What are the birth control options for a 35-year-old female (F) with a bicornuate uterus who smokes and desires future pregnancy?

From the Guidelines

For a 35-year-old female with a bicornuate uterus who smokes and desires future fertility, I strongly recommend using progestin-only contraceptive methods to minimize health risks and preserve fertility options. When considering the patient's smoking status and age, combined hormonal contraceptives are not recommended due to the increased risk of cardiovascular events and blood clots, as indicated by the U.S. medical eligibility criteria for contraceptive use 1. The patient's bicornuate uterus does not necessarily preclude the use of intrauterine devices (IUDs), but placement may require more expertise and ultrasound guidance to ensure proper positioning. Some of the best options for this patient include:

• The progestin-only pill (such as norethindrone 0.35 mg daily, taken at the same time each day)
• The etonogestrel implant (Nexplanon, effective for up to 3 years)
• The levonorgestrel intrauterine device (Mirena or Liletta, effective for up to 7 years, or Kyleena, effective for up to 5 years) These methods are all rapidly reversible upon discontinuation, allowing for a quick return to fertility when she decides to conceive. It is essential to note that if she chooses an IUD, there is a slightly higher risk of expulsion or malposition with a bicornuate uterus, although this is rare. Barrier methods like condoms or diaphragms with spermicide are also options but have higher typical-use failure rates. Given the patient's specific situation, progestin-only methods are the most suitable choice, as they avoid estrogen and minimize health risks while preserving fertility options.

From the FDA Drug Label

WARNINGS Cigarette smoking greatly increases the possibility of suffering heart attacks and strokes. Women who use oral contraceptives are strongly advised not to smoke. The relationship between progestin-only oral contraceptives and these risks have not been established and there are no studies definitely linking progestin-only pill (POP) use to an increased risk of heart attack or stroke. Up to 10% of pregnancies reported in clinical studies of progestin-only oral contraceptive users are extrauterine Although symptoms of ectopic pregnancy should be watched for, a history of ectopic pregnancy need not be considered a contraindication to use of this contraceptive method.

For a 35-year-old female with a bicornate uterus who smokes and wants to have a child in the future, progestin-only oral contraceptives (POPs) like norethindrone may be considered as a birth control option. However, it is crucial to note that:

• Smoking greatly increases the risk of heart attacks and strokes, and women using oral contraceptives are strongly advised not to smoke.
• The risk of ectopic pregnancy is higher with POPs, and up to 10% of pregnancies reported in clinical studies are extrauterine.
• A bicornate uterus may increase the risk of ectopic pregnancy, but it is not a contraindication to using POPs.
• Future fertility is not directly addressed in the label, but there is no indication that POPs would affect future fertility. It is essential to weigh these factors and consider alternative birth control options, especially given the patient's smoking status and desire for future fertility 2.

From the Research

Birth Control Options for a 35-year-old Female with a Bicornate Uterus

• A 35-year-old female with a bicornate uterus who smokes and wishes to have a child in the future has several birth control options to consider, but it's essential to weigh the risks and benefits of each option due to her uterine anomaly and smoking habit.
• The use of intrauterine devices (IUDs) may be complicated by the presence of a bicornate uterus, as it can increase the risk of complications during insertion, use, or removal 3.
• Other birth control options, such as hormonal contraceptives, may be more suitable, but it's crucial to consider the potential risks and benefits, particularly in relation to her smoking habit and desire for future pregnancy.

Risks Associated with Bicornate Uterus

• A bicornate uterus is a rare congenital uterine malformation that can increase the risk of complications during pregnancy, including cervical os insufficiency 4, preterm delivery, and fetal malpresentations.
• Women with a bicornate uterus are also at a higher risk of experiencing pregnancy-induced hypertension, preeclampsia, and placenta previa 5.
• The risk of preterm pre-labor rupture of membranes (PPROM), placental abruption, and postpartum hemorrhage (PPH) is also increased in women with a bicornate uterus 5.

Considerations for Future Pregnancy

• Despite the increased risks associated with a bicornate uterus, it is possible for women with this condition to have a successful pregnancy and delivery 6.
• However, it's essential to carefully monitor the pregnancy and be aware of the potential complications that may arise.
• Women with a bicornate uterus who wish to become pregnant should discuss their individual risks and options with their healthcare provider to determine the best course of action.

Smoking Cessation

• Smoking is a significant risk factor for many health problems, including those related to pregnancy and childbirth.
• Women who smoke and wish to become pregnant should consider quitting smoking to reduce their risk of complications and improve their overall health 7.