A 35-year-old woman with a history of deep vein thrombosis (DVT) 5 years ago (now off anticoagulation) presents requesting contraception. She has no active thrombosis, normal thrombophilia screening, and desires a highly effective, non-hormonal method. Which is the drug of choice for contraception in this patient?

Explanation

## Contraception in History of Venous Thromboembolism ### Risk Stratification & Drug of Choice **Key Point:** In women with a history of DVT/PE (even if resolved and off anticoagulation), **combined estrogen-containing contraceptives are contraindicated** due to residual VTE risk. The copper IUD is the **gold standard** non-hormonal, highly effective option. ### Why Copper IUD? | Feature | Copper IUD | Rationale | |---------|-----------|----------| | **Mechanism** | Foreign body + copper ions → spermicidal effect | No systemic absorption; no hormonal effects | | **VTE risk** | Zero | Non-hormonal; safe in thrombophilia/VTE history | | **Efficacy** | 99.2% (Pearl Index 0.8) | Among the most effective reversible methods | | **Duration** | 10 years | Long-acting; cost-effective | | **Contraindications** | Active infection, Wilson's disease, copper allergy | Resolved DVT is NOT a contraindication | ### WHO Medical Eligibility Criteria (MEC) Classification **High-Yield:** According to WHO MEC 2015: - **Combined estrogen-progestin contraceptives** (COC, patch, ring): **Category 4** (contraindicated) in history of VTE - **Copper IUD**: **Category 1** (no restriction) in VTE history - **Progestin-only methods** (POP, DMPA, implant): **Category 2** (advantages generally outweigh risks) — acceptable but not preferred ### Clinical Pearl **Warning:** Do NOT confuse: - **Current/active VTE** → all hormonal contraceptives contraindicated - **History of VTE (resolved, off anticoagulation)** → estrogen-containing methods contraindicated; progestin-only or non-hormonal methods acceptable; copper IUD preferred ### Why Other Options Are Suboptimal | Option | Why NOT first-line | |--------|-------------------| | **Levonorgestrel-only pill (POP)** | Category 2 (acceptable but not preferred); requires daily compliance; higher failure rate than IUD; progestins may have mild prothrombotic effects | | **Combined oral contraceptive (EE + LNG)** | **CONTRAINDICATED** (WHO Category 4); estrogen significantly increases VTE risk in women with thrombophilia/VTE history | | **DMPA injection** | Category 2 (acceptable); but less effective than copper IUD; requires repeat injections; progestins have mild prothrombotic potential | ### Algorithm for Contraception in VTE History ```mermaid flowchart TD A[History of VTE<br/>resolved, off anticoagulation]:::outcome --> B{Desire highly effective<br/>long-acting method?}:::decision B -->|Yes| C[Copper IUD]:::action B -->|No, prefer shorter-acting| D{Accept progestin-only?}:::decision D -->|Yes| E[POP or DMPA]:::action D -->|No| F[Barrier methods<br/>or fertility awareness]:::action C --> G[WHO Category 1<br/>Safe, preferred]:::outcome E --> H[WHO Category 2<br/>Acceptable but not preferred]:::outcome F --> I[Category 1<br/>Safe but lower efficacy]:::outcome J[AVOID: COCs, patches, rings]:::urgent ``` **Mnemonic:** **VETO COCs** — **V**enous **E**mbolism **T**hrombosis → **O**mit **C**ombined **O**ral **C**ontraceptives [cite:KD Tripathi 8e Ch 62; WHO Medical Eligibility Criteria 2015]