HY USMLEQ#8 Obs Gyn Concepts Step 2CK
Level = Step 2CK/3 (Inspired Uworld step 3)
A 35-year-old woman comes to the office for a contraception prescription. The pateint previously used oral contraceptive pills for menstrual regulation, but she frequently forgot to take them. During her previous pregnancy the postpartum coruse was complicated by severe postpartum depression requiring psychiatry consultation. She does not intend on becoming pregnant again. Her mensus occur every 45 to 90 days with 5 to 6 of heavy beleeding and passage of large clots. She has no other chronic medical conditions and no previous surgeries. She is married and has 3 children. Her rotuine Pap testing was normal. She does not use tobacoco, alcohol or illict drugs. BMI is 33 kg/m2. Pevlic examination is unremarkable. Serum LH, Prolactin and TSH are within normal ranges. Pelvic ultrasodun revleas multifollicular ovaries bilaterally.
Which of the following is the best contraceptive option for this patient ?
A. Laparoscopic tubal ligation
B. Cyclic progestin only pills
C. Copper-containing intrauterine device
D. High dose combination oral contraceptive pills
E. Progestin containing intrauterine device
✅ Correct answer = Progestin containing intrauterine device.
Education Objective:
High BMI –> insulin resistance –> abnormal GnRH pulsation –> increased LH/FSH ratio –> high LH over-stimulates theca interna cells (hirsutism); low FSH leads to poor follicular development (anovulation / retention of follicles as cysts) —> lack of
ovulation means no formation of corpus luteum —> since corpus luteum normally secretes progesterone, there is no progesterone production—> unnopposed estrogen —> endometrial hyperplasia and increased risk of endometrial cancer (progesterone normally limits growth of endometrium; estrogen stimulates it).
Hence progestine intrauterine device is required here.
❌ Choice A. Although she doesn't intend on becoming pregnant again, laparoscopic tubal ligation does not provide endometrial protection against hyperplasia and cancer.
❌ Choice B and D. Both pill options are wrong because she keeps forgetting to take pills.
❌ Choice C. Copper-containing IUDs do not protect the endomterium. Furthermore, they typically increase menstrual bleeding and cramping, this patient already has heavy menstural hence copper IUD would not be useful here. Copper IUD releases copper ions that are toxic to sperm but it also stimulates the endometrium and causes chronic inflammatory reaction.