The scenario describes a patient experiencing recurrent, severe dysmenorrhea that is refractory to standard hormonal and non-steroidal anti-inflammatory drug (NSAID) therapy. The patient also reports dyspareunia and dyschezia, strongly suggesting the presence of endometriosis. Given the failure of conservative management and the likely diagnosis of endometriosis, a surgical approach is indicated. Laparoscopic excision of endometriotic implants is the gold standard for definitive treatment and symptom relief in such cases. This procedure directly addresses the underlying pathology. While hormonal suppression can manage symptoms, it does not resolve existing implants and is often used adjunctively or for maintenance after surgery. Hysterectomy with bilateral salpingo-oophorectomy would be a more radical intervention, typically reserved for cases where fertility is not desired and other treatments have failed, and it carries significant hormonal consequences. Diagnostic laparoscopy alone would confirm the diagnosis but would not provide therapeutic relief. Therefore, laparoscopic excision of endometriotic implants represents the most appropriate next step in management for this patient at the American Board of Obstetrics and Gynecology – Subspecialty in Complex Family Planning University context, aiming for both symptom resolution and improved quality of life.

The question assesses the understanding of managing a patient with a history of venous thromboembolism (VTE) seeking highly effective, long-acting reversible contraception. The key consideration is the risk of recurrent VTE associated with hormonal contraceptives. According to current guidelines from organizations like the CDC and WHO, combined hormonal contraceptives (CHCs) containing estrogen are generally contraindicated in individuals with a history of VTE due to an increased risk of thrombotic events. Progestin-only methods, particularly those that do not significantly impact coagulation pathways or are not associated with increased VTE risk, are preferred. The levonorgestrel-releasing intrauterine system (LNG-IUS) is a progestin-only method that has a very low systemic absorption of progestin and is not associated with an increased risk of VTE. Therefore, it is considered a safe and highly effective contraceptive option for this patient. Other options, such as combined oral contraceptives, transdermal patches, or vaginal rings, all contain estrogen and carry a contraindication due to the VTE history. The subcutaneous implant, while progestin-only, has systemic absorption and its VTE risk profile, while generally considered low, is not as definitively established as the LNG-IUS in this specific high-risk population. Thus, the LNG-IUS represents the most appropriate and safest choice for a patient with a history of VTE seeking highly effective contraception.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of the question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those that increase thrombotic risk. Combined hormonal contraceptives (CHCs), which contain both estrogen and progestin, are contraindicated in individuals with a history of VTE due to the estrogen component’s prothrombotic effect. Progestin-only methods, such as the progestin-only pill (POP), depot medroxyprogesterone acetate (DMPA), and etonogestrel implants, generally do not carry this contraindication as they lack estrogen. However, the question specifically asks for a method that is *not* a progestin-only method but is still safe for this patient. Among the available options, a copper intrauterine device (IUD) is a non-hormonal method that provides highly effective, long-acting reversible contraception and is not associated with an increased risk of VTE. Therefore, it is the most appropriate choice for a patient with a history of DVT seeking highly effective contraception without hormonal influence on thrombotic risk. The other options, while effective contraceptives, carry contraindications or are hormonal methods that would be inadvisable in this clinical context.

The scenario describes a patient presenting with symptoms suggestive of an ectopic pregnancy, specifically a ruptured ectopic pregnancy given the hemodynamic instability. The primary goal in managing such a critical condition is immediate stabilization and surgical intervention. The question asks about the most appropriate initial management strategy. A ruptured ectopic pregnancy is a life-threatening gynecological emergency. The patient is hemodynamically unstable, indicated by hypotension (blood pressure of \(80/50\) mmHg) and tachycardia (heart rate of \(120\) bpm). This signifies hemorrhagic shock. The immediate priority is to restore circulatory volume and control the source of bleeding. The calculation for fluid resuscitation involves providing a rapid infusion of intravenous crystalloids. While specific fluid volumes are not provided in the options, the principle is aggressive volume replacement. For a patient in hemorrhagic shock, initial fluid boluses of \(1-2\) liters of crystalloid are typically administered rapidly. This is followed by blood product transfusion if the patient remains unstable or if there is significant blood loss. Surgical intervention, specifically laparoscopy or laparotomy, is essential to definitively manage the ruptured ectopic pregnancy by removing the ectopic tissue and controlling the hemorrhage. However, surgical intervention cannot be performed safely without initial resuscitation. Therefore, the most appropriate *initial* management is to address the shock. Considering the options, the most critical first step is to provide immediate hemodynamic support. This involves aggressive intravenous fluid resuscitation to improve blood pressure and organ perfusion. While a pregnancy test is diagnostic, it is not the immediate life-saving intervention. Administering oxytocin would be contraindicated as it can cause uterine contractions and potentially worsen bleeding from a ruptured ectopic pregnancy. Delaying surgical consultation while focusing solely on medical management would also be inappropriate. Therefore, the immediate focus must be on stabilizing the patient’s vital signs through fluid resuscitation, which then allows for safer surgical management.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of the question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those that increase thrombotic risk. Combined hormonal contraceptives (CHCs), which contain both estrogen and progestin, are generally contraindicated in individuals with a history of VTE due to the estrogen component’s association with increased coagulation factors. Progestin-only methods, such as the etonogestrel implant and the levonorgestrel intrauterine system (LNG-IUS), do not contain estrogen and are therefore considered safer options for individuals with contraindications to estrogen-containing methods. Specifically, the etonogestrel implant is highly effective, has a low failure rate, and is reversible. The LNG-IUS also offers similar benefits in terms of efficacy and reversibility, but the implant offers a non-intrauterine option which might be preferred in certain circumstances or if there are concerns about uterine perforation or expulsion with IUDs. Considering the patient’s history of DVT, the most appropriate recommendation would be a method that avoids estrogen. Among the options, a progestin-only method like the etonogestrel implant or a levonorgestrel-releasing IUD would be suitable. However, the question asks for the *most* suitable option, and the etonogestrel implant is a highly reliable, reversible, and estrogen-free method that directly addresses the patient’s need for effective long-term contraception while mitigating the risk associated with her DVT history. The other options, such as combined oral contraceptives or a transdermal patch, contain estrogen and would therefore be contraindicated. A copper IUD is also a viable estrogen-free option, but the question implies a preference for hormonal methods given the context of “hormonal contraception” in the prompt, and the etonogestrel implant offers a hormonal mechanism of action that is safe in this context. Therefore, the etonogestrel implant stands out as the most appropriate choice due to its efficacy, reversibility, and lack of estrogen.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of this question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those that increase thrombotic risk. Combined hormonal contraceptives (CHCs), which contain both estrogen and progestin, are generally contraindicated in individuals with a history of VTE. Progestin-only methods, such as progestin-only pills (POPs), the progestin implant, and the progestin-only injectable, do not carry the same estrogen-associated thrombotic risk and are considered safe options for this patient. Intrauterine devices (IUDs), both hormonal (levonorgestrel-releasing IUDs) and non-hormonal (copper IUDs), are also considered safe as they have minimal systemic absorption and do not increase VTE risk. Therefore, the most appropriate recommendation would be a method that avoids estrogen. Among the options provided, a copper IUD offers highly effective, long-acting, non-hormonal contraception, making it an excellent choice for a patient with a history of DVT. Similarly, a levonorgestrel-releasing IUD is also a suitable option due to its localized progestin action and minimal systemic effects. The question asks for the *most* appropriate option, and while both IUDs are excellent, the copper IUD is a definitive non-hormonal choice that completely bypasses any potential hormonal interactions with thrombotic risk. The explanation focuses on identifying the method that best mitigates the specific risk factor presented by the patient’s medical history, aligning with the principles of complex family planning where patient-specific medical conditions dictate contraceptive recommendations. The emphasis is on the mechanism of action and systemic effects of different contraceptive modalities in the context of a contraindication.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-acting reversible contraception. The core of this question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those containing estrogen, in individuals with a history of thromboembolic events. The World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC) is the gold standard for assessing the safety of contraceptive methods in specific medical conditions. According to the MEC, a history of deep vein thrombosis or pulmonary embolism is classified as a Category 4 contraindication for combined hormonal contraceptives (CHCs), which include combined oral contraceptives (COCs), the vaginal ring, and the transdermal patch. This classification signifies that the method is generally not recommended due to an unacceptable health risk. Progestin-only methods, such as progestin-only pills (POPs), the etonogestrel implant, and the etonogestrel subdermal implant, are generally considered safe for individuals with a history of VTE, as they do not contain estrogen and have a lower risk of thrombotic events. Among the long-acting reversible contraceptives (LARCs), the etonogestrel implant and the copper intrauterine device (IUD) are excellent options. The etonogestrel implant provides continuous progestin release and is highly effective. The copper IUD is a non-hormonal LARC that is also highly effective and does not carry a risk of VTE. Considering the patient’s desire for a LARC and her history of DVT, both the etonogestrel implant and the copper IUD are appropriate choices. However, the question asks for the *most* appropriate LARC given the specific context of a patient with a history of DVT seeking highly effective contraception. While both are suitable, the etonogestrel implant offers a hormonal option that is well-tolerated and has a very low failure rate, addressing the patient’s need for highly effective contraception without the thrombotic risks associated with estrogen. The copper IUD is also a valid choice, but the etonogestrel implant directly addresses the hormonal aspect of contraception while mitigating the specific risk factor. Therefore, the etonogestrel implant is the most fitting recommendation in this complex family planning scenario, aligning with the principles of safe and effective contraceptive counseling at the American Board of Obstetrics and Gynecology – Subspecialty in Complex Family Planning University.

The question assesses the understanding of managing a complex contraceptive scenario involving a patient with a history of venous thromboembolism (VTE) and a desire for highly effective, long-term contraception. The patient is 32 years old, has a history of provoked VTE secondary to surgery 5 years ago, and is now seeking highly effective contraception. She has no other significant medical history and is not currently on any hormonal therapy. The core of the question lies in applying the World Health Organization’s (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC). For patients with a history of VTE, the MEC provides specific guidance. A history of VTE, even if provoked, generally necessitates caution with combined hormonal contraceptives (CHCs) due to the increased risk of recurrent VTE. Specifically, CHCs are typically categorized as MEC Category 3 or 4 in such cases, meaning their use is generally not recommended or is contraindicated unless other methods are not suitable. Progestin-only methods, particularly progestin-only injectables (like DMPA), progestin-only pills (POPs), and particularly long-acting reversible contraceptives (LARCs) such as etonogestrel implants and levonorgestrel-releasing intrauterine systems (LNG-IUS), are generally considered safe for individuals with a history of VTE, provided there are no other contraindications. These methods have a lower or negligible impact on coagulation compared to CHCs. Considering the patient’s desire for highly effective and long-term contraception, LARCs are an excellent option. The etonogestrel implant offers over 99% effectiveness and a duration of use of up to three years. Similarly, LNG-IUS devices can provide highly effective contraception for 3 to 8 years, depending on the specific device. These methods avoid systemic estrogen, which is the primary driver of increased VTE risk with CHCs. Therefore, an etonogestrel implant is a highly appropriate and safe choice for this patient. It meets her criteria for high effectiveness and long duration, while circumventing the risks associated with estrogen-containing methods in the context of her VTE history.

The scenario describes a patient with a history of deep vein thrombosis (DVT) and a current desire for highly effective, long-acting reversible contraception (LARC). The key consideration is the contraindication of estrogen-containing contraceptives in individuals with a history of venous thromboembolism (VTE). Progestin-only methods are generally considered safe, but the specific context of a recent DVT and the need for a LARC narrows the options. The patient has a history of DVT, which is a significant risk factor for future thromboembolic events. Current guidelines from organizations like the CDC and WHO classify a history of VTE as a contraindication for combined hormonal contraceptives (CHCs) due to the increased risk of recurrent VTE. Therefore, any option that includes estrogen is inappropriate. The patient is seeking a LARC. The available LARC options include etonogestrel implants, levonorgestrel intrauterine systems (LNG-IUS), and copper intrauterine devices (IUDs). Etonogestrel implants and LNG-IUS are progestin-only methods. Copper IUDs are non-hormonal. Considering the patient’s history of DVT, the most appropriate LARC would be one that does not carry an increased risk of VTE. Both the etonogestrel implant and the LNG-IUS are considered safe for individuals with a history of VTE, as the progestin is primarily acting locally with minimal systemic absorption, and the risk of VTE associated with these methods is not significantly different from that of the general population. The copper IUD is also a safe and effective LARC option for this patient. However, the question asks for the *most* appropriate LARC, implying a consideration of efficacy, patient preference, and potential side effect profiles in the context of the underlying condition. While all three are technically viable, the progestin-only methods (implant and LNG-IUS) offer the added benefit of menstrual cycle regulation, which can be advantageous for many women, including those who may experience heavier or more painful periods, a common concern in family planning discussions. The etonogestrel implant provides continuous progestin release, offering high efficacy and long-term protection. The LNG-IUS also offers high efficacy and can lead to amenorrhea or lighter menses, which can be beneficial. The copper IUD, while highly effective, does not offer hormonal benefits and can sometimes lead to heavier or more irregular bleeding, which might be less desirable for some patients, especially those with a history of bleeding concerns or who are seeking menstrual cycle management. Therefore, focusing on highly effective, long-acting, and generally well-tolerated progestin-only LARC options that do not exacerbate VTE risk, the etonogestrel implant stands out as a primary consideration due to its proven efficacy, ease of use, and favorable side effect profile for many users, including those with contraindications to estrogen. The LNG-IUS is also a strong contender, and the choice between the implant and LNG-IUS would often depend on patient preference and specific menstrual cycle characteristics. The copper IUD is a valid alternative, particularly if hormonal methods are to be avoided entirely, but the progestin-only LARCs often align better with the desire for menstrual cycle control often discussed in complex family planning scenarios. The calculation is conceptual, focusing on risk stratification and method selection based on contraindications. There is no numerical calculation. The correct approach involves identifying the contraindication (estrogen with history of VTE) and then selecting a LARC that bypasses this contraindication while offering high efficacy and potential benefits like menstrual cycle regulation.

The scenario describes a patient seeking to manage heavy menstrual bleeding and irregular cycles, which are classic symptoms of abnormal uterine bleeding (AUB). The patient has a history of a recent pelvic inflammatory disease (PID) and expresses a desire for future fertility. This history of PID raises concerns about potential Asherman’s syndrome or adhesions that could impact fertility and complicate certain interventions. The patient’s desire for future fertility is a crucial factor in selecting an appropriate management strategy. Considering the patient’s presentation of AUB, the history of PID, and the desire for future fertility, a conservative approach focusing on medical management is paramount. Hormonal therapies are the cornerstone of managing AUB, particularly in individuals desiring future fertility. Specifically, a progestin-releasing intrauterine system (IUS) is highly effective in reducing menstrual blood loss and regulating cycles. Its localized action minimizes systemic hormonal exposure, and its reversibility makes it an excellent option for those who wish to conceive later. Furthermore, the progestin released by the IUS can help to thin the endometrium, potentially counteracting any proliferative effects that might exacerbate bleeding. Other options, while potentially addressing bleeding, carry significant drawbacks for this specific patient. Surgical interventions like hysterectomy or endometrial ablation would definitively preclude future fertility, making them unsuitable. GnRH agonists, while effective for severe AUB, are typically used for short-term management due to side effects and the need for add-back therapy, and they also induce a temporary state of amenorrhea that might not be ideal for cycle regulation in the long term. Oral progestins can be effective but require daily adherence, and their efficacy in significantly reducing heavy bleeding may be less consistent than an IUS. Therefore, the progestin-releasing IUS represents the most appropriate first-line management strategy, balancing symptom control with the preservation of future reproductive potential, especially in the context of a history that warrants caution with more invasive procedures.

The scenario describes a patient presenting with a complex contraceptive need due to a history of venous thromboembolism (VTE) and current management for a chronic autoimmune condition requiring immunosuppression. The core of the question lies in understanding the contraindications and special considerations for various contraceptive methods in the context of specific medical histories, a key area of expertise for complex family planning specialists. For a patient with a history of VTE, combined hormonal contraceptives (CHCs), which contain estrogen, are generally contraindicated due to an increased risk of recurrent VTE. Progestin-only methods are typically considered safer. However, the patient’s autoimmune condition and the immunosuppressive therapy (e.g., corticosteroids or other immunomodulators) introduce further complexities. Some immunosuppressants can affect the metabolism of hormones, potentially altering contraceptive efficacy or increasing the risk of side effects. Furthermore, certain autoimmune conditions themselves can increase thrombotic risk, even without estrogen. Considering these factors, the most appropriate contraceptive approach would prioritize methods with minimal systemic hormonal exposure or those with a well-established safety profile in the presence of immunosuppression and a history of VTE. Progestin-only pills (POPs) are an option, but their efficacy can be affected by certain enzyme-inducing medications sometimes used in immunosuppression. Injectable progestins (like DMPA) are generally safe but can have side effects and may not be ideal for long-term management of complex cases. Sterilization is a permanent option but may not be desired by all patients. Long-acting reversible contraceptives (LARCs) like the etonogestrel implant or levonorgestrel intrauterine systems (IUS) offer highly effective, non-estrogenic contraception. The etonogestrel implant releases a progestin and has a low systemic absorption rate, making it a favorable option for many women with contraindications to estrogen. Levonorgestrel IUSs provide highly localized progestin action, with minimal systemic absorption, and are also considered safe in patients with a history of VTE and those on certain medications, provided there are no other contraindications to IUD placement. The question requires evaluating which method best balances efficacy, safety, and patient-specific risk factors within the framework of complex family planning principles taught at the American Board of Obstetrics and Gynecology – Subspecialty in Complex Family Planning University. The etonogestrel implant offers a robust, reversible, non-estrogenic option with a favorable pharmacokinetic profile in the context of immunosuppression and prior VTE, making it the most suitable choice among the given options.

The question assesses the understanding of managing a complex contraceptive scenario involving a patient with a history of venous thromboembolism (VTE) and a desire for highly effective, long-term contraception. The calculation is conceptual, focusing on the relative risk reduction and absolute risk increase associated with different contraceptive methods in this specific patient profile. First, consider the baseline annual risk of VTE in a healthy young woman, which is approximately 2-5 per 10,000 woman-years. For a woman with a history of VTE, this baseline risk is significantly elevated. The question implies a need to quantify the additional risk posed by various hormonal contraceptives. Combined hormonal contraceptives (CHCs) containing estrogen are known to increase VTE risk by approximately 2-4 times. Progestin-only methods, particularly depot medroxyprogesterone acetate (DMPA) and etonogestrel implants, generally have a lower or negligible impact on VTE risk compared to CHCs. Intrauterine devices (IUDs), including levonorgestrel-releasing IUDs (LNG-IUDs) and copper IUDs, are considered safe for women with a history of VTE, as they do not contain estrogen and their association with VTE is not established. The core of the assessment lies in understanding the risk-benefit profile. A woman with a history of VTE has a contraindication to estrogen-containing contraceptives due to the significantly increased risk of recurrent VTE. Therefore, options that include estrogen are inappropriate. Progestin-only methods are generally considered safer, but the specific risk profile of DMPA regarding potential weight gain and other side effects might make it less ideal than other progestin-only options or non-hormonal methods in certain contexts, though it does not carry the estrogen-associated VTE risk. The most appropriate approach for a patient with a history of VTE seeking highly effective, long-acting reversible contraception is a method that does not confer an increased risk of VTE. Both copper IUDs and LNG-IUDs fit this criterion. LNG-IUDs offer the additional benefit of menstrual suppression or reduction, which can be advantageous for many women. Copper IUDs are a non-hormonal option that is also highly effective and safe in this population. The question asks for the *most* appropriate management strategy. Given the patient’s history of VTE, avoiding estrogen is paramount. Among the remaining options, a progestin-only method or a non-hormonal method would be considered. However, the specific scenario implies a need for highly effective, long-term contraception. While progestin-only pills are an option, they require daily adherence. DMPA has its own set of potential side effects. The LNG-IUD offers a favorable risk profile for VTE, high efficacy, and long duration of action, making it a leading choice. Similarly, a copper IUD is also a highly effective and safe non-hormonal alternative. The correct answer represents the option that prioritizes VTE safety while offering high efficacy and long-term reversibility, aligning with the principles of complex family planning in managing patients with contraindications. The calculation is conceptual: Baseline VTE Risk (estimated): 2-5 per 10,000 woman-years Risk with CHCs (estimated): 4-10 per 10,000 woman-years (2-4x increase) Risk with Progestin-only (e.g., implant, IUD): Negligible or no significant increase over baseline. The correct approach is to select a contraceptive method that does not increase the risk of VTE in a patient with a history of this condition. This means avoiding estrogen-containing methods. Progestin-only methods and non-hormonal methods are generally considered safe. Among these, long-acting reversible contraceptives (LARCs) like levonorgestrel-releasing intrauterine devices (LNG-IUDs) and copper intrauterine devices (IUDs) are highly effective, have a favorable safety profile for women with VTE, and provide long-term contraception, aligning with the patient’s stated desire. The explanation focuses on the avoidance of estrogen due to the contraindication of VTE history and the safety profile of LARCs in this context.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of this question lies in understanding contraindications for various contraceptive methods, particularly in the context of complex family planning, a key area of focus for the American Board of Obstetrics and Gynecology – Subspecialty in Complex Family Planning University. The World Health Organization (WHO) Medical Eligibility Criteria (MEC) for Contraceptive Use is the standard reference for such decisions. For individuals with a history of current or recent DVT or pulmonary embolism (PE), combined hormonal contraceptives (CHCs), which include combined oral contraceptives (COCs), transdermal patches, and vaginal rings, are generally contraindicated (MEC Category 4). This is due to the increased risk of venous thromboembolism (VTE) associated with estrogen. Progestin-only methods, such as progestin-only pills (POPs), the etonogestrel implant, and the levonorgestrel intrauterine system (LNG-IUS), are considered safe and highly effective options for this patient population, as they do not carry the same VTE risk as CHCs. Specifically, the LNG-IUS and the etonogestrel implant are long-acting reversible contraceptives (LARCs), offering excellent efficacy and convenience, aligning with the goals of complex family planning. Therefore, the most appropriate recommendation, considering both efficacy and safety in a patient with a history of DVT, would be a LARC, such as an LNG-IUS or etonogestrel implant.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-acting reversible contraception (LARC). The core of the question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those that increase thrombotic risk. Combined hormonal contraceptives (CHCs), which contain estrogen and progestin, are generally contraindicated in individuals with a history of VTE. Progestin-only methods, such as the etonogestrel implant and the levonorgestrel intrauterine system (LNG-IUS), do not contain estrogen and therefore do not carry the same increased risk of VTE. The copper intrauterine device (IUD) is a non-hormonal LARC and is also a safe option for this patient. However, the question asks for the *most* appropriate LARC given the patient’s history and desire for highly effective contraception. While both the copper IUD and LNG-IUS are suitable, the LNG-IUS offers an additional benefit of potentially reducing menstrual bleeding and dysmenorrhea, which can be advantageous for many patients. The etonogestrel implant is also a progestin-only LARC and a valid option. Considering the options provided, the etonogestrel implant is a progestin-only LARC that avoids estrogen and is therefore a safe and highly effective choice for a patient with a history of DVT. The copper IUD is also safe but does not offer the potential menstrual benefits of the LNG-IUS or the implant. Combined oral contraceptives and the vaginal ring both contain estrogen and are contraindicated. Therefore, the etonogestrel implant is the most appropriate LARC among the choices that directly addresses the patient’s specific medical history and contraceptive needs.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of this question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those that increase thrombotic risk. Combined hormonal contraceptives (CHCs), which contain estrogen and a progestin, are known to increase the risk of venous thromboembolism (VTE). Progestin-only methods, such as progestin-only pills (POPs), the etonogestrel implant, and the levonorgestrel intrauterine system (LNG-IUS), do not contain estrogen and are generally considered safe for individuals with a history of VTE, provided there are no other contraindications. However, the question specifically asks for a method that is *not* associated with an increased risk of VTE. Among the available options, the levonorgestrel intrauterine system (LNG-IUS) is a progestin-only method that has demonstrated a favorable safety profile regarding VTE risk, even in populations with pre-existing risk factors, as its systemic absorption of progestin is minimal. Other options, such as combined oral contraceptives, transdermal patches, and vaginal rings, all contain estrogen and are therefore contraindicated in patients with a history of VTE. The LNG-IUS provides highly effective, long-acting reversible contraception and is an appropriate choice for this patient. The absence of estrogen in the LNG-IUS is the critical factor that differentiates it from the other hormonal options in terms of VTE risk.

The question assesses understanding of the nuanced ethical and clinical considerations surrounding the provision of complex family planning services, specifically addressing the management of a patient with a history of venous thromboembolism (VTE) seeking highly effective contraception. The scenario involves a patient with a documented history of unprovoked deep vein thrombosis (DVT) that resolved with anticoagulation, now presenting for long-acting reversible contraception (LARC) at the American Board of Obstetrics and Gynecology – Subspecialty in Complex Family Planning University. The correct approach involves carefully weighing the risks and benefits of various contraceptive methods in the context of her medical history and the established contraindications. Combined hormonal contraceptives (CHCs), which contain estrogen, are generally contraindicated in individuals with a history of VTE, especially if unprovoked or recent, due to an increased risk of recurrent thrombotic events. This contraindication is well-established by major reproductive health organizations and is a cornerstone of safe contraceptive counseling. Progestin-only methods, particularly those that do not contain estrogen, are typically considered safer alternatives for individuals with a history of VTE. Among these, progestin-only injectables (like DMPA), progestin-only pills (POPs), and etonogestrel implants are generally categorized as Category 1 (no restrictions) or Category 2 (advantages generally outweigh theoretical or proven risks) by the Centers for Disease Control and Prevention (CDC) for women with a history of VTE, provided the VTE is resolved and there are no other risk factors. However, the question specifically asks about the *most* appropriate LARC. The etonogestrel implant is a highly effective LARC that provides continuous progestin release. Its systemic absorption is consistent, and it does not carry the estrogen-related risks associated with combined methods. While the progestin-only injectable is also an option, the implant offers longer duration of action and avoids the need for repeated injections, potentially improving adherence and convenience. Intrauterine devices (IUDs), both levonorgestrel-releasing IUDs (LNG-IUDs) and copper IUDs, are also excellent LARC options and are generally considered safe for individuals with a history of VTE as they have minimal systemic hormonal effects (for LNG-IUDs) or no hormonal effects (for copper IUDs). However, the question asks for the *most* appropriate LARC, and the etonogestrel implant is a strong contender due to its efficacy, reversibility, and favorable risk profile in this specific clinical context. The key is to select a method that minimizes thrombotic risk while providing highly effective contraception. The calculation is not a numerical one but a clinical decision-making process based on established guidelines. The patient’s history of unprovoked DVT, even if resolved, places her in a higher risk category for future thrombotic events if exposed to estrogen. Therefore, estrogen-containing methods are to be avoided. Progestin-only methods are preferred. Among the LARC options, the etonogestrel implant offers a highly effective, reversible, and estrogen-free method that aligns with the patient’s medical history and the principles of complex family planning care emphasized at the American Board of Obstetrics and Gynecology – Subspecialty in Complex Family Planning University.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-acting reversible contraception. The core of this question lies in understanding the contraindications for combined hormonal contraceptives (CHOCs), which include estrogen. Estrogen-containing methods, such as combined oral contraceptives (COCs), transdermal patches, and vaginal rings, are associated with an increased risk of venous thromboembolism (VTE), particularly in individuals with a history of DVT. Progestin-only methods, on the other hand, do not carry this estrogen-related VTE risk and are generally considered safe for individuals with a history of VTE, provided there are no other contraindications. Among the progestin-only options, the etonogestrel implant (e.g., Nexplanon) is a highly effective LARC with a Pearl Index of approximately 0.05, indicating a very low annual failure rate. Similarly, the levonorgestrel intrauterine system (LNG-IUS) is also a highly effective LARC with a Pearl Index of approximately 0.1-0.2. Both are excellent choices for this patient. However, the question asks for the *most* appropriate option considering the patient’s specific history and desire for highly effective contraception. While both the implant and LNG-IUS are suitable, the prompt implies a need to differentiate based on nuanced understanding of contraindications and efficacy. The etonogestrel implant is a progestin-only method that bypasses the estrogen-related VTE risk, making it a safe and highly effective choice. The copper IUD is also a progestin-free, highly effective LARC, but it is not a hormonal method and its efficacy is slightly lower than the progestin-only LARCs. Combined oral contraceptives, due to their estrogen component, are contraindicated in this patient with a history of DVT. Therefore, the etonogestrel implant represents the most appropriate and safest highly effective contraceptive option.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of the question lies in understanding contraindications for hormonal contraceptive methods, particularly those containing estrogen, in individuals with a history of thromboembolic events. Current guidelines from organizations like the CDC and WHO strongly advise against estrogen-containing contraceptives in individuals with a history of DVT or pulmonary embolism due to an increased risk of recurrent thrombosis. Progestin-only methods, such as the etonogestrel implant and the levonorgestrel intrauterine system (LNG-IUS), are considered safe and highly effective alternatives for this patient population. These methods do not contain estrogen and have a lower risk profile for thromboembolic events. Therefore, offering either the etonogestrel implant or a levonorgestrel-releasing IUD is the most appropriate management strategy. The explanation focuses on the mechanism of increased thrombotic risk with estrogen and the safety profile of progestin-only contraceptives in this specific clinical context, aligning with the principles of complex family planning and patient safety emphasized at the American Board of Obstetrics and Gynecology – Subspecialty in Complex Family Planning University.

The scenario describes a patient with a history of deep vein thrombosis (DVT) and pulmonary embolism (PE) who is seeking highly effective, long-term contraception. The core of the question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those with estrogen. Estrogen-containing contraceptives, including combined oral contraceptives (COCs), transdermal patches, and vaginal rings, are generally contraindicated in individuals with a history of venous thromboembolism (VTE) due to an increased risk of recurrent VTE. Progestin-only methods are typically considered safer in this population. Among the progestin-only options, the etonogestrel implant and the levonorgestrel-releasing intrauterine system (LNG-IUS) are highly effective, long-acting reversible contraceptives (LARCs). The progestin-only pill (POP) is also an option but requires strict adherence to daily dosing to maintain efficacy and is generally less effective than LARCs. Given the patient’s desire for highly effective, long-term contraception and her history of VTE, a progestin-only LARC is the most appropriate choice. The etonogestrel implant provides continuous progestin release for up to three years and has a very low failure rate, making it an excellent option for this patient. The LNG-IUS also offers high efficacy and long duration of use, but the etonogestrel implant offers a non-uterine approach which might be preferred by some patients and has a slightly higher typical-use effectiveness in some studies. Therefore, the etonogestrel implant is the most suitable recommendation.

The scenario describes a patient presenting with a complex contraceptive need due to a history of venous thromboembolism (VTE) and ongoing management for a chronic autoimmune condition. The core of the question lies in understanding the contraindications and relative contraindications for various hormonal contraceptive methods, particularly in the context of increased thrombotic risk. Combined hormonal contraceptives (CHCs), which contain both estrogen and progestin, are generally contraindicated in individuals with a history of VTE or current VTE risk factors due to the estrogen component’s association with increased coagulation. Progestin-only methods, such as progestin-only pills (POPs), depot medroxyprogesterone acetate (DMPA), and etonogestrel implants, do not contain estrogen and are therefore considered safer alternatives in such cases. Intrauterine devices (IUDs), both hormonal (levonorgestrel-releasing IUDs) and non-hormonal (copper IUDs), are also excellent options as their systemic absorption of hormones is minimal or absent, respectively, and they do not carry the same thrombotic risk as CHCs. Considering the patient’s history of VTE and the need for highly effective contraception, progestin-only methods and IUDs are the most appropriate choices. Among the options provided, a progestin-only method such as an etonogestrel implant or a levonorgestrel-releasing IUD would be the most suitable. The explanation focuses on the mechanism of action and safety profiles of these methods in the presence of VTE risk factors. Progestin-only methods primarily work by thickening cervical mucus, inhibiting ovulation (though less consistently than CHCs), and thinning the endometrium. LARCs, like the etonogestrel implant and levonorgestrel IUDs, offer the highest efficacy rates among reversible methods, which is crucial for a patient seeking reliable contraception. The absence of estrogen in these methods mitigates the increased thrombotic risk associated with VTE history. Therefore, a progestin-only method or a LARC is the correct approach.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of the question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those that increase thrombotic risk. Combined hormonal contraceptives (CHCs), which contain estrogen, are generally contraindicated in individuals with a history of VTE due to the increased risk of recurrence. Progestin-only methods, such as the etonogestrel implant and the levonorgestrel intrauterine system (IUGS), do not contain estrogen and are therefore considered safe and highly effective options for patients with a history of VTE. Depot medroxyprogesterone acetate (DMPA) is a progestin-only injectable that also does not contain estrogen and is a viable option, but it is not a long-acting reversible contraceptive (LARC) in the same category as implants or IUGS regarding duration of action and reversibility without a procedure. Transdermal patches and vaginal rings, while effective, typically contain estrogen and would therefore be contraindicated in this patient. Considering the patient’s desire for highly effective, long-term contraception and her history of DVT, a progestin-only LARC is the most appropriate recommendation. The etonogestrel implant offers a duration of up to three years and is highly effective. The levonorgestrel IUGS also offers long-term protection (up to 5-8 years depending on the device) and is equally effective. Both are excellent choices. However, the question asks for the *most* appropriate method given the patient’s specific request for highly effective, long-term reversible contraception and her medical history. The etonogestrel implant directly addresses these needs by providing a reversible, highly effective, and long-acting contraceptive option without estrogen, thus avoiding the contraindication associated with VTE history. The explanation focuses on the mechanism of action and contraindications of hormonal contraceptives in the context of thrombotic risk.

The question assesses the understanding of pharmacokinetics and pharmacodynamics of hormonal contraceptives in the context of drug interactions, specifically focusing on enzyme induction. When a patient is on a combined oral contraceptive (COC) and initiates therapy with rifampin, a potent inducer of cytochrome P450 enzymes (primarily CYP3A4), the metabolism of the ethinylestradiol (EE) and the progestin component of the COC is significantly accelerated. This increased metabolism leads to lower circulating levels of the hormones, thereby reducing contraceptive efficacy and increasing the risk of unintended pregnancy. The standard recommendation in such scenarios, as per guidelines from organizations like the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC), is to advise the patient to use a backup method of contraception, such as condoms, for the duration of rifampin therapy and for 7 days after its discontinuation. This is because the enzyme induction effect can persist for some time after the inducing agent is stopped. Furthermore, switching to a more highly effective contraceptive method, such as an LARC (e.g., etonogestrel implant or levonorgestrel IUD) or a depot injection (e.g., DMPA), is often recommended as a primary strategy to mitigate the risk of contraceptive failure during treatment with enzyme-inducing drugs. This approach ensures a more consistent and reliable level of contraception, less susceptible to metabolic fluctuations. The rationale behind this recommendation is rooted in the principle of ensuring adequate hormonal exposure for ovulation inhibition, which is compromised by accelerated drug metabolism. Therefore, the most appropriate management involves a combination of enhanced backup contraception and consideration of a more robust contraceptive method.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of the question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those that increase thrombotic risk. Combined hormonal contraceptives (CHCs), which contain both estrogen and progestin, are known to increase the risk of venous thromboembolism (VTE). Therefore, a patient with a history of DVT is an absolute contraindication for their use. Progestin-only methods, such as the progestin-only pill (POP), the etonogestrel implant, and the levonorgestrel intrauterine system (LNG-IUS), do not contain estrogen and are generally considered safe for individuals with a history of VTE, provided there are no other contraindications. Among the options presented, the etonogestrel implant is a highly effective LARC that relies solely on progestin, making it a suitable choice for this patient. The explanation of why this is the correct choice involves understanding the hormonal components of different contraceptive methods and their associated risks, particularly concerning VTE. The progestin-only implant avoids the estrogenic component that drives the increased thrombotic risk in CHCs. Therefore, it offers a safe and effective long-term solution for this patient, aligning with the principles of complex family planning where individual risk factors must be meticulously assessed.

The scenario describes a patient presenting with a complex reproductive health issue requiring a nuanced understanding of contraceptive management in the context of chronic illness and potential teratogenicity. The patient has a history of systemic lupus erythematosus (SLE) with active renal involvement, for which she is taking mycophenolate mofetil (MMF). MMF is a potent immunosuppressant with significant teratogenic potential, making highly effective contraception paramount. When considering contraceptive options for a patient on MMF, several factors are critical: efficacy, safety, drug interactions, and patient preference. Long-acting reversible contraceptives (LARCs) are generally considered the most effective reversible methods due to their high continuation rates and low failure rates. Among LARCs, the etonogestrel implant and the levonorgestrel intrauterine system (LNG-IUS) are highly effective. However, the question specifically asks about a patient with active renal involvement and MMF use. MMF is primarily metabolized by glucuronidation, and while direct pharmacokinetic interactions with progestin-only contraceptives are not well-established, the primary concern is the absolute need for highly effective contraception due to MMF’s teratogenicity. The etonogestrel implant provides continuous progestin release and has a Pearl Index of approximately 0.05, indicating very high efficacy. The LNG-IUS also offers high efficacy, with Pearl Indices typically ranging from 0.1 to 0.2. Both are excellent options. However, the question implies a need to consider potential interactions or contraindications related to the underlying condition or medication. While neither the etonogestrel implant nor the LNG-IUS are contraindicated in SLE or with MMF use, the question asks for the *most appropriate* method given the context. The etonogestrel implant offers a consistent, predictable hormonal profile and avoids potential issues related to uterine instrumentation or infection that might be a concern in an immunocompromised patient with active renal disease, although these risks are generally low with sterile technique. Furthermore, the continuous release of etonogestrel from the implant may offer a more stable hormonal environment compared to the cyclical release of levonorgestrel from some LNG-IUS formulations, which could be theoretically advantageous in managing complex hormonal needs or potential subtle interactions, though this is not a primary contraindication. Considering the absolute requirement for preventing pregnancy due to MMF’s teratogenicity, and the high efficacy and favorable safety profile of the etonogestrel implant in this complex patient, it stands out as the most robust choice. The other options, while effective, present slightly higher failure rates or potential considerations that make them less ideal in this specific high-stakes scenario. For instance, combined hormonal contraceptives carry a theoretical risk of increasing thrombotic events in SLE patients, although this is more associated with estrogen. Progestin-only pills require daily adherence, which can be a barrier to consistent efficacy. Injectable progestins, while effective, can have effects on bone mineral density with long-term use, which might be a consideration in a patient with chronic illness. Therefore, the etonogestrel implant represents the most secure and practical option for this patient at the American Board of Obstetrics and Gynecology – Subspecialty in Complex Family Planning University.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of this question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those that increase thrombotic risk. Combined hormonal contraceptives (CHCs), which contain both estrogen and progestin, are known to increase the risk of venous thromboembolism (VTE). Therefore, a patient with a history of DVT is an absolute contraindication for their use. Progestin-only methods, such as the progestin-only pill (POP), the etonogestrel implant, and the levonorgestrel intrauterine system (LNG-IUS), do not carry this increased thrombotic risk because they lack estrogen. Among the long-acting reversible contraceptives (LARCs), the LNG-IUS and the etonogestrel implant are highly effective and suitable for patients with a history of VTE. Sterilization, while permanent, is also a viable option. However, the question asks for a *contraceptive method* that is appropriate, implying a reversible option unless otherwise specified. Considering the need for high efficacy and reversibility, and the absolute contraindication of estrogen-containing methods due to the DVT history, progestin-only LARCs are the most appropriate choices. Specifically, the levonorgestrel-releasing intrauterine system is a well-established, highly effective, and safe option for individuals with a history of VTE, as its systemic progestin absorption is minimal and it does not increase thrombotic risk.

The question probes the understanding of managing a complex contraceptive scenario involving a patient with a history of deep vein thrombosis (DVT) and current use of a progestin-only injectable contraceptive. The core of the question lies in assessing the appropriate next steps for contraception given the patient’s medical history and current method. A patient with a history of DVT is generally considered to have an increased risk for thromboembolic events, especially when exposed to estrogen-containing contraceptives. The World Health Organization (WHO) Medical Eligibility Criteria (MEC) for Contraceptive Use is the standard reference for this. For a history of DVT or pulmonary embolism (PE), estrogen-progestin methods (combined oral contraceptives, transdermal patches, vaginal rings) are typically contraindicated (MEC Category 4). Progestin-only methods, such as depot medroxyprogesterone acetate (DMPA) injections, are generally considered safe (MEC Category 1 or 2 depending on specific circumstances and recency of event). The patient is currently using DMPA, which is a progestin-only method. The question asks about the *next* step in management. Since DMPA is generally considered safe for individuals with a history of DVT, continuing it is a reasonable option, provided there are no other contraindications or patient preferences against it. However, the question implies a need for a change or re-evaluation. Considering the options, the most appropriate next step, especially in the context of complex family planning and ensuring patient safety and autonomy, is to engage in a thorough discussion about alternative contraceptive methods that are also safe and effective, while acknowledging the suitability of the current method. This involves exploring patient preferences, understanding any potential side effects they might be experiencing with DMPA, and discussing other progestin-only options or non-hormonal methods that would also be appropriate given their DVT history. Option a) accurately reflects this comprehensive approach: discussing alternative contraceptive methods that are safe given the DVT history, while also acknowledging the current method’s suitability. This demonstrates an understanding of both the safety profile of DMPA in this context and the importance of shared decision-making in complex family planning. Option b) is incorrect because while DMPA is generally safe, suggesting a switch to an estrogen-containing method without a thorough risk-benefit analysis and consideration of contraindications would be inappropriate given the DVT history. Option c) is incorrect because discontinuing all hormonal contraception without exploring suitable alternatives that align with the patient’s needs and medical history would be an oversimplification and potentially lead to unintended pregnancy. Option d) is incorrect because while monitoring for side effects is important, it does not address the proactive step of discussing alternative contraceptive options that are equally or more suitable, especially if the patient expresses dissatisfaction or concerns with the current method. The emphasis should be on providing a range of safe and effective choices. Therefore, the most nuanced and patient-centered approach, aligning with the principles of complex family planning at the American Board of Obstetrics and Gynecology – Subspecialty in Complex Family Planning University, is to engage in a detailed discussion of all safe and appropriate contraceptive options, including continuing the current method if desired, or transitioning to another suitable method.

The scenario presents a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-acting reversible contraception. The core of this question lies in understanding the contraindications for various hormonal contraceptive methods, particularly in the context of thrombotic risk. Combined hormonal contraceptives (CHCs), which contain both estrogen and progestin, are generally contraindicated in individuals with a history of venous thromboembolism (VTE) due to the increased risk of recurrent VTE associated with estrogen. Progestin-only methods, such as the etonogestrel implant and the levonorgestrel-releasing intrauterine system (LNG-IUS), do not carry this estrogen-related thrombotic risk and are considered safe alternatives. Therefore, the etonogestrel implant is a suitable and highly effective option for this patient. The copper intrauterine device (IUD) is also a non-hormonal and safe option, but the question implies a preference for a method with a higher degree of efficacy and potentially other benefits associated with hormonal methods, though not explicitly stated. However, the etonogestrel implant directly addresses the need for highly effective, long-acting reversible contraception without the contraindications associated with estrogen. The other options are either contraindicated due to the patient’s history or are less effective or not long-acting reversible methods. Specifically, a combined oral contraceptive pill would be contraindicated due to the DVT history. A progestin-only pill, while a progestin-only method, is less effective than LARCs and requires daily adherence, which may not be ideal for a patient seeking highly effective, long-term contraception. The vaginal ring also contains estrogen and would therefore be contraindicated. The etonogestrel implant offers a high efficacy rate of over 99% and a duration of up to three years, making it an excellent choice for this patient’s complex needs.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of this question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those that increase thrombotic risk. Combined hormonal contraceptives (CHCs), which include estrogen and progestin, are generally contraindicated in individuals with a history of venous thromboembolism (VTE) due to the increased risk of recurrence. Progestin-only methods, such as the progestin-only pill (POP), depot medroxyprogesterone acetate (DMPA), and etonogestrel implants, do not carry this estrogen-related thrombotic risk and are therefore considered safe options. Among the long-acting reversible contraceptives (LARCs), the etonogestrel implant is a highly effective progestin-only method. Intrauterine devices (IUDs) are also excellent LARC options. While copper IUDs are non-hormonal and thus safe, the levonorgestrel-releasing IUDs (LNG-IUDs) release a progestin directly into the uterus, resulting in minimal systemic absorption and a very low risk of VTE, making them a viable and highly effective option for this patient. Therefore, an LNG-IUD is a suitable choice.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who presents for family planning counseling. The core of the question lies in understanding the contraindications for various hormonal contraceptive methods, particularly those containing estrogen, in individuals with a history of thromboembolic events. Current guidelines, such as those from the Centers for Disease Control and Prevention (CDC) Medical Eligibility Criteria for Contraceptive Use, categorize the risk associated with estrogen-containing contraceptives in patients with a history of DVT. A history of DVT is generally considered a contraindication for combined hormonal contraceptives (CHCs) due to the increased risk of recurrent thrombosis. Progestin-only methods, such as the progestin-only pill (POP), depot medroxyprogesterone acetate (DMPA), and etonogestrel implant, do not contain estrogen and are therefore considered safer alternatives for individuals with this risk factor. The levonorgestrel-releasing intrauterine system (LNG-IUS) is also a progestin-only method and is generally considered safe. Therefore, the most appropriate recommendation for this patient, considering her history and the need for effective contraception, would be a method that avoids estrogen.

The scenario describes a patient with a history of deep vein thrombosis (DVT) who is seeking highly effective, long-term contraception. The core of this question lies in understanding the contraindications for hormonal contraceptive methods, particularly those containing estrogen, in individuals with a history of thromboembolic events. The American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use are key resources for this assessment. Specifically, a history of DVT or pulmonary embolism is a Category 4 contraindication for combined hormonal contraceptives (CHCs), meaning the risks generally outweigh the benefits. Progestin-only methods, such as the progestin-only pill (POP), depot medroxyprogesterone acetate (DMPA), etonogestrel implant, and levonorgestrel-releasing intrauterine systems (LNG-IUS), are generally considered safe in this population, provided there are no other contraindications. Among the available options, the etonogestrel implant and LNG-IUS are long-acting reversible contraceptives (LARCs) offering superior efficacy and convenience compared to daily pills or injections. The question asks for the *most* appropriate LARC. Both the etonogestrel implant and LNG-IUS are excellent choices. However, considering the nuances of complex family planning and patient counseling, the etonogestrel implant offers a non-hormonal option for managing potential side effects that might arise from progestin exposure, such as irregular bleeding, which can be a concern with LNG-IUS. While both are highly effective, the etonogestrel implant is often favored in complex cases due to its predictable hormonal release and ease of removal, minimizing the risk of uterine perforation or expulsion associated with IUDs, though these risks are low. Therefore, the etonogestrel implant represents a superior choice in this specific clinical context for a patient with a history of DVT seeking a LARC.