A progestin-releasing intrauterine device (IUD) would be most appropriate for this patient. Other choices include the progestin-only pill, depot injection, or implanted rod. She is at increased risk for venous thromboembolism (VTE) because of her family history of VTE in two first-degree relatives and her obesity. Progestin-releasing IUDs do not appear to increase VTE risk, so they are a good contraceptive choice for women who are at increased risk for VTE. It is uncertain if oral progestin-only contraceptives (mini-pill) lead to an increased risk of VTE; however, the risk appears to be more clearly increased if additional VTE risk factors are present (obesity, immobility, surgery). Injectable progestins do appear to increase the risk of VTE.

Oral contraceptive pills (OCPs) include combination estrogen-progestin products and progestin-only pills. Combinations with lower estrogen doses are as effective with fewer side effects. Combined products are also available as a patch and a vaginal ring. Contraindications to combination products include history or increased risk of thrombosis, liver disease, breast cancer, migraine with aura, and uncontrolled hypertension. Women older than 35 years who smoke more than 15 cigarettes per day should not be prescribed estrogen-containing preparations because of an increased risk of stroke. Because this patient is at increased risk for thrombosis, she should not use any method of contraception containing estrogen.