What are the appropriate considerations for contraceptive management and gynecologic care in a 22-year-old nulligravid woman with a family history of ovarian cancer?

From the Guidelines

For this 22-year-old nulligravid woman seeking contraception, I recommend considering a combined hormonal contraceptive (CHC) method such as oral contraceptive pills, the vaginal ring, or the transdermal patch, as these methods are not only effective for contraception but also have a protective effect against ovarian cancer, as noted in the study by 1.

Key Considerations

• The patient's family history of ovarian cancer at a young age increases her risk, and the use of oral contraceptives has been shown to decrease this risk, as supported by 1.
• Given her regular menstrual cycles and no contraindications, CHC methods or long-acting reversible contraception (LARC) methods like an intrauterine device (hormonal or copper) or the etonogestrel implant could provide reliable protection while preserving future fertility.
• Completing the HPV vaccination series is also recommended, as it protects against HPV types that cause cervical cancer and genital warts.
• Genetic counseling should be discussed to assess her risk for hereditary cancer syndromes like BRCA mutations, which might influence both cancer screening and contraceptive choices in the future, as suggested by 1 and 1.

Contraceptive Options

• Combined hormonal contraceptives offer the dual benefit of effective contraception and reduced risk of ovarian cancer.
• LARC methods provide long-term protection with minimal user dependence and are highly effective.

Additional Recommendations

• Genetic counseling for hereditary cancer syndromes.
• Completion of the HPV vaccination series.

Evidence Support

The recommendation for using oral contraceptives for their protective effect against ovarian cancer is supported by the most recent and highest quality study available, 1, which highlights the importance of this method in reducing ovarian cancer risk. Additionally, the importance of genetic counseling and HPV vaccination is underscored by studies such as 1 and 1, emphasizing a comprehensive approach to her health and risk management.

From the FDA Drug Label

PRECAUTIONS 2. Physical examination and follow up It is good medical practice for all women to have annual history and physical examinations, including women using oral contraceptives The physical examination, however, may be deferred until after initiation of oral contraceptives if requested by the woman and judged appropriate by the clinician.

The patient can start using oral contraceptives without a physical examination, but it is recommended that she have an annual history and physical examination. The decision to defer the physical examination until after initiation of oral contraceptives should be made on a case-by-case basis, considering the patient's individual needs and the clinician's judgment.

• Key considerations:
  • Annual history and physical examinations are recommended for all women, including those using oral contraceptives.
  • The physical examination may be deferred until after initiation of oral contraceptives if requested by the woman and judged appropriate by the clinician.
  • The decision to defer the physical examination should be made on a case-by-case basis, considering the patient's individual needs and the clinician's judgment 2.

From the Research

Contraception Options

The patient is a 22-year-old nulligravid woman who has become sexually active and is seeking contraception options. She is currently using condoms, but may be interested in exploring other methods.

• The patient's medical history and current health status are important factors to consider when discussing contraception options.
• According to 3, emergency contraception is a critical component of medical care for sexual assault survivors and can reduce the risk of pregnancy by 60 to 94% when used within 120 hours after unprotected sexual intercourse.

Combined Oral Contraceptives

Combined oral contraceptives (COCs) are a popular and effective method of contraception.

• A study published in 4 found that a 21/7-active COC regimen was efficacious and well tolerated for pregnancy prevention, with a Pearl Index of 2.68.
• Another study published in 5 reviewed the literature on a low-dose, extended-cycle COC with continuous ethinyl estradiol and found that it had a similar efficacy and adverse effect profile compared to other extended-regimen OCs.

Counseling and Education

Counseling and education are essential components of contraception care.

• According to 6, modern contraceptives are very effective when used correctly, and effective counseling regarding contraceptive options and provision of resources to increase access are key components of adolescent health care.
• The American College of Obstetricians and Gynecologists recommends that discussions about contraception begin with information on the most effective methods first, and that emergency contraception should be included in discussions about contraception.

Hormonal Contraceptives

Hormonal contraceptives, such as COCs, contain estrogens and progestins that can have various effects on the body.

• A study published in 7 reviewed the pharmacokinetics, pharmacodynamics, and risk assessment of ethinyl estradiol and 17β-estradiol in combined oral contraceptives, and found that new progestin formulations combined with lower doses of ethinyl estradiol have reduced the incidence of venous thromboembolism and other negative outcomes of COC treatment.