What is the recommended contraception and emergency contraception for a 40-year-old patient with diabetes (Diabetes Mellitus) and hypercholesterolemia (High Cholesterol) who is interested in using a progestin-only pill (POP) and Plan B (levonorgestrel)?

Progestin-Only Pills and Plan B Are Appropriate for This Patient

A 40-year-old patient with diabetes and hypercholesterolemia can safely use progestin-only pills (POPs) for ongoing contraception and levonorgestrel (Plan B) for emergency contraception, as these methods avoid estrogen-related cardiovascular and metabolic risks. 1

Why Progestin-Only Methods Are Preferred

Avoiding Combined Hormonal Contraceptives

• Combined hormonal contraceptives (CHCs) containing estrogen are generally not recommended for patients with hyperlipidemia, particularly when other cardiovascular risk factors are present (U.S. MEC 2/3 depending on severity) 1
• Screening for hyperlipidemia before initiating hormonal contraceptives is not required, but since this patient has known hypercholesterolemia, avoiding estrogen-containing methods is prudent 1
• Women with diabetes can experience adverse effects on glucose metabolism with hormonal contraceptives, though the clinical effect with progestin-only methods is minimal 1

Safety of Progestin-Only Pills

• POPs receive a Category 1 classification (no restriction) for patients with diabetes and hyperlipidemia in the U.S. Medical Eligibility Criteria 1
• Progestin-only methods have significantly fewer adverse metabolic effects compared to combined oral contraceptives, with minimal impact on lipid profiles and insulin sensitivity 2, 3
• Research demonstrates that progestin-only formulations have only minor metabolic effects, making them preferable for women with metabolic risk factors 2, 3

Initiating Progestin-Only Pills

Timing and Backup Contraception

• Norethindrone or norgestrel POPs can be started anytime; if started >5 days after menses began, use backup contraception (condoms) for 2 days 1
• Drospirenone POP can be started anytime; if started >1 day after menses began, use backup contraception for 7 days 1
• No examination or laboratory tests are required before initiating POPs 1

Important Counseling Points

• POPs must be taken at the same time every day for maximum effectiveness—even a few hours late can reduce efficacy 4
• Typical failure rate is approximately 5% due to late or missed pills, compared to 0.5% with perfect use 4
• Irregular bleeding is the most common side effect, occurring in up to 25% of users and is the primary reason for discontinuation 5
• Counsel that bleeding patterns may include increased frequency, breakthrough bleeding, spotting, or prolonged bleeding 5
• Consider combining POPs with barrier methods given the higher typical-use failure rate, especially important at age 40 when pregnancy carries increased risks 1

Emergency Contraception with Plan B

Levonorgestrel Emergency Contraception

• Levonorgestrel 1.5 mg (Plan B) can be taken as a single dose within 72 hours of unprotected intercourse, with effectiveness decreasing over time 1, 6, 7
• The sooner it is taken, the better it works—about 7 out of 8 women who would have gotten pregnant will not become pregnant 6
• Levonorgestrel emergency contraception is safe for patients with diabetes and hypercholesterolemia, as the short duration of use poses minimal risk 1

Alternative Emergency Contraception

• If BMI >30 kg/m², levonorgestrel may be less effective; consider ulipristal acetate (UPA) or copper IUD instead 1
• Copper IUD is the most effective emergency contraception (<1% failure rate) and can be inserted within 5 days of unprotected intercourse 1

Critical Monitoring and Follow-Up

Expected Menstrual Changes

• Next period should come at the expected time or within 1 week of expected time after using Plan B 6
• If period is delayed >1 week, obtain pregnancy test 6
• Severe abdominal pain after emergency contraception may indicate ectopic pregnancy and requires immediate medical attention 6

Drug Interactions to Monitor

• Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, topiramate, oxcarbazepine) and rifampin significantly reduce POP effectiveness (U.S. MEC 3) 1
• If taking these medications, consider alternative contraception such as copper IUD or LNG-IUD 1
• These same medications also reduce levonorgestrel emergency contraception effectiveness; UPA or copper IUD should be considered instead 6

Common Pitfalls to Avoid

• Do not delay POP initiation waiting for laboratory tests—none are required 1
• Do not assume regular bleeding patterns—counsel extensively about expected irregular bleeding to prevent discontinuation 5
• Do not rely on POPs alone if patient has difficulty with medication adherence—consider long-acting reversible contraception (LARC) like LNG-IUD as an alternative 1
• Do not use combined hormonal contraceptives in this patient given the presence of both diabetes and hypercholesterolemia 1