UCaSeFiles: Clinical Cases from the UCSF Wards

Thursday, April 24, 2014

Welcome to UCaSeFiles, a column in which short case vignettes are submitted by UCSF medical students, residents and attendings based on the stories of real patients seen on the wards, with each vignette followed by a brief discussion of salient learning points. Some cases are rare diagnoses; others are common ailments that might have had a unique or puzzling presentation. All are welcome to submit your medical mysteries to Theresa Poulos (Theresa.poulos@ucsf.edu) for editing and final submission.

Contraceptive Switch: Tri-al and Error

Case submitted by Theresa Poulos, MS3

The Patient: A 26-year-old woman presented to primary care clinic complaining of “feeling like a crazy, emotional wreck.” Since switching from monthly Depo-Provera birth control shots to the Ortho Try-Cyclen oral contraceptive (OCP) four months ago, she describes having uncontrollable fits of tears and reactions that are out of proportion to the situation; she is worried that her husband is growing increasingly frustrated with her moodiness. She notes that these symptoms are the worst when she starts her week of sugar (placebo) pills. She had been on the Depo shot for six years, but made the switch to the OCP because she and her husband plan to start trying to get pregnant within the next year. Otherwise, the patient is in good health with no other complaints and nothing of note on physical exam.

The Diagnosis: Combined OCPs are birth control pills that contain forms of both estrogen and progestogen. They come in two major flavors: monophasic, which contains the same doses of hormones throughout the 21-pill cycle, and multiphasic, which contain varying doses of hormones. Ortho Try-Cyclen is an example of a multi phasic — more precisely, a triphasic.  A month’s cycle of pills includes seven days each of three differently dosed hormones, followed by a week of placebo pills. Although the changing hormone levels are intended to reflect the changing hormone levels in a woman’s natural cycle, many patients experience moodiness as a  side effect from hormone level variations, particularly when going from the highest dose (third week of pills) to the placebo pills (no hormones).

Because this patient wanted to try for pregnancy within the next 12 months, she was not a good candidate for an IUD or the Depo shot (which she had been using happily for the last six years), since it may take months to regain fertility after discontinuing those methods. Other options for hormonal birth control include a progestogen-only pill, which needs to be taken at the exact same time each day, and is therefore a difficult option in terms of adherence; or, a monophasic combined pill, which is often reported to have fewer mood-related side effects because of the stable hormone levels throughout the cycle. Barrier contraceptives were also discussed, however the patient and her husband preferred a non-barrier approach. After discussing the various options with the patient, the decision was made to switch from the triphasic pill to a monophasic formula. During a follow-up phone call five weeks later, the patient reported greatly improved mood stability and satisfaction with her new contraception.