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CASE 15.1

A 24-year-old nulligravida female presents for her annual examination. Her gynecologic history is remarkable for irregular menses, menstruating every 4 to 8 weeks. She would like a more reliable form of contraception (currently using condoms) and would like to have predictable menses, but is very concerned regarding weight gain with various contraceptive methods.

Question 15.1.1 How would you counsel her regarding weight changes and contraception?

A) Studies show there is no significant difference in weight gain of women initiating oral contraceptive pills (OCPs) versus placebo

B) Weight gain of 10 lb is expected during the first year of use with any type of OCPs

C) Weight gain of 10 lb is expected during the first year of use with monophasic pills but not with triphasic formulations

D) Weight loss of 10 lb is expected during the first year of use with Depo-Provera (medroxyprogesterone acetate)

Answer 15.1.1 The correct answer is "A." Studies have shown no significant weight gain with OCP use when compared with placebo. Trials have been conducted evaluating estrogen components of 20 to 50 μg, both monophasic and triphasic. There is no evidence to support the premise that triphasic formulations offer improvement in weight changes. Depo-Provera has variable effects on weight gain. Several studies have shown a weight gain of 3 to 6 kg in the first year of use; however, other studies have shown no difference in weight gain between Depo-Provera and placebo.

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Recall that in 2004 the FDA placed a "black box warning" on Depo-Provera for bone loss that "may not be reversible." However, subsequent studies showed bone gain after stopping Dep-Provera. The prudent thing would be to avoid Depo-Provera in women at high risk of osteoporosis.

Question 15.1.2 After reassuring her regarding the concerns of weight gain, you tell her about the additional potential benefit(s) of OCPs, which include:

A) Improvement in acne

B) Decreased dysmenorrhea

C) Decreased menstrual flow

D) Decreased risk of ovarian cancer

E) All of the above

Answer 15.1.2 The correct answer is "E." Besides these, additional potential benefits of OCP use include regulation and predictability of menses, decreased anemia, decreased hirsutism, and decreased risk of endometrial and colon cancers. (Note: the cancer risk reduction is based on epidemiologic studies, not randomized controlled trials.)

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After starting OCPs, patients should follow up within a few months for blood pressure checks, assuring compliance, etc.


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