Rene’s headaches may also require investigation. 4,5 Head-to-head trials are lacking for a benefit of one contraceptive pill, or even one method compared to another, in relation to an impact on mood. In relation to mood changes, it is useful to remember that many factors can impact on mood and that these may change over time, and that all hormonal contraceptive options can potentially affect mood but a causal association has not been proven. Progestogen-only methods can be associated with irregular bleeding or can result in amenorrhoea so it would be important to explore these options with her. Given that Rene liked the COC because she could use it continuously to avoid withdrawal bleeds and because she felt that the COC has improved her mood, it will be important to address both of these issues when discussing alternatives. Rene should cease combined hormonal contraception and be recommended alternative contraception methods. 3 The Faculty of Sexual and Reproductive Healthcare, the publishers of UKMEC, also provides useful resources for making a migraine diagnosis and distinguishing migraines with aura from those without ( ĭiagnosis_of_migraine_with_or_without_aura). Of primary importance, however, Rene’s history is consistent with a diagnosis of new onset migraine with aura, which is an absolute contraindication (United Kingdom Medical Eligibility Criteria for Contraceptive Use category 4) for use of a combined hormonal method of contraception. As Rene is 43 years of age, she has a higher background risk of cardiovascular disease and venous thromboembolism than younger women, although in the absence of other risk factors the COC can be a suitable choice for women up to the age of 50 years. Rene’s history has revealed a series of clinically relevant areas that can impact on her contraceptive options. What is concerning about Rene’s history of migraines in combination with her use of the COC pill? Commentary You explain to Rene that you believe these episodes are consistent with migraine with aura. These headaches respond well to a rizatriptan 10 mg wafer, which she was given by an after-hours GP a few weeks ago. On closer questioning, Rene indicates that these symptoms are accompanied by unilateral loss of vision that develops gradually and lasts around 20 minutes, after which she becomes nauseous and develops a left-sided headache. These episodes are happening about every six weeks. Rene does not take any other medication and has no significant past medical history, although she tells you that during the past four months she has been experiencing episodes of blurred vision followed by a unilateral headache. Recent blood tests, including fasting lipid profile, liver function, renal function and electrolytes, were normal. She has never smoked, her body mass index (BMI) is 27 kg/m 2 and she is normotensive. Rene has 5-year-old twins and does not want to become pregnant again. She says ‘it changed my life’ as she has been skipping the hormone-free break, resulting in absent withdrawal bleeding, and she feels it has been helpful for her mood after previously experiencing negative mood changes with other hormonal contraception. Rene, a 43-year-old woman, has been taking the combined oral contraceptive (COC) for around five years.
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