Contraception

Question 1

Ruth, 33 years, G4P1 T3 has used Depot Provera for the past 5 years. She has no problems with this and wishes to continue. It is 91 days since her last Depot and she had intercourse last night. What is your management plan?

a) Advise condoms for 1 week and pregnancy test prior to Depo Provera

b) Give Depo Provera now

c) Give the emergency contraceptive pill

d) Insert post coital IUD

e) Wait for next period and give Depo

Answer 1

b) Give Depo Provera now

Question 2

Anne, aged 33 years, had her Jadelle implant inserted 10 weeks ago. She is worried as she has had spotting bleeding most days since insertion. You feel her arm and both rods are easily palpable and the insertion site is well healed. She is fit and well with no past history of note, apart from the fact that she smokes 5 cigarettes per day. Her BMI is 28 kg/m2. A pregnancy test is negative. Your advice about the bleeding is:

a) Bleeding may be due to her weight and she should have Jadelle removed after 4 years

b) If she waits for another few weeks this irregular bleeding is likely to settle

c) She should have the Jadelle removed as the bleeding means it is not an effective contraceptive

d) You prescribe the oral contraceptive pill on top today for 3 months

e) You prescribe Provera tablets on top as she cannot use the combined pill due to her age and smoking status

Answer 2

d) You prescribe the oral contraceptive pill on top today for 3 months

Question 3

Anne, aged 33 years, had her Jadelle implant inserted 10 weeks ago. She is worried as she has had spotting bleeding most days since insertion. You feel her arm and both rods are easily palpable and the insertion site is well healed. She is fit and well with no past history of note, apart from the fact that she smokes 5 cigarettes per day. Her BMI is 28 kg/m2. A pregnancy test is negative. Your advice about the bleeding is:

a) Bleeding may be due to her weight and she should have Jadelle removed after 4 years

b) If she waits for another few weeks this irregular bleeding is likely to settle

c) She should have the Jadelle removed as the bleeding means it is not an effective contraceptive

d) You prescribe the oral contraceptive pill on top today for 3 months

e) You prescribe Provera tablets on top as she cannot use the combined pill due to her age and smoking status

Answer 3

d) You prescribe the oral contraceptive pill on top today for 3 months

Question 4

Sarah usually takes her Levelen 30 continuously. She has just forgotten 4 pills in the first week of hormones in her new packet and had sex last night. Her BMI is 25 kg/m2. She wants your advice as she does not want to become pregnant. You advise that:

a) She needs to take the emergency contraceptive pill

b) She should have a postcoital IUD inserted as the emergency contraceptive pill won’t work as her BMI is 25 kg/m2

c) She just needs to keep on taking her pill every day

d) She should use double the dose of the emergency contraceptive pill as her BMI is 25 kg/m2

e) She needs to use condoms for the next 7 days

Answer 4

c) She just needs to keep on taking her pill every day

Question 5

A patient who is 8 weeks pregnant has been using a copper containing intrauterine device. On vaginal examination, the string is seen. Which of the following would be the most appropriate management of this patient?

a) Cut the string high in the cervix so that the device will retract up as the pregnancy develops

b) Perform a therapeutic abortion

c) Perform laparoscopy immediately to rule out ectopic pregnancy

d) Remove the device immediately after counselling about the risk of miscarriage

e) Remove the device only if signs of infection develop

Answer 5

d) Remove the device immediately after counselling about the risk of miscarriage

Question 6

The best lubricant to use with condoms is:

a) KY Jelly

b) Petroleum jelly

c) Mineral oil

d) Vegetable oil

e) Nonoxynl 9

Answer 6

a) KY Jelly

Question 7

Which of the following contraceptives is the most appropriate for a woman using Rifampicin?

a) Microlut

b) Femulen

c) Copper IUCD

d) Noriday

e) Marvelon 28

Answer 7

c) Copper IUCD

Question 8

Sally is a 42 year old current smoker and has been using Noriday for the last few years. She really does not want to get pregnant and has heard that there is another progestogen only pill called Cerazette and wonders would that give her better contraception. She does find it difficult to remember to take her Noriday at the same time every day. You advise:

a) At age (40) Cerazette will give her better contractive efficacy than Noriday.

b) Cerazette may be better for her as it has a “12 hour leeway“

c) If she takes 2 Noriday she will get better contraceptive cover

d) Neither progestogen only pill should be used in a woman who smokes cigarettes

e) She could change to the combined oral contraceptive pill as this will give her better contraceptive efficacy than Noriday

Answer 8

b) Cerazette may be better for her as it has a “12 hour leeway“

Question 9

Margaret, 40 years old, is starting Noriday. You discuss pill taking instructions. Which of the following is correct

a) If Margaret starts the pill on day 6 of her cycle she will have contraceptive protection from that day

b) If Margaret misses a pill she will not have contraceptive protection until she has taken 2 hormone pills in a row

c) Margaret will not have contraceptive protection while she takes antibiotics

d) Margaret must take the pill daily within 12 hours of the time that she usually takes the pill to maintain contraceptive cover

e) Margaret should always use condoms as well when she takes antibiotics

Answer 9

b) If Margaret misses a pill she will not have contraceptive protection until she has taken 2 hormone pills in a row

Question 10

Sally is fully breastfeeding Max, 5 months old. Sally has not had a menstrual period since becoming pregnant. She is feeding Max 3 or 4 times each day and once in the night. Sally and her partner are relying on condoms for contraception but are considering alternatives. They definitely do not want another pregnancy at this stage. Which of the following is correct?

a) You advise Sally that she does need contraception and cannot rely on lactational amenorrhoea method

b) Introducing solids to Max’s diet can reduce the effectiveness of contraceptive protection from breastfeeding

c) She should not have an IUD inserted because she has not had a period

d) She should not have a Jadelle subdermal implant as she is breast feeding

e) The combined oral contraceptive pill is contraindicated as Sally is breastfeeding

Answer 10

b) Introducing solids to Max’s diet can reduce the effectiveness of contraceptive protection from breastfeeding

Question 11

Natalie, 19 years old, would like to use Depo Provera. Possible side effects are discussed. Which of the following is correct?

a) Depot Provera has a risk of pregnancy of 1 in 100 users

b) She is likely to have no change to her bleeding pattern

c) She has an increased risk of developing ovarian cysts

d) There is no delay in return to fertility after stopping Depot Provera

e) There are no long term concerns about Depot Provera affecting bone density

Answer 11

e) There are no long term concerns about Depot Provera affecting bone density

Question 12

John is concerned about the possible risks and long term side effects of vasectomy. Which of the following is correct? Vasectomy:

a) Can be associated with the development of sperm granuloma

b) Has a failure rate of 1 per 200 procedures

c) Is performed under general anaesthesia

d) Increases the risk of a heart attack

e) May cause impotence

Answer 12

a) Can be associated with the development of sperm granuloma

Question 13

Which one of the following is correct?

a) Basal temperature monitoring is a more reliable form of contraception than the combined oral contraceptive pill

b) Fertile mucus is typically sticky and yellow

c) Sperm can survive up to 7 days in the vaginal crypts

d) The ovum is no longer fertilisable 48 hours after ovulation

e) The corpus luteum produces oestrogen which prepares the endometrial lining for implantation

Answer 13

c) Sperm can survive up to 7 days in the vaginal crypts

Question 14

Regarding the Mirena IUS, which statement is correct:

a) May cause initial irregular vaginal bleeding between periods

b) The Mirena IUS can be used as emergency contraception

c) The expulsion risk of an IUCD is 1 in 100

d) The Mirena IUS cannot be used for endometrial protection for a postmenopausal woman taking oral oestrogen for severe hot flushes

e) The Mirena IUS cannot be left in place for more than 5 years for a woman using it successfully for heavy menstrual bleeding and who has had a tubal ligation

Answer 14

a) May cause initial irregular vaginal bleeding between periods

Question 15

Which woman requires emergency contraception for unprotected intercourse?

a) After her placebo pills she missed 2 pills in the first active week of the combined pill and had sexual intercourse the next day

b) On day 3 of a 29 day cycle not using contraception

c) Missed 2 pills in the second week of a combined pill pack and had sexual intercourse the next day

d) On day 20 of a 29 day cycle not using contraception

e) Was 2 hours late with her progestogen only pill and had sexual intercourse the next day

Answer 15

a) After her placebo pills she missed 2 pills in the first active week of the combined pill and had sexual intercourse the next day

Question 16

A 35 year old woman, non-smoker, with a past medical history of an ectopic pregnancy and BP in clinic of 138/78 attends the clinic requesting contraception. You advise her that:

a) Levonorgestrel-releasing IUS (mirena) is UK MEC category 2

b) The Copper IUD is UK MEC category 1

c) The combined oral contraceptive pill is UK MEC 2

d) The progestogen only pill is UK MEC category 2

e) The depot medroxyprogesterone acetate injection is UK MEC category 3

Answer 16

b) The Copper IUD is UK MEC category 1

Question 17

Sarah is taking the combined oral contraceptive pill. She has is on day 4 of the first week of her hormone pills after taking her 7 placebo pills. She tells you that she is taking a 3 day course of antibiotics for a UTI which she started yesterday She has intercourse last night. She does not want to become pregnant. Your advice to Sarah:

a) To double up pills to minimize breakthrough bleeding

b) She needs to take the Emergency Contraceptive pill

c) She needs to take the 7 next pills in packet before contraception safe

d) No action required, continue taking pills

e) Use condoms for the next 7 days

Answer 17

d) No action required, continue taking pills

Question 18

Angela is 24 and is going to start Cerazette as she has had problems with all the combined pills she had previously tried. You advise her that:

a) If she started this pill on day 1-7 of her cycle she will have immediate contraception

b) She will get regular periods with this pill

c) She should try to take Cerazette at the same time every day and if she forgets she has a 12 hour leeway

d) The contraceptive efficacy of Cerazette is mainly from thickening of the cervical mucous

e) Cerrazette is fully subsidized in NZ

Answer 18

c) She should try to take Cerazette at the same time every day and if she forgets she has a 12 hour leeway

Question 19

Jane is 38 and a heavy smoker. She is an epileptic on sodium valproate and has a bicornuate uterus. Her BMI is 25. She had intercourse last night (Day 11 of 28 day regular cycle). The condom broke. She does not wish a pregnancy. You advise:

a) Emergency Contraceptive Pill is contraindicated

b) Postcoital IUCD

c) Postinor 1 – 1 pill stat

d) Postinor 1 – 2 pills stat

e) That she is not at risk of pregnancy

Answer 19

c) Postinor 1 – 1 pill stat

Question 20

The combined oral contraceptive pill increases the risk of which of the following:

a) Increases the overall risk of bladder cancer

b) Increases the overall risk of endometrial cancer

c) Increases the overall risk of ovarian cancer

d) Increases the overall risk of malignant melanoma

e) Increases the overall risk of thromboembolic disease

Answer 20

e) Increases the overall risk of thromboembolic disease

Question 21

Which of the following statements regarding copper IUD is true?

a) The main mode of action is to stop implantation

b) More women using IUDs will have an ectopic pregnancy compared to women using no contraception

c) When actinomyces is found in an IUD user the device must always be removed

d) When used as a postcoital contraceptive it needs to be inserted within 5 days (120 hours) after the first UPSI in a cycle or within 5 days after the earliest estimated date of ovulation

e) When used as emergency contraception has a failure rate of 5%

Answer 21

d) When used as a postcoital contraceptive it needs to be inserted within 5 days (120 hours) after the first UPSI in a cycle or within 5 days after the earliest estimated date of ovulation

Question 22

Which one of the following statements regarding the UK Medical eligibility criteria for contraceptive use is correct?

a) A history of cholecystectomy UKMEC category is 3 for combined pill

b) A history of positive antiphospholipid antibody UKMEC category is 2 for combined pill

c) A family history of mother with breast cancer UK MEC category is 1 for combined pill

d) Diabetic retinopathy is UKMEC category 2 for CuIUD

e) Gestational diabetes is UKMEC category 2 for the combined pill

Answer 22

c) A family history of mother with breast cancer UK MEC category is 1 for combined pill

Question 23

Jenny, 30 years old, is considering having a copper IUD inserted. She is married to Ben; they have a 3 year old daughter and would like another child in the future. Which one of the following would mean that you will suggest an alternative method of contraception for Jenny?

a) She had an ectopic pregnancy last year, treated by salpingectomy

b) She had an ovarian cyst diagnosed 5 years ago. This settled spontaneously

c) She has dysmenorrhea requiring pain relief each month

d) She had chlamydia cervicitis diagnosed and treated when she was 18 years old

e) She had Lletz treatment for CIN2 two years ago

Answer 23

c) She has dysmenorrhea requiring pain relief each month

Question 24

Which of the following are true of the emergency contraceptive pill (Postinor-1)

a) It is over 99% effective

b) It is effective up to 5 days after unprotected sex

c) Availability over the counter has been shown to decrease the rate of unplanned pregnancy at the population level

d) It is only effective before ovulation has taken place

e) Its main effect is to thicken cervical mucus

Answer 24

d) It is only effective before ovulation has taken place

Question 25

Which of the following statements regarding the copper IUD is correct

a) It is recommended for patients with Wilsons disease

b) It may be used as emergency contraception up to day 21 of a 30-day cycle

c) The commonest reported side effect is irregular bleeding

d) It is UKMEC 2 for nulliparous women

e) It is the second most effective form of emergency contraception

Answer 25

b) It may be used as emergency contraception up to day 21 of a 30-day cycle

Question 26

Maria presents for planned Mirena IUS insertion. She stopped her oral contraceptive pill 3 weeks ago and had unprotected sex 4 days ago. What would you do?

a) Explain she cannot have Mirena inserted today

b) Do a pregnancy test and if this is negative fit the Mirena IUS today

c) Fit the Mirena IUS today as emergency contraception

d) Fit the Mirena IUS today and bring her back for a pregnancy test in 3 weeks’ time

e) Insert the Mirena IUS today and give the emergency contraceptive pill at the same time

Answer 26

a) Explain she cannot have Mirena inserted today

Question 27

Jade is about to start the oral contraceptive pill. She discloses that she also takes St Johns Wort for mild depression. You should inform her

a) That she should ‘tricycle’ the pill, having a pill free interval only once every 3 months

b) That she is more likely to experience nausea as a side effect

c) That she is more likely to experience migraine as a side effect

d) That St John’s wort interacts with the oral contraceptive pill and advise her to use another method

e) That taking the contraceptive pill may cause her depression to worsen

Answer 27

d) That St John’s wort interacts with the oral contraceptive pill and advise her to use another method

Question 28

Which of the following statements regarding the progesterone only pill is true

a) Its main effect is to suppress ovulation

b) Its effect is lessened by lamotrigine

c) It may inhibit lactation

d) It inhibits sperm transport in the fallopian tubes

e) Its main effect is to thicken cervical mucus

Answer 28

e) Its main effect is to thicken cervical mucus

Question 29

Sarah is 16 and has come to the clinic to request Jadelle as her choice of contraception. She has been using condoms until now. Her periods are always irregular and she does not think she has had a period for 8 or 9 weeks. Pregnancy test today is negative. Which of the following would be the best option?

a) She should wait until her next period starts, then return for Jadelle insertion

b) She should be encouraged to start the oral contraceptive pill to regulate her cycles

c) She can have the Jadelle inserted today as long as she continues to use condoms for 7 days and returns for a pregnancy test in 3 weeks

d) She should be discouraged from having a Jadelle inserted as it is likely to make her periods more irregular

e) She should be investigated for polycystic ovarian syndrome before starting a new form of contraception

Answer 29

c) She can have the Jadelle inserted today as long as she continues to use condoms for 7 days and returns for a pregnancy test in 3 weeks

Question 30

Alba is 21 and would like to start the oral combined contraceptive pill. She has a complex past medical and family history. Which of the conditions below would lead you to recommend a different method for her?

a) A BMI of 37

b) Mother has had breast cancer aged 46

c) Past history of severe PID requiring hospital admission

d) Past history of depression and anxiety requiring medication

e) Sister had severe pre-eclampsia in her last pregnancy

Answer 30

a) A BMI of 37