The most appropriate contraceptive method to recommend to this woman is an intrauterine device (IUD), along with condom use to reduce risk from sexually transmitted infections. Evidence shows that IUDs can be offered to nulliparous or multiparous women across the entire reproductive span, with high rates of continuation and efficacy. There is no evidence of increased risk of pelvic inflammatory disease, infection, or infertility with IUDs. There are two types of IUDs available, one that is hormone free, and one that contains levonorgestrel. The levonorgestrel IUD generally causes significant diminution of menstrual bleeding, although endometrial response is variable. Given that this patient did not tolerate progestin well, the hormone-free IUD is a reasonable choice also.

In choosing contraception, patient preference, acceptability, concurrent medical conditions, and prior response to other methods should be considered. Because of her migraine with visual aura, this patient should not be treated with an estrogen-containing contraceptive. Although the absolute risk of venous thromboembolism or stroke in young women is low, this risk is increased by a history of migraine with visual aura when estrogen-containing preparations are used. Therefore, either an estrogen-progestin oral contraceptive or a vaginal ring is contraindicated.

This patient also indicated that she experienced unpredictable breakthrough bleeding with depot medroxyprogesterone acetate injections, which is a common side effect. Other progestin-only methods, including implantable inserts and pills, although frequently inducing periods of amenorrhea, may all be associated with breakthrough or irregular bleeding and may be less desirable for this patient.