Question of the Week #117

117) A 35-year-old woman with history of smoking 1 ppd x 15 yrs, comes to you 4 months after beginning OC pills. Shortly after starting OCs, she started experiencing headaches twice a week lasting  12 hours. The headaches are bilateral, throbbing, and accompanied by nausea and sensitivity to light and sound. They are heralded by a 50-minute visual disturbance consisting of a “bright, zigzag lines” and then fades away as the headache begins. Upon questioning, she reports occasional similar headaches prior to OC use but they were not this bad and never had visual disturbances earlier. Her physical examination is normal. She is sexually active with one partner and desires effective contraception. Her partner does not like using condoms. The next step in management?
A. Reduce the dose of estrogen in the combination pill
B. Switch to mini pill
C. Ask her to convince her partner to use condoms
D. Reassure her and continue OC Pills
E. Stop OC pills and restart after one month.

7 Responses

  1. B: this is a progesterone only pill, no risk for DVT, no risk of decreasing breast milk and safe for pts with falcemia (sickle cell dz).

    becomes an easy Q. if u know what is the mini pill.

  2. B

  3. in aura patient stop ocp altogether ,increases risk of ischemic stroke, switch to non estrogen modes like IUD/CONDOM/PROGESTIN PILL,here condoms cant be used so switch to minipill

  4. bbbbbbbbbbbbbbbbbbbbbbb

  5. b

  6. She’s a 35 year old female who smokes cigarettes. Beyond the age of 35, smokers have to quit smoking to use combined contraceptive pills because the risk of thromboembolic phenomenon increases exponentially after this age. (WHO/ACOG/IHS recommendation)
    Our patient may not successfully quit smoking so quickly, so we have to stop giving her combined oral contraceptive pills.
    Progesterone only pill is safer and more acceptable alternative option says World Health Organization.
    We have to switch to mini pills. Answer B
    Option A, D, & E increase risk of thromboembolism and myocardial infarction.
    Option C barrier countraception is the least effective form of contraceptive technique and it increases the risk of accidental conception.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938905/#!po=36.9565
    http://www.ncbi.nlm.nih.gov/m/pubmed/20136566/
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756661/
    http://www.aafp.org/afp/1999/1101/p2073.html
    http://www.neurology.org/content/66/3/349.abstract

    • Migraine with aura (like in this patient) and oral contraceptive pills are independent risk factors for stroke in retrospective studies but recall bias makes the interpretation of these studies less reliable compared to studies done prospectively on the effect of smoking after age 35.
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481021/

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