Clinical challenge

Case 1

Michelle, a previously well woman, 18 years of age, presents to you seeking advice regarding contraception. She has been sexually active in a stable, monogamous relationship for the past six months. Michelle and her partner have been using condoms intermittently and the withdrawal method for contraception. She would like to know more about the various forms of contraception and their effectiveness.

Question 1

Which one of the following is the least effective form of contraception?

1. Progestogen subdermal implant
2. Copper intrauterine device (IUD)
3. Progesterone IUD
4. Progesterone injections

Question 2

Michelle is interested in learning more about the progestogen subdermal implant. Which one of the following conditions is an absolute contraindication to the use of the implant?

1. Severe cirrhosis
2. Unexplained vaginal bleeding
3. Migraines
4. Current breast cancer

Case continued

Michelle discloses that she had vaginal intercourse the night before without a condom and is concerned that her partner may not have withdrawn prior to ejaculation. She is early in her cycle and requests medical intervention to prevent pregnancy.

Question 3

Which one of the following emergency contraception methods is the most effective?

1. Copper IUD
2. Levonorgestrel (LNG) tablets
3. Ulipristal (UPA) tablets
4. Progesterone IUD

Question 4

Michelle decides that she would like to use tablets for emergency contraception and you prescribe UPA. In which one of the following situations is UPA safe and effective?

1. While breastfeeding
2. If taken during the luteinising hormone surge
3. If using combined oral contraceptive
4. If vomiting occurs within three hours of ingestion

Case continued

Following further discussion regarding long-term contraception, Michelle decides that she would prefer to take the combined oral contraceptive pill. Her only personal medical history of note is occasional migraines without aura.

Question 5

Which one of the following pre-existing medical conditions precludes safe prescription of the combined oral contraceptive pill?

1. Aged ≥40 years
2. Migraine with aura
3. Dyslipidaemia
4. Organ transplant

Question 6

As part of prescribing the combined oral contraceptive pill, you explain the seven-day rule to Michelle in relation to a missed pill. What is the definition of a missed pill in this context, in terms of number of hours late?

1. <12
2. 12–18
3. 18–24
4. >24

Question 7

Michelle has read about the risk of blood clots in association with the use of the combined oral contraceptive pill and is quite concerned. What is the rate of venous thromboembolism per 10,000 women in those taking the LNG and northisterone containing combined oral contraceptive pill?

1. <1
2. 1–4
3. 5–7
4. 8–10

Case continued

Michelle returns to see you several months after commencing the combined oral contraceptive pill. She states that she has been consistently experiencing spotting while taking the active pills. She is feeling well otherwise. You advise her that breakthrough bleeding is common in the first three to four months of combined oral contraceptive pill use, but declines over time.

Question 8

What is the approximate rate of breakthrough bleeding in women who have been on the combined oral contraceptive pill for 12 months?

1. 5%
2. 10%
3. 20%
4. 25%

Question 9

Which one of the following combined oral contraceptive pill preparations is the most effective management option for a patient with irregular bleeding on the combined oral contraceptive pill?

1. Preparation containing 20 µg ethinyloestradiol
2. Gestodene containing preparations
3. Triphasic preparations
4. Preparation containing 500 mg norethisterone

Case continued

After using the COCP for 12 months, Michelle finds that she is having difficulty remembering to take the pills on a regular basis and would like to try a long-acting reversible contraceptive (LARC). She has a close friend who had a copper IUD inserted, and she recommended it to Michelle, who would like more information. She is particularly concerned about reports of an elevated risk of ectopic pregnancy in IUD users.

Question 10

According to the European Active Surveillance Study for Intrauterine Devices, what is the overall ectopic pregnancy rate (reported as per 100 women-years) for copper IUD users?

1. 0.1–0.8
2. 0.9–1.6
3. 1.7–2.5
4. 2.6–3.3

Question 11

After considering the LARC options, Michelle elects to have a progestogen subdermal implant inserted. After 12 months, she presents with persistent irregular spotting, which she finds quite bothersome. Which one of the following is the least appropriate first-line management option for her irregular bleeding?

1. Norethisterone 5 mg three times a day for 21 days
2. Combined hormonal contraceptive for three months
3. Mefenamic acid 500 mg twice daily for five days
4. Tranexamic acid 500 mg twice daily for five days