What is the best treatment approach for a 28-year-old female patient with moderate anxiety and increased menstrual flow, who is currently using Nexplanon (etonogrel), has borderline dyslipidemia, and is interested in starting medication to manage symptoms?

Treatment Approach for Moderate Anxiety and Heavy Menstrual Bleeding in a 28-Year-Old on Nexplanon

Start sertraline 50 mg daily for the moderate anxiety (GAD-7 score of 12), continue Nexplanon for now while monitoring menstrual bleeding patterns over the next 2-3 cycles, and initiate lifestyle modifications for the borderline dyslipidemia rather than statin therapy given her age and low cardiovascular risk. 1

Anxiety Management

For this patient's moderate anxiety symptoms, pharmacotherapy with an SSRI is the appropriate first-line treatment given her explicit request for medication and work-related functional impairment. 2

• Sertraline should be initiated at 50 mg once daily, taken either morning or evening consistently 1
• The dose can be titrated up to 200 mg/day if inadequate response after 4-6 weeks, with dose changes occurring no more frequently than weekly intervals 1
• SSRIs (selective serotonin reuptake inhibitors) are first-line pharmacotherapy for generalized anxiety disorder, with established efficacy in randomized controlled trials 2, 3
• While cognitive behavioral therapy has the highest level of evidence for anxiety disorders, this patient has already accepted counseling and is specifically requesting medication to manage symptoms that are interfering with her work performance 4, 2

Continue sertraline for 6-12 months after achieving remission of anxiety symptoms to prevent relapse. 2

Nexplanon and Menstrual Bleeding Management

Do not remove the Nexplanon implant immediately; instead, monitor bleeding patterns for 2-3 additional cycles while treating the anxiety. 4

• The patient reports her anxiety began after Nexplanon insertion, but this temporal association does not establish causation—her work stress as a kindergarten teacher is a more plausible trigger 4
• Heavy menstrual bleeding (using 4 extra-large pads/tampons daily for 5 days) is a common side effect of etonogestrel implants, particularly in the first 3-6 months after insertion 4
• Her previous Nexplanon at age 21 worked well, suggesting she may tolerate this method once the implant stabilizes 4
• Progesterone-only contraceptives like etonogestrel are appropriate contraceptive methods and avoid estrogen-related risks 4

If bleeding remains unacceptable after 3 months or the patient develops anemia, consider switching to a levonorgestrel intrauterine device or combined hormonal contraception (if no contraindications). 4

Dyslipidemia Management

For borderline dyslipidemia (LDL 103 mg/dL) in a 28-year-old woman with no other cardiovascular risk factors, lifestyle modification is the sole indicated treatment—do not start statin therapy. 4, 5

• Initiate a Mediterranean-style diet emphasizing vegetables, fruits, whole grains, legumes, nuts, and olive oil as the primary fat source 5
• Recommend at least 150 minutes per week of moderate-intensity aerobic exercise 5
• This patient does not meet criteria for pharmacologic lipid-lowering therapy: she is young, has no diabetes, no clinical atherosclerotic disease, and her 10-year cardiovascular risk is extremely low 4, 5
• Recheck lipid panel in 3-6 months after lifestyle modifications 5

Important Drug Interaction Consideration

Sertraline may have a modest effect on lipid profiles, but this should not preclude its use in this patient given her borderline dyslipidemia and the primacy of treating her symptomatic anxiety disorder. 6

• Sertraline has been associated with slight increases in total and LDL cholesterol in some studies, though the clinical significance is unclear 6
• If lipids worsen significantly on sertraline, consider switching to citalopram, which has a neutral or slightly positive effect on HDL cholesterol 6
• However, the anxiety treatment takes priority over the borderline lipid elevation, as untreated anxiety significantly impairs quality of life and work function 2

Monitoring Plan

Reassess anxiety symptoms in 4-6 weeks using the GAD-7 score, monitor for SSRI side effects, and track menstrual bleeding patterns. 1

• Schedule follow-up at 4-6 weeks to assess treatment response and tolerability 1
• No routine laboratory monitoring is required for sertraline in healthy young adults 1
• Document menstrual bleeding patterns (number of pads/tampons, duration, associated symptoms) at each visit 4
• Recheck lipid panel in 3-6 months after lifestyle modifications are implemented 5

Common Pitfalls to Avoid

Do not prematurely remove the Nexplanon based solely on the patient's perception that it caused her anxiety—work-related stress is the more likely primary trigger. 4

• Removing effective contraception without a clear indication may lead to unintended pregnancy, which carries far greater health risks than continuing the implant 4
• The temporal association between Nexplanon insertion and anxiety onset may be coincidental, especially given the identified work stressors 4

Do not start statin therapy in this young, low-risk patient with borderline LDL elevation—this represents overtreatment and exposes her to unnecessary medication risks. 4, 5

Do not use benzodiazepines for routine treatment of generalized anxiety disorder, as they are not recommended for first-line use and carry risks of dependence. 2, 3