What prescription options are available for a patient with a history of Premenstrual Dysphoric Disorder (PMDD), lactose intolerance, and severe reactions, who cannot take Combined Oral Contraceptive Pills (COCPs) due to migraines with aura, is not keen on Selective Serotonin Reuptake Inhibitors (SSRIs), and for whom most Progestin-Only Pills (POPs) are contraindicated?

Contraceptive Options for Patient with PMDD, Migraines with Aura, and SSRI Intolerance

A progestin-only intrauterine device (levonorgestrel IUD) is the most appropriate contraceptive option for this patient with PMDD, migraines with aura, and SSRI intolerance.

Patient-Specific Considerations

This patient presents with several important factors that limit contraceptive options:

• History of premenstrual dysphoric disorder (PMDD)
• Lactose intolerance with severe reactions
• Migraines with aura (contraindication for estrogen-containing contraceptives)
• Not keen on SSRIs (first-line treatment for PMDD)
• Not keen on depot medroxyprogesterone acetate (DMPA) injection

Contraceptive Options Analysis

Combined Hormonal Contraceptives

• CONTRAINDICATED due to history of migraines with aura
• Migraines with aura significantly increase thrombosis risk when combined with estrogen 1

Progestin-Only Options

1. Levonorgestrel IUD (Recommended First Choice)

   • Highly effective (>99%) contraception
   • Low systemic hormone exposure
   • May help with PMDD symptoms through partial suppression of ovulation
   • No estrogen-related risks
   • Safe for patients with migraines with aura 1

2. Progestin-Only Pills (POP) (Alternative Option)

   • Effective but requires strict adherence to timing
   • Must be taken at the same time daily
   • Lower efficacy than IUDs (91-99%)
   • Norethindrone is available as a POP 2
   • Requires backup method if taken >3 hours late 2

3. Progestin Implant (Possible Alternative)

   • Highly effective (>99%)
   • Limited data on thrombosis risk 1
   • May be considered if IUD and POP not suitable

4. DMPA Injection (Not Recommended)

   • Patient already expressed disinterest
   • Some evidence suggests higher thrombosis risk compared to other progestin-only methods 1

Non-Hormonal Options

1. Copper IUD (Alternative Option)
   • Highly effective (>99%)
   • No hormonal side effects
   • May increase menstrual bleeding and cramping 1
   • Could potentially worsen PMDD symptoms in some patients

PMDD Management Without SSRIs

Since the patient is not keen on SSRIs (which are first-line treatment for PMDD), consider:

1. Cognitive Behavioral Therapy (CBT)

   • Effective for PMDD symptoms 1
   • Can be used alongside contraceptive methods

2. Alternative Pharmacological Options for PMDD

   • Calcium supplementation 3
   • Chasteberry (Vitex agnus-castus) 3
   • Consider lamotrigine as an adjunctive treatment if symptoms remain severe 4
   • In rare cases with family history of bipolar disorder, lithium might be considered 5

Recommendation Algorithm

1. First-line recommendation: Levonorgestrel IUD

   • Provides highly effective contraception
   • Minimal systemic hormone exposure
   • May help with PMDD symptoms
   • Safe with migraines with aura

2. If IUD is declined or contraindicated:

   • Offer progestin-only pill (norethindrone)
   • Emphasize importance of taking at same time daily
   • Discuss backup methods if pill is taken late

3. If hormonal methods are declined:

   • Consider copper IUD with additional non-hormonal PMDD management
   • Discuss barrier methods with lower efficacy rates

Important Counseling Points

• Explain that taking progestin-only pills at exactly the same time every day is crucial for effectiveness 2
• Discuss that backup contraception is needed for 48 hours if a POP is taken 3+ hours late 2
• Warn about potential menstrual irregularities with progestin-only methods
• Emphasize that non-hormonal PMDD treatments may need to be combined with contraceptive methods for symptom management

Follow-up Recommendations

• Review effectiveness and side effects after 3 months
• Monitor for changes in PMDD symptoms
• Assess need for additional PMDD management strategies
• Consider referral to specialist if symptoms remain poorly controlled