A 34-year-old woman with a mechanical mitral valve takes warfarin, with a target INR of 2.5–3.5. During the past year she has required two emergency

Question

A 34-year-old woman with a mechanical mitral valve takes warfarin, with a target INR of 2.5–3.5. During the past year she has required two emergency admissions for haemoperitoneum caused by ruptured corpus-luteum cysts. Pelvic imaging between episodes is normal, and the gynaecology team considers recurrent ovulatory bleeding exacerbated by anticoagulation to be the cause. She wants highly effective reversible contraception that is also likely to suppress ovulation. She does not want an intrauterine method or a daily pill and accepts the possibility of delayed return to fertility. She has no osteoporosis risk factors. It is day 3 of a normal menstrual period, pregnancy has been excluded, and her INR today is 3.0. Which is the most appropriate contraceptive plan?

Accepted Answer

Initiate subcutaneous depot medroxyprogesterone acetate 104 mg every 13 weeks without interrupting warfarin

Answer

Initiate continuous ethinylestradiol–levonorgestrel combined hormonal contraception while continuing warfarin

Answer

Insert an etonogestrel implant without interrupting warfarin and apply a pressure bandage

Answer

Insert a 52 mg levonorgestrel intrauterine device without interrupting warfarin

Answer

Initiate intramuscular depot medroxyprogesterone acetate 150 mg every 13 weeks after withholding warfarin until the INR is below 1.5

Recurrent haemorrhagic corpus-luteum cysts during warfarin therapy — DFSRH MCQ