Day 2 Contraception

Question 1

A 35-year-old woman is due to be discharged from the postnatal ward 12 hours after delivering her son via normal vaginal delivery. She enquires about contraceptive options as she feels her family is now complete.

She has no past medical history and there were no complications during her pregnancy or labour.

In the past, she has used the intrauterine system (IUS) and would ideally like to go back to this.

What advice should she be given?

Answer 1

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks

It is correct that she may have the intrauterine system (IUS) inserted up to 48 hours after delivery if she wishes. The IUS may be inserted up to 48 hours after delivery otherwise insertion should be delayed for 4 weeks. This is due both to the significantly increased risk of expulsion between these times and also the lack of data surrounding uterine perforation with newer models (there was an increased risk of uterine perforation in the 4 weeks following delivery in older models).

Question 2

A 31-year-old female presents 5 weeks postpartum. She asks about methods of contraception that would be safe for her baby as she is exclusively breastfeeding.

Which method of contraception would not be recommended for this patient?

Answer 2

According to the UK Medical Eligibility Criteria for Contraceptive Use, the combined oral contraceptive pill is absolutely contraindicated in women who are breastfeeding and less than 6 weeks postpartum.

This is because combined hormonal contraceptives reduce breast milk volume.

Between 6 weeks and 6 months postpartum, they are classed as UKMEC 2.

Remember that lactational amenorrhoea is effective contraceptive in itself, provided the woman is exclusively breastfeeding i.e. no bottle feeds are being given in addition to breast milk.

Question 3

How long must birth control methods wait to be used post-partum?

(6)

Answer 3

The Mirena intrauterine system and copper IUD can be used from 4 weeks postpartum.

The POP can be started on or after day 21 postpartum.

The progestogen only implant can be inserted at any time, although contraception is not required before day 21 postpartum.

Combined oral contraceptive pill (COCP) is absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum or 3 weeks if not breastfeeding and no risk of VTE

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.

Lactational amenorrhoea method (LAM) is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum

Question 4

A 19-year-old female starts Microgynon 30 (combined oral contraceptive pill) on day 8 of her cycle. How long will it take before it can be relied upon as a method of contraception?

Answer 4

Contraceptives - time until effective (if not first day period):

instant: IUD

2 days: POP

7 days: COC, injection, implant, IUS

Question 5

A 23-year-old woman is being reviewed in the post-natal ward, 24 hours after a vaginal delivery.

The delivery was uncomplicated and she is ready to go home. She has started breastfeeding and is bonding well with her baby.

When asked about contraception, she states that she used to take the progesterone-only pill and is keen to start this again.

What is the earliest she can begin taking this contraception again?

Answer 5

Postpartum women (breastfeeding and non-breastfeeding) can start the progestogen-only pill at any time postpartum

Question 6

A 24-year-old woman attends her GP surgery worried about her risk of pregnancy. She usually takes the combined contraceptive pill. It is currently day 7 of the first week of her pill packet. She missed her pills on days 2 and 3 and then proceeded to have unprotected sexual intercourse (UPSI) on day 4 of the packet.

Which for of emergency contraception should be used?

When can she restart her normal hormonal contraception?

Answer 6

You decide to prescribe ulipristal acetate as a form of emergency contraception.

After taking ulipristal acetate women should wait 5 days before starting regular hormonal contraception

Question 7

A 27-year-old woman presents to her general practitioner after returning from a weekend holiday. She states that she forgot her combined oral contraceptive pills, meaning that she has not had the pill for the last 2 days. She has not had any sexual intercourse during this time and is currently on week 3 of her pill packet.

Which of the following would be the best advice?

Answer 7

COCP: If 2 pills missed in week 3, finish the pills in the current pack and start new pack immediately, omitting pill-free interval

Missed combined oral contraceptive pills (COCPs) can be a complex topic as it relies on the number of missed pills and the current week of the treatment cycle.

In many cases, the first 3 weeks of the COCP are active pills and the 4th week is a pill-free interval (either with no tablets or with placebos).

As this woman has missed 2 pills, she is unable to simply take an active pill and continue as normal.

Instead, she should take an active pill and continue with her current pack.

Once she reaches her planned pill-free interval, she should omit this and move straight onto the next pack.

During this time, she should also be aware that she may have reduced contraceptive protection.

Question 8

A 30-year-old female presents to her GP for advice about contraception. She is provided with information and advice regarding all methods of contraception available and decides to opt for a copper IUD.

A pregnancy test done at the surgery is negative. She has a regular 28-day cycle. At what point in her menstrual cycle can the IUD be inserted?

Answer 8

The copper IUD can be fitted at any point during the menstrual cycle. It can also be fitted immediately after first or second-trimester abortion, and from 4 weeks postpartum.

Question 9

A 22-year-old woman calls her GP surgery. The previous day she visited her pharmacist and was given the levonorgestrel emergency contraceptive pill following an episode of unprotected sexual intercourse. The patient explains to you that she wants a more reliable method of contraception.

You prescribe the combined oral contraceptive pill (COCP).

When can this patient start?

Answer 9

Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception

Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch, or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during these 5 days.

Question 10

A woman of child bearing age comes into your GP surgery.

She wishes to try to conceive for a baby in one years time and does not wish to conceive sooner due to barrister exams she has this year.

She ideally wants to fall pregnant soon after her exams.

Which of the methods of contraception is most associated with delayed return to fertility?

Answer 10

Depo-Provera lasts up to 12 weeks, it can take several months for the body to return to the normal menstrual cycle and hence delay fertility. For this reason, it is the least appropriate method for this woman who wants to return to ovulatory cycles immediately.

Discuss (3)Improve

Question 11

A woman presents asking for the ‘morning after pill’. Up to what period following intercourse is levonorgestrel licensed to be used?

Answer 11

Levonorgestrel must be taken within 72 hours of UPSI

hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception

if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date

Question 12

Which of the contraceptives do the Faculty of Sexual and Reproductive Healthcare (FSRH) recommend should be discontinued after the age of 50 years?

Answer 12

Depo-Provera

women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years

use is associated with a small loss in bone mineral density which is usually recovered after discontinuation

Question 13

When should these contraceptives be stopped?

Answer 13

Question 14

Hormone Replacement Therapy and Contraception

(2)

Answer 14

The FSRH advises that the POP may be be used with in conjunction with HRT as long as the HRT has a progestogen component (i.e. the POP cannot be relied upon to ‘protect’ the endometrium).

In contract the IUS is licensed to provide the progestogen component of HRT.

Question 15

A 17-year-old female calls her GP surgery as she is worried that she forgot to take her combined oral contraceptive pill yesterday.

She is currently in the second week of the packet and had unprotected sex last night.

The patient has called you first thing in the morning - she usually takes the pill around this time but hasn’t yet taken today’s as she wasn’t sure what to do.

What advice should this patient be given regarding the missed pill?

Answer 15

COCP: if 1 pill is missed, take the last pill ASAP but no further action is needed

As only one pill was missed, and she is in her second week of continuous pill-taking, emergency contraception is not required and therefore answers including this are not correct.

Question 16

A 15-year-old female presents to the GP requesting the contraceptive pill, on questioning, she demonstrated Gillick competency, however she discloses that her boyfriend is 25 and the Maths teacher at a local, but not her, state school.

She is not pregnant and her last period was 3 weeks ago.

She asks you not to tell anyone, especially her father who is also one of your patients.

What do you do?

Answer 16

Inform her that you need to tell social services and child protection due to the age and position of trust of her boyfriend. Try to get her consent but explain you will still need to tell them if she doesn’t consent

Question 17

The GMC guidelines in good medical practice, 0-18 years; sexual activity states

‘You should usually share information about abusive or seriously harmful sexual activity involving any child or young person, including that which involves:

(6)

Answer 17

young person too immature to understand or consent

big differences in age, maturity or power between sexual partners

a young persons sexual partner having a position of trust

force or the threat of force, emotional or psychological pressure, bribery or payment, either to engage in sexual activity or to keep it secret

drugs or alcohol used to influence a young person to engage in sexual activity when they otherwise would not

a person known to the police or child protection agencies as having had abusive relationships with children or young people.’

Question 18

The Fraser Guidelines state that all the following requirements should be fulfilled:

(5)

Answer 18

the young person understands the professional’s advice

the young person cannot be persuaded to inform their parents

the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment

unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer

the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent

Question 19

Contraception in young people:

(3)

Answer 19

Choice of contraceptive

clearly long-acting reversible contraceptive methods (LARCs) have advantages in young people as this age group may often be less reliable in remembering to take medication

however, there are some concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice

the progesterone-only implant (Nexplanon) is therefore the LARC of choice is young people

Question 20

STI testing in young people

(1)

Answer 20

young people should be advised to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI)

Question 21

A 24-year-old woman is due to be discharged from the labour ward after an uncomplicated delivery. Prior to discharge, the team discusses contraception with her. The patient was previously taking microgynon (ethinylestradiol 30 microgram/levonorgestrel 50 micrograms) and would like to restart this.

The patient has no significant medical history, takes no other medications, and has no allergies.

She is a non-smoker with a BMI of 19kg/m² and does not plan to breastfeed her baby.

When can the patient safely restart her medication?

Answer 21

The COCP should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum

*she does not plan to breastfeed

Question 22

A 23-year-old female has a telephone appointment with her GP, concerned about forgetting to take her combined oral contraceptive pill.

She has never forgotten to take it previously and is anxious about what to do as she is sexually active with her boyfriend and last had intercourse 2 days ago.

She is on week 3 of the packet and has missed 2 pills this week.

What advice should the GP give?

Answer 22

COCP: If 2 pills missed in week 3, finish the pills in the current pack and start new pack immediately, omitting pill-free interval

This patient has missed 2 pills in the third week of her combined oral contraceptive pill packet - as she has not missed any other doses, she is able to finish the current pack and start the next packet without pill-free interval and does not need to use barrier contraception or emergency contraception as further cover.

If she was not compliant with the pill and had missed more than 2 pills, she should be advised to attend for emergency contraception. However, she reports never having previously missed a dose

Question 23

A 23-year-old female attends your GP practice wanting to discuss options for contraception, having only used condoms in the past. She has no intention of having children in the near future and her menstrual cycle is regular, although she does complain of heavy periods. At the clinic today, she is normotensive and her calculated body mass index (BMI) is 38 kg/m².

Which contraceptive option is most suitable for her?

Answer 23

Mirena (levonorgestrel-releasing intrauterine system)

In this case, this young patient would like to try contraception. Her BMI of >35 is a relative contraindication (UKMEC 3) for the combined hormonal contraceptive options including the pill, patch, and NuvaRing.

Her history of heavy periods and her plan for long-term contraception would be best managed with a levonorgestrel-releasing intrauterine system (LNG-IUS), such as the Mirena.

The copper IUD would also provide long-term contraception, however, is unsuitable in those with heavy periods.

The progesterone-only pill can cause amenorrhea however can also lead to erratic menstrual bleeding. This may also be the case with the Nexplanon implant and the Depo-Provera.

Therefore, the most appropriate contraceptive, in this case, would be the Mirena IUS.

Question 24

Janine, a 34-year-old mother, attends your practice wanting to discuss options for contraception. She was previously using the copper IUD but unfortunately became pregnant whilst on this, which has traumatised her. She is scared of needles. She is currently breastfeeding her 5-week-old son and is otherwise well with no issues. Which contraceptive option would you offer in the first instance?

Which method of contraception would you offer in this case?

Answer 24

Progesterone-only pill

The progesterone-only pill is a suitable method for contraception in breastfeeding mothers from 4 weeks and is the most appropriate option in this case.

Progesterone-only pill76%

Breastfeeding in less than 6 weeks is an absolute contraindication (UKMEC 4) for combined hormonal contraception, making the combined pill, patch and NuvaRing inappropriate.

The Mirena IUS is also an option but given her previous traumatic experience with coils, she is less likely to be amenable to this.

Nexplanon is also another suitable option, however, her fear of needles would make this option less favourable for her.

Question 25

Lisa is a 43-year-old mother who would like to discuss options for contraception. She has previously tried the combined pill and the progesterone-only pill and did not get along with them. She is keen to avoid coils. Her current medications include long-term rifampicin and fexofenadine. Which contraceptive option would be most appropriate?

Answer 25

**The correct answer is: Depo-Provera (injectable medroxyprogesterone acetate)** In this case, the patient has previously tried the combined oral contraceptive and the progesterone-only pill and does not wish to re-try this. She is also keen to avoid coils so both the copper and hormonal coils are not options. Her medication list includes rifampicin, a known enzyme inducer. The Nexplanon implant is known to be affected by enzyme inducers and therefore should be avoided. Other combined hormonal preparations such as the patch and the NuvaRing are also likely to be affected by her medication. The Depo-Provera injection is a safe long-term choice to use in patients taking enzyme-inducers as it is least likely to be affected and should therefore be the most appropriate choice.

Question 26

A 23-year-old female attends her pharmacy as she is concerned that she may need the emergency contraceptive pill. She tells you that she had unprotected sex with her long-term partner 3 days ago and didn't think about contraception, as she gave birth to a baby girl only 2 weeks ago. She is formula-feeding her baby. What is the most appropriate advice?

Answer 26

Post-partum, women only require contraception 21 days from giving birth

Question 27

Zoe is a 21-year-old woman who does not use any form of regular contraception. Yesterday she had unprotected sexual intercourse. She has taken levonorgestrel 2 hours ago and has vomited once since. You have a telephone consultation with Zoe and she is unsure about what she should do next. With regards to her risk of pregnancy, what is the most important advice to give to Zoe?

Answer 27

If a patient vomits within 3 hours of taking the levonorgestrel, she should take another dose NICE guidelines state: If a woman vomits within 3 hours of taking levonorgestrel or ulipristal acetate, prescribe a second dose of emergency hormonal contraception to be taken as soon as possible.

Question 28

A 20-year-old student calls the GP telephone clinic for advice. One of her housemates has been diagnosed with meningococcal meningitis and she has been given ciprofloxacin as contact prophylaxis. However, she has not taken this yet as she is worried that it will reduce the effectiveness of her contraceptive pill. Her only medical history is migraine with aura. She isn't sure what kind of contraceptive pill she takes, but she uses it every day with no break and has no allergies. What should the patient do with regards to contraceptive precautions while taking ciprofloxacin?

Answer 28

**Progestogen only pill + antibiotics - no need for extra precautions** Ciprofloxacin is a cytochrome P450 (CYP450) inhibitor, not an inducer. This means that the efficacy of this patient's contraception is not affected and she does not need to use additional barrier contraception. If she were taking rifampicin, an alternative choice for meningococcal contact prophylaxis, she should also use barrier contraception during and for four weeks after cessation of treatment as this drug is a potent enzyme inducer and therefore can decrease the plasma concentration and efficacy of contraceptive pills.

Question 29

A 44-year-old female has a Mirena (intrauterine system) fitted for contraception on day 12 of her cycle. How long will it take before it can be relied upon as a method of contraception?

Answer 29

**7 days** **Contraceptives - time until effective (if not first day period):** **instant**: IUD **2 days**: POP **7 days**: COC, injection, implant, IUS

Question 30

A 42-year-old woman visits her GP to discuss contraception. Her past medical includes hypertension, type 1 diabetes mellitus and current breast cancer (for which she is receiving treatment). She was also diagnosed with deep vein thrombosis of the left leg, last week, for which she is being treated. She smokes 30 cigarettes per day and her BMI is 38 kg/m2. She is keen on an injectable progesterone contraceptive. Which element of her history is an absolute contraindication to the GP prescribing this?

Answer 30

Current breast cancer is a contraindication for injectable progesterone contraceptives

Question 31

How often is the Depo Provera (medroxyprogesterone acetate) injectable contraceptive given?

Answer 31

Depo Provera is the main injectable contraceptive used in the UK\*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions\*\*

Question 32

You are in your GP practice and are counselling a 25-year-old female about the contraceptive patch. What is the correct way to utilise the contraceptive patch effectively?

Answer 32

**Contraceptive patch regime: wear one patch a week for three weeks and do not wear a patch on week four** This form of combined contraception is becoming increasingly common as the patch change can be delayed for up to 48 hours without the need for additional contraception. This reduces human error in contraceptive effectiveness. Furthermore, its transdermal absorption means that additional precautions are not required in cases of diarrhoea and vomiting. This form of contraception is taken similarly to the pill in the sense that there are 3 weeks of contraception use and then a 1 week break when the woman will have a withdrawal bleed. Therefore option 4 is the correct answer in this scenario.

Question 33

A 25-year-old woman presents for contraceptive advice. The patient is on day 14 of her cycle which is regular and around 28-30 days long. She has no significant medical history and no regular medications. She wants a method that will be effective immediately and something she won't have to remember to take. Which contraceptive method could be recommended to her?

Answer 33

**Contraceptives - time until effective (if not first day period):** ## Footnote **instant**: IUD 2 **days**: POP 7 **days**: COC, injection, implant, IUS

Question 34

A 21-year-old woman comes to see you because she has missed a dose of her combined oral contraceptive pill (COCP). She is on day 10 of her current packet and missed the pill yesterday, around 26 hours ago. She has taken all other pills on time and has not had any recent diarrhoea or vomiting. Her last episode of unprotected sexual intercourse was 12 hours ago. The patient calls to ask whether she needs emergency contraception. What would be the most appropriate management option for this woman?

Answer 34

COCP: If 2 pills are missed in week 1, consider emergency contraception if she had unprotected sex during the pill-free interval or week 1. Patients who are on the combined oral contraceptive pill need to be offered emergency contraception if they have missed two or more pills and have had unprotected sexual intercourse during the pill-free period or week 1 of the pill packet. This woman has missed only one pill on day 9 and therefore does not require emergency contraception. Emergency contraception would be required if she had unprotected sex during the pill-free interval or during week 1 (days 1-7) of the pill packet and had missed two pills.

Question 35

A 39-year-old woman was diagnosed with breast cancer 1-month ago and is currently awaiting a wide local excision. She has commenced a new relationship and requests your advice regarding contraception. Many years ago during her previous relationship, she was on the depo injection and would be keen to restart this if possible. She is a non-smoker and reports no migraines or history of venous thromboembolism. Her body mass index (BMI) is 24kg/m². What is the most appropriate contraception option out of the options below?

Answer 35

Current breast cancer is a contraindication for injectable progesterone contraceptives Current breast cancer is a contraindication for all hormonal contraceptives options (UKMEC 4), including the Depo-Provera.

Question 36

A 29-year-old female presents to her GP as she missed her Micronor pill (progestogen-only) this morning and is unsure what to do. She normally takes the pill at around 08:30 and it is now 10:00. What advice should be given?

Answer 36

Take missed pill now and no further action needed

Question 37

Missed pill rules

Answer 37

Question 38

Rules of progesterone-only missed pills (3)

Answer 38

**Action required, if needed:** ## Footnote take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day continue with rest of pack extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Question 39

A 32-year-old female requests emergency contraception. She had unprotected sexual intercourse 28 hours ago and is not using any regular contraception. She has a diagnosis of obesity, severe asthma and uterine fibroids with distortion of the uterine cavity. Which emergency contraceptive should be used?

Answer 39

**The correct answer is: Levonorgestrel (double standard dose)** Levonorgestrel 1.5mg (standard dose) can be used as emergency contraception and should be taken as soon as possible within 72 hours of unprotected sexual intercourse. The dose should be doubled to 3mg levonorgestrel for those with a BMI \>26 kg/m2 or weight over 70kg. As this patient has a diagnosis of obesity we know her BMI is 30 kg/m2 or higher. Therefore, the answer is levonorgestrel 3mg. Ulipristal should be avoided due to her history of severe asthma. Intrauterine devices are not recommended in patients with distortion of the uterine cavity secondary to fibroids.

Question 40

A 29-year-old female requests emergency contraception. She had unprotected sexual intercourse 7 days ago. Her LMP was 16 days ago, her cycle is usually 30 days. She was using condoms intermittently for contraception and takes no regular medications. What it the most appropriate contraception?

Answer 40

**The correct answer is: Copper intrauterine device** The copper intrauterine device can be used as emergency contraception if it is inserted within 5 days of UPSI, **or up to 5 days after the likely ovulation date.**

Question 41

A 41-year-old female called this morning to request emergency contraception. She had unprotected sexual intercourse 48 hours before calling and is not using any regular contraception. Currently, she is breastfeeding. There is no medical history of note and she weighs 55 kg. She declined an intrauterine device and you prescribed an emergency hormonal contraception however she calls during your afternoon clinic to say she vomited one hour after taking this. What is the most appropriate emergency contraception?

Answer 41

**The correct answer is: Levonorgestrel (standard dose)** Vomiting occurs in around 1% of patients who take levonorgestrel. If vomiting occurs within 3 hours then the dose should be repeated. **Breastfeeding should be delayed for one week after taking ulipristal.** There are no such restrictions with levonorgestrel and so levonorgestrel is more appropriate for this patient.

Question 42

A 33-year-old female presents to her GP as she missed her Noriday pill (progestogen only) this morning and is unsure what to do. She normally takes the pill at around 0900 and it is now 1230. What advice should be given?

Answer 42

**Take missed pill as soon as possible and advise condom use until pill taking re-established for 48 hours** *Action required, if needed:* take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day continue with rest of pack extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Question 43

How does the combined oral contraceptive pill work?

Answer 43

inhibits ovulation

Question 44

How does the Implantable contraceptive (etonogestrel) work?

Answer 44

Inhibits ovulation The Faculty for Sexual and Reproductive Health (FSRH) state The progestogen-only implant is a long-acting reversible method of contraception (LARC). The primary mode of action is to prevent ovulation. Implants also prevent sperm penetration by altering the cervical mucus and possibly prevent implantation by thinning the endometrium.

Question 45

How does the Intrauterine system (levonorgestrel) work?

Answer 45

Primary: Prevents endometrial proliferation Also: Thickens cervical mucus

Question 46

How does the desogestrel-only pill work?

Answer 46

Primary: Inhibits ovulation Also: thickens cervical mucus

Question 47

How does the Progestogen-only pill (excluding desogestrel) work?

Answer 47

Thickens cervical mucus

Question 48

How does the combined oral contraceptive pill work?

Answer 48

Inhibits ovulation

Question 49

A 26-year-old woman presents to her GP, asking about emergency contraception. She had unprotected sexual intercourse with a male partner 7 days ago. She has a regular 28-day menstrual cycle and, based on her last period, estimates that today is day 17 of her current cycle. What can be used as emergency contraception for this patient?

Answer 49

The **copper intrauterine device** can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within **5 days of the earliest estimated date of ovulation**, whichever is later

Question 50

A 27-year-old woman who is on the combined oral contraceptive pill (COCP) requests advice. She is currently on day 10 of her cycle and has forgotten to take her last two pills. Prior to this incident, she took her pill correctly every day. She had unprotected sexual intercourse 12 hours ago and wonders if she needs to take emergency contraception to prevent pregnancy. What would be the most appropriate advice to give her?

Answer 50

**If two pills are missed, between days 8-14 of the cycle, no emergency contraception is required, as long as the previous 7 days of COCP have been taken correctly** The Faculty of Sexual and Reproductive Health advises that for women who are established on the COCP, no emergency contraception is required if two pills are missed between days 8-14 of the cycle, provided that the woman had taken the previous 7 days of pills correctly. We are told that the patient in this scenario doesn't usually have a problem taking her pill, and therefore can be safely assumed that she doesn't require emergency contraception in order to prevent pregnancy.

Question 51

A 19-year-old woman presents to your surgery after engaging in unprotected sexual intercourse (UPSI) 4 days ago. She is not on any contraception and is worried she will become pregnant. This woman has a past medical history of major depression and severe asthma, for which she takes 25mg OD sertraline, 200 micrograms salbutamol inhaler PRN, beclomethasone 400 micrograms BD and formoterol 12 micrograms BD. She is on day 25 of a 35 day cycle. What is the most appropriate intervention to prevent this woman becoming pregnant?

Answer 51

**The answer is the intra-uterine device aka the copper coil.** This woman is presenting 4 days (96 hours) after UPSI. The levonorgestrel pill is only effective up to 72 hours after UPSI, so is not appropriate. Ulipristal is effective up to 120 hours after UPSI, but is cautioned due to this patient's severe asthma, thus the IUD would be the most appropriate in this scenario. **\*Ulipristal should be used with caution in patients with severe asthma**

Question 52

A 25-year-old woman is to have an elective laparoscopic cholecystectomy in 8 weeks time. She takes no medications other than the combined oral contraceptive pill. What should be done with regards to her pill and her upcoming surgery?

Answer 52

**Stop the pill 4 weeks before surgery and restart 2 weeks after surgery** This is a very common situation for surgical patients. The combination of undergoing surgery (especially abdominal or lower limb) and being on the pill are two independent and synergistic risk factors for venous thromboembolism, and so the pill must be stopped.

Question 53

A 28-year-old primigravida has a spontaneous vaginal delivery at 38+2 weeks gestation. It is midwife-led and uncomplicated. She is reviewed the following morning on the post-natal ward by the obstetric team as she is requesting contraception. Her notes show she has no past medical history and no allergies. She is bottle-feeding the infant. Prior to conceiving, she was taking the combined oral contraceptive pill and she is keen to restart this. She reports that she could not tolerate the progesterone-only pill and doesn't like the idea of the intra-uterine system. What should the patient be counselled on?

Answer 53

The COCP should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum

Question 54

Lucy is a 28-year-old trans female (woman who was assigned male at birth) who books an appointment to discuss contraception with you. She is in a stable relationship with another woman and has regular penetrative unprotected intercourse. She has no past medical history and is in the process of gender reassignment using a combination of oestrogen and antiandrogen without as yet any surgical management. What is the most appropriate form of contraception to advise?

Answer 54

For patients assigned male at birth treated with oestradiol, GNRH analogs, finasteride or cyproterone, there may be a reduction or cessation of sperm production but it cannot be relied upon as a method of contraception

Question 55

A 32-year-old woman presents to general practice requesting the progesterone-only injectable contraceptive. She says that she has used this in the past and it works very well for her. She has a past medical history of migraines with aura and irritable bowel syndrome. She is currently receiving treatment for breast cancer and is awaiting investigations for unexplained vaginal bleeding. She smokes approximately 20 cigarettes a day. Why is this contraceptive method contraindicated?

Answer 55

**Current breast cancer is a contraindication for injectable progesterone contraceptives** According to the UK medical eligibility criteria, current breast cancer is an absolute contraindication for progesterone-only injectable contraceptives. Smoking \>15 cigarettes a day is a contraindication for the combined oral contraceptive pill. Migraine with aura is a contraindication for the combined oral contraceptive pill. Unexplained vaginal bleeding is a contraindication for the initiation of the intrauterine device (IUD) and the intrauterine system (IUS). Age \>30 is not a contraindication for any contraceptive.

Question 56

A 27-year-old female asks for advice regarding the Mirena (intrauterine system). What is the most likely effect on her periods?

Answer 56

Initially irregular bleeding later followed by light menses or amenorrhoea

Question 57

A 32-year-old woman attends to have her copper intrauterine device (IUD) removed. She is currently on day 4 of her regular 30-day menstrual cycle. Following the removal of the IUD, she would like to start the combined oral contraceptive pill (COCP). There are no contra-indications to the COCP. What is the most appropriate next step in the management of this patient?

Answer 57

**When switching from an IUD to COCP no additional contraception is needed if removed day 1-5 of cycle** The correct answer is that she can start the combined oral contraceptive pill (COCP) today , and does not require any additional contraception. When starting the COCP, it is effective immediately if started on days 1 - 5 of the menstrual cycle and this patient is on day 4. If the patient is unable to start the COCP today and she starts it from day 6 onwards, barrier contraception is required for 7 days.

Question 58

A 24-year-old woman presents to the clinic for family planning. She requests a form of contraception that will not interfere with sexual intercourse and is reversible upon stopping. She currently experiences heavy, painful, and irregular periods, but is otherwise fit and well. It is suggested she starts the combined oral contraceptive pill (COCP) as there are no contraindications and it might help her symptoms. What additional health benefits might this medication provide?

Answer 58

**Decreased risk of endometrial cancer​** Combined oral contraceptive pill * increased risk of breast and cervical cancer * protective against ovarian and endometrial cancer

Question 59

What is less common in women who take the combined oral contraceptive pill?

Answer 59

**Decreased risk of endometrial cancer​ and ovarian cancer** **Combined oral contraceptive pill** * increased risk of breast and cervical cancer * protective against ovarian and endometrial cancer

Question 60

A 33-year-old lady presents for pre-op assessment 4 weeks before elective ankle surgery. She will be immobilised for a minimum of 10 days following her surgery. What is the correct information to tell the patient regarding her combined oral contraceptive pill prior to surgery?

Answer 60

Stop immediately and switch to progestogen-only pill (POP) Oestrogen-containing contraceptives should preferably be discontinued 4 weeks before major elective surgery and all surgery to the legs or surgery which involves prolonged immobilisation of a lower limb. A progestogen-only contraceptive may be offered as an alternative and the oestrogen-containing contraceptive restarted after mobilisation.

Question 61

A 36-year-old woman attends her GP surgery seeking contraception. She smokes 20 cigarettes a day and has a body mass index of 25 kg/m². She denies a personal or family history of venous thromboembolism. She had a right-sided salpingectomy for an ectopic pregnancy six years ago. Which of the following methods of contraception would be contraindicated in this patient?

Answer 61

All methods of combined hormonal contraception, including the pill, patch and vaginal ring, are absolutely contraindicated in women over 35 smoking 15 cigarettes or more a day. The other four methods above can be used safely in this group.

Question 62

A 12-year-old girl presents to your GP clinic requesting some contraception. She has had a boyfriend for 8 months who is aged 13. What is the most appropriate immediate course of action to take?

Answer 62

**Contact the relevant safeguarding lead as this is a child protection issue.** A child under the age of 13 is always considered to be unable to consent for sexual intercourse. This is regardless of whether they are Gillick competent. As a result all consultations with this age group should automatically trigger child protection measures.

Question 63

A 34-year-old female presents to her GP for advice regarding contraception. She recently began seeing a new partner following a divorce and wants to begin the combined oral contraceptive pill. Her body mass index is 32 kg/m² and she is an ex-smoker, previously smoking 20 per day quitting 2 years previously. Her medical history is significant for frequent migraines as a teenager with no preceding aura, factor V Leiden disease and gestational hypertension during the pregnancy of her 2-year-old daughter. Which element of her history is the most significant contraindication to the combined oral contraceptive?

Answer 63

This question focuses on the different contraindications for the combined oral contraceptive. From NICE guidelines, the only absolute contraindication in the patients history is factor V leiden (a UKMEC 4 level, - unacceptable health risk) V leiden is a clotting disorder

Question 64

A 36-year-old female starts Cerazette (desogestrel) on day 7 of her cycle. How long will it take before it can be relied upon as a method of contraception?

Answer 64

2 days **Contraceptives - time until effective (if not first day period):** instant: IUD 2 days: POP 7 days: COC, injection, implant, IUS

Question 65

A 43-year-old woman would like to discuss her contraceptive options. She gave birth 6 months ago and has since been using the lactational amenorrhoeic method. Prior to this, she was only using barrier methods but after an unplanned pregnancy, she now wishes for a more reliable method that lasts as long as possible. She has no long-term medical conditions and smokes 5 cigarettes daily. Her only medication is mefenamic acid for heavy menstrual bleeding. What would be the most appropriate contraception?

Answer 65

**The correct answer is: Levonorgestrel intrauterine system** The levonorgestrel intrauterine system (LNG-IUS) would the most appropriate mode of contraception in this patient. The 52 mg LNG-IUS (Mirena) is licensed for 5 years of use, and hence provides a longer duration of contraceptive cover than the progestogen-only implant (3 years) and injection (3 months). She has expressed that she would prefer a reliable long-acting contraceptive, hence oral contraception would not be the ideal option. **Her smoking status also contraindicates the use of the combined oral contraceptive.** The copper intrauterine device tends to make periods heavier and therefore is less suitable in a woman with existing heavy menstrual bleeding.

Question 66

A 50-year-old woman would like to discuss her contraceptive options. She has recently been started on combined sequential HRT in the form of a transdermal patch as she has been having troublesome hot flushes and night sweats. Since starting HRT, she has been having monthly menstrual periods. She also has a history of large uterine fibroids which distort her uterine cavity. She is not taking any other medication and would prefer an option that she does not need to remember to take regularly.

Answer 66

**The correct answer is: Progestogen-only implant** It is important to remember that sequential/cyclical hormone replacement therapy (HRT) should not be relied on as contraception. All progestogen-only methods of contraception are safe to use as contraception alongside sequential HRT. In this patient, the coil would be inappropriate due to her history of fibroids distorting the uterine cavity - this would fall into UK Medical Eligibility Criteria (UKMEC) category 3 (risks outweigh the advantages). **In addition, the progestogen-only injectable is not recommended in women after the age of 50 due to its effect on reducing bone mineral density.** As a result, she could be offered either the progestogen-only pill or implant. As she has stated a preference for a long-acting contraceptive, the implant would be the most suitable option.

Question 67

Which contraceptive is never offered in women over 50?

Answer 67

The progestogen-only injectable is not recommended in women after the age of 50 due to its effect on **reducing bone mineral density.**

Question 69

A 21-year-old woman presents to her GP concerned as she had unprotected sexual intercourse (UPSI) four days previously. Her past medical history includes asthma and psoriasis. She has a latex allergy. She uses oral steroids to control her asthma and takes no regular medication. You recommend the copper coil. The patient states that her housemate recently took the 'EllaOne emergency pill' (ulipristal acetate) and she states that she would rather take a pill than have a coil inserted. Why can this patient not use the same method as her housemate?

Answer 69

Ulipristal should be used with caution in patients with severe asthma

Question 70

A 21-year-old female presents to general practice requesting emergency contraception. She had unprotected sexual intercourse with her long-term partner around 15 hours ago. She is not taking any regular contraception. She has no past medical history or family history of note. Her body mass index (BMI) is 32kg/m². She is a non-smoker. Which is the most effective method of emergency contraception for this patient?

Answer 70

The copper intra-uterine device is the most effective form of emergency contraception and is not affected by BMI The BNF states that the copper intra-uterine device is the most effective method of emergency contraception and should be offered to all appropriate women seeking emergency contraception. Its effectiveness is not known to be affected by BMI or other medications. An additional benefit of the copper intra-uterine device in this patient would be providing long-term contraception. The BNF states that oral hormonal emergency contraception should be offered if the copper intra-uterine device is not appropriate or acceptable to the patient. In addition, the effectiveness of the oral hormonal emergency contraceptives is thought to be reduced in patients with a high BMI. A double dose of levonorgestrel (Levonelle) is advised in patients with a BMI of over 26kg/m² or body weight greater than 70kg. It is not known which of the two oral hormonal contraceptives is more effective for patient with a raised BMI.

Question 71

A 24-year-old woman presents to the sexual health clinic requesting emergency contraception. She had unprotected sexual intercourse 2 days ago. She usually takes the combined oral contraceptive pill, but she has missed her last 3 pills. She is on the 8th day of her cycle. She has asthma and takes fluticasone and salbutamol inhalers. She is given levonorgestrel. What would be the correct advice to give the patient?

Answer 71

**Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception** Levonorgestrel is a method of emergency contraception (EC) that is licensed for use up to 72 hours after unprotected sexual intercourse. It is the oral EC of choice in patients with asthma as ulipristal is not recommended in patients with severe asthma. After taking levonorgestrel as EC, patients can restart their pill immediately. **This is in contrast to ulipristal where they are generally advised to wait 5 days**. The patient should be advised to use condoms for 7 days after restarting her combined oral contraceptive pill (COCP).

Question 72

Levonorgestrel important information | (10)

Answer 72

mode of action not fully understood - acts both to stop ovulation and inhibit implantation ## Footnote should be taken as soon as possible - efficacy decreases with time must be taken within 72 hours of unprotected sexual intercourse (UPSI)\* single dose of levonorgestrel 1.5mg (a progesterone) the dose should be doubled for those with a BMI \>26 or weight over 70kg 84% effective is used within 72 hours of UPSI levonorgestrel is safe and well-tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1% if vomiting occurs within 3 hours then the dose should be repeated can be used more than once in a menstrual cycle if clinically indicated hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception

Question 73

Ulipristal imoportant information | (7)

Answer 73

a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation ## Footnote 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse concomitant use with levonorgestrel is not recommended Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period caution should be exercised in patients with severe asthma repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

Question 74

A 34-year-old woman attends her GP surgery as she is worried about having forgotten to change her combined contraceptive patch. She is 24 hours late in changing the patch and has had sexual intercourse during this time. This is the first time it has happened. What advice will you give her?

Answer 74

**Apply a new patch immediately, no further precautions needed** **If the delay in changing the patch is less than 48 hours**, it should be changed immediately and no further precautions are needed. **If the delay is greater than 48 hours,** the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.

Question 75

A 21-year-old woman at 34 weeks gestation telephones her GP for advice. Her pregnancy is progressing well but she is keen to explore which contraceptive options are available to her following childbirth. After an extended discussion, her preferred option would be the contraceptive implant. The patient has no underlying medical conditions and does not plan to breastfeed. From what timepoint could this patient commence on this treatment?

Answer 75

**A contraceptive implant can be safely inserted any time after childbirth** Contraceptive implants can be safely inserted immediately following childbirth. Although only minimal amounts of the progesterone released by a contraceptive implant will enter breastmilk, the manufacturer of the UK's most widely used implant Nexplanon® advises inserting after 4 weeks postpartum in a breastfeeding woman. Although there is no evidence that a contraceptive implant can result in foetal or maternal harm, inserting an implant during pregnancy is inappropriate as the risk of a complication cannot be fully excluded.

Question 76

A 23-year-old woman is requesting combined oral contraception. She has been taking the progesterone-only pill (norethisterone) due to concerns about blood clotting adverse effects. She is not satisfied with the irregular bleeding she gets with this medication and wants to change. There are no contraindications to the combined oral contraceptive pill. What advice should be given to her regarding additional contraception when switching?

Answer 76

**When switching from a traditional POP to COCP (with correct prior use) 7 days of barrier contraception is needed** The safest option in this situation would be to recommend 7-days of barrier contraception while commencing the combined oral contraceptive to prevent unwanted pregnancy. This is the standard length of time that protection needs to be used when commencing this medication outside of menstruation.

Question 77

A 32-year-old woman is reviewed at 3 days post-partum on the postnatal ward. She had an uncomplicated, elective lower-segment caesarean section. This was her first child and she is keen to exclusively breastfeed. Her lochia is normal and she is mobilising to the bathroom independently. She is to be discharged later that day and is keen to start contraception immediately. At different points in time before her pregnancy, she reports using the combined oral contraceptive pill and an intrauterine device, both of which suited her. What should she be offered?

Answer 77

**Postpartum women (breastfeeding and non-breastfeeding) can start the progestogen-only pill at any time postpartum** While an intrauterine device can be fitted during a caesarean section (ideally within 10 minutes of the passage of the placenta), **once the wound is closed it is advised to wait 4-6 weeks post-partum** before having it inserted vaginally. While contraception may reduce the volume of breast milk produced, **it is incorrect to inform the patient that she cannot start any contraception if she wishes to breastfeed** as the progesterone

Question 78

A 24-year-old female presents to her general practitioner seeking contraception. She has a past medical history of spina bifida, for which she uses a wheelchair. She has a family history of endometrial cancer, smokes 5 cigarettes a day and regularly drinks 20 units of alcohol per week. Her observations show: * Respiratory rate 18/min * Blood pressure 95/68mmHg * Temperature 37.1ºC * Heart rate 92 bpm * Oxygen saturation 97% on room air Which of the following would be a contraindication for starting the combined oral contraceptive pill for this patient?

Answer 78

Wheelchair users should not be prescribed the COCP as first-line contraceptive, as they are 'UKMEC 3'- risks outweigh benefits

Question 79

An 18-year-old presents to her GP to discuss contraception. After counselling her on the various options, the patient decides to start a progesterone-only pill. She is currently on day 16 of her normal 29 day cycle. If the patient were to start the pill today, for how many additional days would she need to use additional contraceptive methods to prevent pregnancy?

Answer 79

2 days **Contraceptives - time until effective (if not first day period):** **instant**: IUD **2 days**: POP **7 days**: COC, injection, implant, IUS

Question 80

A woman presents to have a Nexplanon (etonogestrel) inserted. Where is the most appropriate place to insert the implant?

Answer 80

Implantable contraceptives (Nexplanon) - subdermal

Question 81

What is the correct site for epidural anesthesia?

Answer 81

The correct site for epidural anaesthesia is * L2-3 * L3-4