Postpartum Contraception with Migraine with Aura and Smoking
A 35-year-old woman attends a family planning clinic 8 weeks after an uncomplicated vaginal birth. She is exclusively breastfeeding, her body mass index is 32, and her blood pressure is 128/82 mmHg. She has had migraine with aura since her teens and smokes about 10 cigarettes a day. She has no history of venous thromboembolism, liver disease or breast cancer. She wants a reliable method and asks for 'the injection' because combined pills made her feel sick in the past. She also asks whether she can restart the combined pill now that the birth is over. She has no current pregnancy symptoms and her lochia has stopped.
1. Assess her eligibility for combined hormonal contraception and for progestogen-only methods, giving the reasoning.
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Combined hormonal contraception is WHO MEC category 4 for this woman because she has migraine with aura. Aura indicates an increased risk of ischaemic stroke, and adding a combined pill raises that risk further. Age 35 or older with smoking also makes combined hormonal contraception category 3 or 4, and breastfeeding before 6 months postpartum adds another caution. She should not restart the combined pill.
Progestogen-only methods are much safer. The etonogestrel implant and levonorgestrel intrauterine device are category 1 or 2, and the progestogen-only pill is also suitable. Depot medroxyprogesterone acetate is category 2 with migraine and smoking; it can be used after counselling about bleeding changes and bone density, but it is not the only option.
The copper intrauterine device is a highly effective non-hormonal option. Screen for pregnancy, unexplained bleeding, current breast cancer and pelvic infection before insertion. Her blood pressure should be monitored, but it does not contraindicate progestogen-only methods.
2. Recommend a method and explain how you will counsel her, including effectiveness and follow-up.
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Offer long-acting reversible contraception first because it is the most effective and does not depend on daily adherence. The etonogestrel implant lasts 3 years and is inserted in the upper arm; the levonorgestrel intrauterine device lasts 5 to 8 years depending on the product; the copper intrauterine device lasts up to 10 years. If she prefers an injection, depot medroxyprogesterone acetate is given every 12 to 13 weeks and requires a reliable recall system.
Explain that progestogen-only methods often cause unpredictable bleeding, which is not dangerous but may be inconvenient. The implant and intrauterine device can be removed if she has side effects. The injection may reduce bone mineral density with prolonged use, but this is usually reversible; she should not rely on it alone if she cannot return on time.
Discuss emergency contraception if she has unprotected intercourse before starting, and offer condoms for sexually transmitted infection protection. Arrange follow-up in 4 to 6 weeks to review bleeding, blood pressure and satisfaction.
3. What will you document, and what safety-netting advice will you give about her migraine?
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Document the postpartum date, breastfeeding status, blood pressure, body mass index, smoking history, migraine with aura and the MEC category for each method discussed. Record the method chosen, consent, insertion details if applicable, the next injection date or review date, and the advice given about bleeding and bone density. Note that combined hormonal contraception was declined or not prescribed because of category 4 criteria.
Safety-net advice: seek urgent review if she develops sudden severe headache, weakness, speech difficulty, visual loss, chest pain, shortness of breath, leg swelling or calf pain. These could indicate stroke or venous thromboembolism. If her migraine pattern changes or aura becomes more frequent, she should return for reassessment. Encourage smoking cessation and offer support, because smoking increases cardiovascular risk independently.
Give her written information and a contact number. If she misses an injection or has unprotected intercourse, advise her to return for emergency contraception as soon as possible.