What is the best course of action for a patient with a history of trauma, currently on estrogen and progesterone (progestin) birth control, experiencing headaches and hypertension, who refuses Depo (medroxyprogesterone) and Nexplanon (etonogestrel) due to past adverse effects, and presents with constipation and a protruding hernia repair site?

From the Guidelines

I strongly recommend switching the patient to a progesterone-only pill, such as norethindrone 0.35mg daily, due to her history of headaches and cardiovascular risk from hypertension, which can be exacerbated by estrogen-containing contraceptives. This change is supported by the most recent guidelines, including the U.S. Selected Practice Recommendations for Contraceptive Use, 2024 1. According to these guidelines, progesterone-only pills like norethindrone can be started at any time, with the recommendation to abstain from sexual intercourse or use barrier methods for 2 days if started more than 5 days after menses began.

Given the patient's history of undesirable effects with Depo-Provera and Nexplanon, the progesterone-only pill is a suitable alternative. It's essential to educate the patient on the importance of taking the pill at the same time every day without breaks to ensure its effectiveness.

Regarding her hernia concerns and constipation, I recommend the following:

• Increase fiber intake to 25-30g daily
• Drink at least 8 glasses of water daily
• Take a stool softener like docusate sodium 100mg twice daily to manage constipation The patient should monitor the hernia protrusion and schedule a surgical consultation if it becomes painful, larger, or irreducible. While her recent bowel movement is reassuring, continued constipation management is crucial to prevent strain that could worsen the hernia. Coordination with her previous provider, Dr. McKay, is also necessary to ensure continuity of care during this insurance transition to Texas Healthy Women.

From the FDA Drug Label

WARNINGS AND PRECAUTIONS • High blood pressure: Do not prescribe drospirenone and ethinyl estradiol tablets for women with uncontrolled hypertension or hypertension with vascular disease. (5.6) • Headache: Evaluate significant change in headaches and discontinue drospirenone and ethinyl estradiol tablets if indicated. (5.9)

The patient is currently experiencing headaches and has hypertension, which are concerns when considering the use of drospirenone and ethinyl estradiol tablets. Given these conditions, it is reasonable to consider alternative contraceptive methods, such as progestin-only methods, as you have offered. Since the patient refused depo and Nexplanon due to past undesirable effects, other progestin-only options may be considered. However, the FDA label does not provide direct guidance on the best alternative for this patient. 2

From the Research

Patient's Current Situation

• The patient has experienced trauma in her life due to the loss of her brother and son.
• She has changed insurance to Texas Healthy Women and is establishing care with a new provider.
• The patient is currently taking estrogen and progesterone birth control, but is experiencing headaches and cardiovascular risk related to hypertension.
• Education has been given on prescribing progestone only birth control method due to these risks.

Birth Control Options

• The patient was offered Depo or Nexplanon, but refused due to undesirable effects in the past 3.
• Progestin-only pills (POP) are a viable option, with studies showing high contraceptive effectiveness and a low risk of cardiovascular side effects 4, 5.
• A new progestin-only pill containing 4mg of drospirenone has been authorized in the USA and EU, with clinical trials demonstrating high effectiveness and a favorable menstrual bleeding pattern 4.

Progestin-Only Contraception

• Progestin-only contraception is a popular method of birth control, with options including implants and injections 3.
• These methods have few contraindications and are effective in preventing pregnancy, with a low risk of serious side effects 3, 6.
• Progestin-only pills have been shown to have a median Pearl Index rate of 1.63, indicating a low failure rate during typical use 7.

Patient's Medical History

• The patient has undergone hernia surgery in February and is experiencing constipation and a protrusion in the hernia area, but denies having any pain.
• Her last bowel movement was this morning.
• The patient's medical history and current symptoms should be taken into consideration when selecting a birth control method 6.