:

www.managingcontraception.com and click on Choices.  You can also order this wonderful new educational book from our website or by calling 404-875-5001.  Do you have your copy yet?


Michael Policar, MD, MPH

Clinical Professor of Obstetrics, Gynecology and Reproductive Sciences

UCSF School of Medicine

Attending Gynecologist, San Francisco General Hospital

Medical Director, UCSF Family PACT Evaluation

Bixby Center for Global Reproductive Health, UCSF

 

 

Key words:  Contraceptive Technology Conference, Depo-Provera, period, heavy periods, spotting, sexually active, ultrasound, contraception, FSH, obese, condoms, Mirena IUD, bleeding, risk, endometrial hyperplasia, progestin-only pills, combined pills, estrogenic contraceptive, Dr. Michael Policar, post-menopausal bleeding, pregnancy risk, arterial, venous complications

 

Posted 5-27-2013, Updated 6-10-2013, Updated 11-4-2013

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November 5, 2013