24 Year Old Woman With Heart Murmur Inquiring About Contraception

A 24-year-old woman presents for a well-adult visit. Her health history includes the diagnosis of mitral valve prolapse without significant mitral regurgitation. She is feeling well, has no chief complaint, and denies activity intolerance, stating she plays tennis or pickleball for about one hour three to four times a week. Her only medication is an oral combined hormonal contraceptive and reports being pleased with her contraceptive method. She states that she read online that “I know I have a heart murmur and I'm worried about whether the birth control pill is safe for me.” The nurse practitioner considers the following when advising this patient

A. she should switch to a progestin only contraceptive method

B. if no other contraindications are present, she can continue to use combined hormonal contraception

C. in this clinical scenario, barrier contraceptive method is advised

D. she should be referred to cardiology for advice on contraceptive methods

---

YouTube: https://www.youtube.com/watch?v=fkJkZLA1BM8&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=144

Visit fhea.com to learn more!

Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

Margaret Fitzgerald: A 24-year-old woman presents for a well adult visit. Her health history includes a diagnosis of mitral valve prolapse without significant mitral regurgitation. She is feeling well, has no chief complaint, and denies activity intolerance, stating she plays tennis or pickle ball for about 1 hour three to four times a week. Her only medication is an oral combined hormonal contraceptive and reports being pleased with her contraceptive method. She states that she read online that quote, "I know I have a heart murmur and I'm worried about whether the birth control pill is safe for me." The nurse practitioner considers the following when advising this patient. 

A. She should switch to a progestin only contraceptive method 

B. If no other contraindications are present, she can continue to use combined hormonal contraception 

C. In this clinical scenario, barrier contraceptive method is advised 

D. She should be referred to cardiology for advice on contraceptive methods

The correct answer is B. If no other contraindications are present, she can continue to use combined hormonal contraception. 

Where should we start with this question? First, determine what kind of a question it is. Given that we're provided with a diagnosis, mirtal valve prolapse are being asked about a contraceptive issue. This is an evaluation question. Keep in mind, evaluation questions. the patient has already been diagnosed and now you're providing ongoing care. 

A bit of background information, mitral valve prolapse, usually abbreviated MVP, is the most common valvular heart issue and it might be present in up to 10% of the population with most people not realizing they have it. In MVP, one of the two mitral valve leaflets is a little bit longer than is typical. Therefore, when the heart valves approximate, that lower valve leaflet prolapses into the left atrium. This causes the characteristic mid-systolic click followed by a mid to late systolic murmur, often described as having a honking quality. The murmur will move forward into systole with position change from supine to stand. As I've mentioned in other podcasts, always look for what's special or specific in the clinical scenario presented in the question. Again, mitral valve prolapse, that's what's special here. In addition, she states she's feeling well, but is concerned if combined hormonal contraception. An example of that would be a contraceptive method that has both estrogen and progestin is a safe option for her to use. 

The US medical eligibility criteria for contraceptive use, usually abbreviated USMEC or just MEC, includes recommendations for the use of specific contraceptive methods for individuals with certain health issues or other characteristics. When counseling about contraceptive method choice, USMEC can be used to identify safe and effective contraceptive choices above and beyond barrier methods for all persons. The USMEC categories, just as a quick review, are as follows. 

Category one, no restrictions for the use of the contraceptive method. Category two, advantages outweigh risk with one obvious advantage being avoiding pregnancy. Category three, exercise caution. Theoretical or proven risk usually outweighs benefit. Category four, use represents unacceptable health risk. And what do we know about using CHC in the presence of mitral valve prolapse? This is actually MEC category 1 where no restriction. The progestin products such as implant and progestin only pills are also category 1. In other words, there are no restrictions for these uses of hormonally based contraceptive methods in this patient.

Let's take a moment then and say when would combined hormonal contraception use be a MEC three or four? While there are myriad of reasons for this higher MEC category that would advise to avoid their use, the major reason would be when there's significant thrombotic risk such as uncontrolled hypertension, established ASCVD, a history of thrombotic disease including PE and DVT and the reason for this is estrogen has pro-thrombotic tendencies which the progestins tend not to have. What heart valve disease would result in restricting combined hormonal contraceptive use? Well, first of all, these are conditions that are really uncommon in a younger adult such as we have here in this case study. It would include things like high-grade aortic stenosis, symptomatic rheumatic heart disease, usually with mitral stenosis, and a number of uncorrected congenital heart diseases with cyanosis. None of that is mentioned in her brief history. We shouldn't assume that the boards are hiding information from us. 

With this information in mind, let's take another look at the question. A 24 year old woman presents for a well adult visit. Her health history includes a diagnosis of mitral valve prolapse without significant mitral regurgitation. She's feeling well, has no chief complaint, denies activity intolerance, stating she plays tennis or pickle ball for about 1 hour 3 to four times a week. Her only medication is oral combined hormonal contraception and reports being pleased with her contraceptive method. She states that she read online that quote, "I know I have a heart murmur and I'm worried about whether the birth control pill is safe for me." The NP considers the following when advising the patient. 

A, she should switch to a progestin only contraceptive method. So, is it a contraindication to give her a progestin only method? No. But this is certainly not the best answer. And the reason why I would say it's not the best answer is it implies that there would be some risk with combined hormonal contraceptive use in uncomplicated MVP. And there is not. So that's a good example of an answer that's not incorrect, but it's not a good choice.

B. If no other contraindications are present, she can continue to use combined hormonal contraception. This is of course the correct answer as there's no noted increased risk in an otherwise young healthy adult who has mitral valve prolapse and is taking CHC. By the way, in this particular situation, remember she's taking this orally. Other examples of combined hormonal contraceptive include the contraceptive ring and the contraceptive patch. They're all same MEC category in this situation, MEC one.

C.  In this clinical scenario, a barrier contraceptive method is advised. You might think, well, barrier methods, there's so few contraindications to these, therefore they're among the safest contraceptive options. You would be correct. At the same time, barrier method contraceptive failure ranges from 14 to 21% plus per year. Combined hormonal contraceptive failure rate ranges from less than 1% with perfect use to as high as 7% a year. And the 7% per year is generally seen with birth control pills in adolescence. Therefore, she is using a highly effective method. And remember, every word in the story, the stem of the question is important. She said she's happy with the method. Leave her be. When a person is using a contraceptive method that they're pleased with and there are no new or ongoing reasons to switch that method, leave them be. 

Option D, she should be referred to cardiology for advice on contraceptive methods. Okay, I've mentioned this in other podcasts, but seldom is deferring care to a specialist or sub-specialist the correct answer on the family or adult-gero primary care boards. They want to have you demonstrate that you'll provide safe, competent entry-level NP practice. And you might think, well, this person might already see a cardiologist because of the mitral valve prolapse, which is a pretty big leap. Not everybody with mitral valve prolapse is seen by cardiology. and that the cardiologist would be happy to prescribe the contraceptive method. With all great respect to cardiology providers, you as the PCP have more expertise and hormonal contraceptive prescribing than they do. And in fact, if you did that and say, "Well, I want you to go to cardiology and they can write the birth control pill prescription if it's safe." I could almost write you a guarantee what's going to happen. The patient will be sent back to you, and cardiology will say you make the decision. 

Key takeaway: Knowing which hormonal contraception options are safe to use and a variety of health issues is key to safe practice.

Voiceover: Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit fhea.com.