A 30-year-old woman attends the SH clinic requesting ‘the pill’. She has recently started a new relationship. In the past she has relied on condoms for contraception but she would like to use something different. You take her clinical history and some baseline measurements. Her BMI is 38 kg/m2 and her BP is 145/89 mmHg. On noting this she tells you that her father has HBP and had an MI 2 years ago at the age of 52. She is a non-smoker and is not taking any medication.
-
1. Would you recommend a CHC method for this woman? Explain your reasoning.
Show Answer
Correct answer: I would not recommend a CHC method for this woman. Use of a CHC method with a BMI of >=35kg/m2 is awarded a UKMEC 3, and multiple risks for cardiovascular disease are awarded a UKMEC 3 or 4. While a single elevated BP measurement does not indicate HBP, in addition to her obesity she has a strong family history of CVS disease. Obesity alone increases the risk of VTE and cardiovascular disease. Studies in COC users have demonstrated a two to five fold increase in VTE risk in women with a BMI >30 kg/m2. There is consensus that the COC is absolutely contraindicated in women with a BMI >39 kg/m2
-
2. On further discussion she says she might consider ‘the pill without oestrogen’ or the contraceptive implant but her friend read that it might not work in heavier women. What advice do you give her?
Show Answer
Correct answer: The POP, DMPA and progestogen-only implant can be used without restriction in obesity. DMPA is given a UKMEC 3 if the woman has multiple risk factors for CVS disease.
In the past there were concerns that there was an increase in the failure rate associated with POPs in overweight women. It had been suggested that women who weigh >70 kg and were taking the traditional POP should take two POPs per day (unlicensed). There is no evidence to support a reduction in efficacy in women weighing >70 kg and therefore the use of one pill per day is recommended.
The SPC for the progestogen-only implants advises that earlier replacement can be considered in overweight women. This recommendation is based on the observation of an inverse relationship between body weight and serum etonogestrel levels. No increased risk of pregnancy has been shown in women weighing up to 149 kg; however, a reduction in the duration of contraceptive efficacy cannot be entirely excluded. The manufacturer does not specify a particular body weight at which earlier replacement should be considered, nor after what duration replacement should be considered. The FSRH advises that women should be made aware of the manufacturer’s advice however there is no direct evidence to support earlier replacement.
-
3. She says that she is not keen to have a family and might consider a permanent method such as sterilisation. How would you counsel her with regards to this request?
Show Answer
Correct answer: Female sterilisation is most commonly carried out laparoscopically in the UK under general anaesthetic. Given her BMI she is at higher risk from complications of both laparoscopic surgery and anaesthesia. An alternative permanent contraceptive option would be hysteroscopic sterilisation which can be carried out under a local anaesthetic. This would be a safer option in an extremely obese woman.
-
4. She mentions that her periods have become irregular over the last few years, coinciding with significant weight gain. This is not particularly troubling her but she wonders why this might have happened. What is the most likely cause in this woman?
Show Answer
Correct answer: The most likely diagnosis is PCOS. This is the commonest cause of secondary amenorrhoea. The incidence of PCOS appears to be increasing in line with the current obesity epidemic. Diagnosis is made using the Rotterdam criteria. Management depends on the symptoms however a weight loss of just 5-10% can restore menstrual regularity. PCOS is associated with an increased risk of CVS disease, diabetes and endometrial cancer.
