Contraception

Question 1

A 35-year-old woman presents to her GP to talk about contraception options. She has recently started a new relationship but is unsure if she may want children in the future. When you question her she has no problems with needles or insertion procedures. However, she struggles with heavy painful periods and dyspareunia and asks which option would be best for this. She has a past medical history of hypertension that runs in her family. There is no other relevant past medical or family history. An STI screen is negative.

What form of contraception would be best for this patient?

A. Combined oral contraceptive pill

B. Intrauterine device (IUD)

C. Intrauterine system (Mirena coil)

D. Progesterone-only implant

E. Progesterone-only pill

Answer 1

Answer: C
-An intrauterine system (e.g. Mirena) is particularly useful if patients have underlying medical problems (e.g. hypertension) +/- menstrual problems such as heavy periods
-1/3: lighter periods, irregular periods, no periods

Question 2

What are UKMEC3 conditions?

Answer 2

-more than 35 years old and smoking less than 15 cigarettes/day
-BMI > 35 kg/m^2*
-family history of thromboembolic disease in -first degree relatives < 45 years
-controlled hypertension
-immobility e.g. wheel chair use
-carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
-current gallbladder disease

Question 3

What are UKMEC4 conditions?

Answer 3

-Migraine with aura
-Current breast cancer
-Significant VTE risk factors (e.g. previous VTE, thrombogenic mutations, previous stroke, SLE, atrial fibrillation, age >35 and smoking >15 -cigarettes daily)
-Cardiovascular risk factors: hypertension (>160mmHg systolic or >100mmHg diastolic), history of ischaemic heart disease
-Severe liver disease
-breastfeeding <6 weeks

Question 4

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?

A. Copper coil

B. Levonorgestrel (Levonelle)

C. Mirena coil

D. No action required

E. Ulipristal acetate (EllaOne)

Answer 4

D: No action needed. Post-partum, women only require contraception 21 days from giving birth.

As sperm can survive in the vagina for up to 7 days, and the earliest date of ovulation after giving birth is 28 days postpartum, no contraception is needed until day 21. As this patient is 14 days postpartum, she does not need emergency contraception.

Question 5

Contraceptives - time until effective (if not first day period):
a) IUD
b) POP
c)COC, injection, implant, IUS

Answer 5

a) Immediately
b) 48 hours (2 days); takes 48 hours for progesterone to thicken cervical mucus
c) 7 days: takes this long for COCP to inhibit ovulation

Question 6

what is a safe long-term choice to use in patients taking enzyme-inducers?

Answer 6

1. Depo-Provera injection, 2. IUS, 3. IUD not affected by enzyme inducers) (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

COCP/POP affected by enzyme inducers

Question 7

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?

A. Start the combined oral contraceptive pill today, no further contraceptive is required

B. Use barrier contraception for 2 more days and start the combined oral contraceptive pill on day 7 of the menstrual cycle

C. Start the combined oral contraceptive pill today and use barrier contraception for 5 days

D. Wait for 5 days and then start the combined oral contraceptive pill

E. Start the combined oral contraceptive pill today and use barrier contraception for 7 days

Answer 7

A. Start the combined oral contraceptive pill today, no further contraceptive is required

-When switching from an IUD to COCP no additional contraception is needed if removed day 1-5 of cycle

• If the patient is unable to start the COCP today and she starts it from day 6 onwards (ie after day 5), barrier contraception is required for 7 days.

Question 8

why is BMI >35 relevant?

Answer 8

Her BMI of >35 is a relative contraindication (UKMEC 3) for the combined hormonal contraceptive options including the pill, patch, and NuvaRing.

Question 9

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 contraception option & why?

A. Ethinylestradiol
B. Levonorgestrel (standard dose)
C. Levonorgestrel (double standard dose)
D. Norethisterone
E. Ulipristal
F. Copper intrauterine device
G. Mirena intrauterine system
H. She has presented too late for emergency contraception

Answer 9

B. Levonorgestrel (double standard dose)

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.

Norethisterone and ethinylestradiol are not used as an emergency contraceptive.

Intrauterine devices are not recommended in patients with distortion of the uterine cavity secondary to fibroids.

Question 10

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.

A. Ethinylestradiol
B. Levonorgestrel (standard dose)
C. Levonorgestrel (double standard dose)
D. Norethisterone
E. Ulipristal
F. Copper intrauterine device
G. Mirena intrauterine system
H. She has presented too late for emergency contraception

Answer 10

Vomiting occurs in around 1% of patients who take levonorgestrel. If vomiting occurs within 3 hours then the dose should be repeated. She already had emergency contraception therefore repeat it (standard dose)

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 11

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?

A. Intra-uterine device

B. Levonorgestrel

C. Mirena coil

D. No intervention needed

E. Ulipristal (EllaOne)

Answer 11

A. IUD

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.

If period is 35 days, then ovulation should occur at 21 days (luteal phase=14 days fixed. Therefore, ovulation=cycle length-14 days)

IUD insertion:
-must be inserted within 5 days of UPSI, or
-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

When can IUD/IUS be inserted post-partum?

Answer 12

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks (28 days)

Question 13

What are the 2 types of POP (with names):

Answer 13

1. Traditional progestogen-only pill (eg Micronor, Noriday, Nogeston, Femulen)
2. Desogestrel-only pill (e.g. Cerazette)

Question 14

A 27-year-old female presents to her GP as she missed her desogestrel contraceptive pill (progestogen only) this morning and is unsure what to do. She normally takes the pill at around 0900 and it is now 1430. What advice should be given?

A. Emergency contraception should be offered

B. Perform a pregnancy test

C. Take missed pill as soon as possible and omit pill break at end of pack

D.Take missed pill now and no further action needed

E.Take missed pill now and advise condom use until pill taking re-established for 48 hours
42%

Answer 14

D.Take missed pill now and no further action needed

As desogestrel has a 12-hour window this patient should take the pill now with no further action being needed

Question 15

What are the missed pill rules for POP pills (traditional vs desogestrel)?

Answer 15

Question 16

What are the missed pill rules for COCP (if in week 1, 2 or 3)

Answer 16

-if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1

-if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*

-if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Question 17

What can be done to mitigate heavy, unscheduled bleeding (a side effect of the contraceptive implant (Nexplanon)?

Answer 17

3 months of COCP (makes periods lighter & more regular)

Question 18

A 22-year-old student consults her GP as she has some questions about the combined oral contraceptive pill. After her own background reading she is struggling to understand what the risk of an unplanned pregnancy would be if she were to start taking this form of contraception. Assuming the Pearl Index of the combined oral contraceptive pill is 0.2, how will you explain the failure rate of this form of contraception if used correctly?

A. For every thousand women using this form of contraception for one year, two would become pregnant

B. For every thousand women using this form of contraception for ten years, two would become pregnant

C. For every hundred women using this form of contraception for one year, two would become pregnant

D. 0.2% of women using this form of contraception become pregnant

E. If used as the sole form of contraception, the risk of an unplanned pregnancy after each episode of coitus is 0.2%

Answer 18

A. For every thousand women using this form of contraception for one year, two would become pregnant

-The Pearl Index describes the number of pregnancies that would be seen if one hundred women were to use the contraceptive method in question for one year. Therefore in the question, assuming the Pearl Index is 0.2 and the medication is adhered to perfectly, we would expect to see 0.2 pregnancies for every hundred women using the pill for one year - or 2 for every thousand.

Question 19

Which contraception option is most associated with weight gain?

Answer 19

Injectable contraception (eg Depo Provera)

Question 20

What are adverse effects of Depo Provera?

Answer 20

-irregular bleeding
-weight gain
-may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
-not quickly reversible and fertility may return after a varying time (up to 12 months)

Question 21

What is the only contraindication for Progesterone treatments (eg POP, implant) (UKMEC4)?

Answer 21

Active breast cancer

Question 22

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?

A. She can re-start at any time

B. She can restart after 48 hours

C. She can restart after 1 week

D. She can restart after 3 weeks

E. She can restart after 6 weeks

Question 23

A 24-year-old female attends for her 6-week postnatal check-up. She is not breastfeeding. She had a normal delivery. She would like to start contraception but is concerned about a delay in returning to fertility as she would like to try for another baby in the next 1-2 years. Which of these would most likely cause a delay in returning to normal fertility?

A. Progesterone only contraceptive implant

B. Intrauterine system (IUS) e.g. Mirena

C. Progesterone only injectable contraception

D. Combined oral contraceptive pill (COCP)

E. Progesterone only pill (POP)

Answer 23

C. Progesterone only injectable contraception

With progesterone only injectable contraception there can be a delay in return to natural fertility of up to 12 months. The other methods are not associated with such a delay.

Question 24

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?

A. Apply a new patch and use additional contraception for 7 days

B. Stop using the patch and change to a different contraceptive

C. Offer emergency contraception

D. Apply a new patch immediately, no further precautions needed

E. Offer a pregnancy test

Answer 24

The Evra patch is the only combined contraceptive patch licensed for use in the UK. The patch cycle lasts 4 weeks. For the first 3 weeks, the patch is worn everyday and needs to be changed each week. During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.

If the patch change is delayed at the end of week 1 or week 2:

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.

If the patch removal is delayed at the end of week 3:

The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.

If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.

Question 25

what is the mechanism of action of the Implantable contraceptive (etonogestrel)?

Answer 25

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.

The progestogen-only implant is a long-acting reversible method of contraception (LARC)

Question 26

A 47-year-old woman,comes to the clinic to discuss contraception. She stopped having her periods 12 months ago. She is normotensive with a blood pressure recording of 122/78 mmHg in clinic. She smokes 10 cigarettes per day. She has a past history of breast cancer, successfully treated 4 years ago. You advise:

A. Cerazette (Progesterone-only-pill)

B. No longer requires contraception

C. Copper Intrauterine Device (Cu-IUD)

D. Rigevidon (Combined oral contraceptive pill)

E. Depot injection

Answer 26

C. Copper Intrauterine Device (Cu-IUD)

This woman has entered the postmenopausal period as she has not had a period for 12 months. Even though she is postmenopausal she still requires contraception because she is under the age of 50. Guidelines advise: ‘Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman is aged under 50 years.’ (FSRH)

A copper coil is the best option for this woman because of her past history of breast cancer. All other methods, as they are hormonal, are a UKMEC Category 3, and this may be considered an unacceptable risk.

Question 27

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?

A. Stop in 2 weeks and use barrier contraception

B. Stop in 2 weeks and use progestogen-only pill (POP)

C. Stop immediately and switch to progestogen-only pill (POP)

D. Continue throughout surgery

E. Stop 2 days before surgery and use progestogen-only pill (POP)

Answer 27

C. 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 28

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?

A. To have a copper intrauterine device (IUD) fitted

B. No emergency contraception is required and to continue taking her pill as normal

C. To arrange oral emergency contraception

D. Depo-Provera (medroxyprogesterone acetate) injection

E. Advise her that it is too late for emergency contraception

Answer 28

B. No emergency contraception is required and to continue taking her pill as normal

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

If 1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed

If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’

if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1

if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Question 29

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

A. Condoms

B. Progestogen only pill

C. Intrauterine system (e.g. Mirena)

D. Injectable contraceptives (e.g. Depo-Provera)

E. Implantable contraceptive (e.g. Nexplanon)

Answer 29

D. Injectable contraceptives (e.g. Depo Provera)

due to its effect on reducing bone mineral density.

Question 30

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?

A. Days 1-7

B. Days 8-14

C. Days 15-21

D. Days 22-28

E. Anytime during cycle

Answer 30

E. Anytime during cycle

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.

Note the importance of advising the patient to refrain from intercourse or use adequate contraception to prevent pregnancy until the IUD is fitted.

Question 31

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?

A. Days 1-7

B. Days 8-14

C. Days 15-21

D. Days 22-28

E. Anytime during cycle

Answer 31

E. Anytime during cycle

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.

Note the importance of advising the patient to refrain from intercourse or use adequate contraception to prevent pregnancy until the IUD is fitted.

Question 32

A 53-year-old woman has recently entered into a relationship with a male partner. She has not been sexually active for 10 years and is now seeking advice regarding contraception. Her last menstrual period was 16 months ago. She does not take any regular medication. Her sister was recently diagnosed with breast cancer, hence she is keen to consider the option which confers the lowest risk of this.

A. Combined oral contraceptive pill
B. Progestogen-only pill
C. Progestogen-only injectable
D. Progestogen-only implant
E. Levonorgestrel intrauterine system
F. Copper intrauterine system
G. No contraception required

Answer 32

G. No contraception required

As this woman is over 50 years old and has been amenorrhoeic for over 12 months, she no longer requires contraception and it can be assumed that she is menopausal.

If she were under 50 years old, contraception would need to be continued until she was amenorrhoeic for 24 months.

Question 33

A 21-year-old who is not yet sexually active presents to her GP requesting contraception. She is aware that she does not wish to use barrier or long-acting contraception. Currently, her menstrual cycle is 28-days and she denies any gynaecological symptoms. Her past medical history is significant for migraine with aura, for which she uses sumatriptan. She takes no other medications and has no allergies.

On examination, her BMI is 20kg/m² and her blood pressure is 105/75mmHg.

Given the most appropriate contraceptive for her, what is the most likely side effect she will experience?

A. Breast tenderness

B. Dysmenorrhoea

C. Irregular vaginal bleeding

D. Mood changes

E. Weight gain

Answer 33

C. Irregular vaginal bleeding

Progestogen-only pill: irregular vaginal bleeding is the most common adverse effect

We can deduce that this patient has been prescribed the POP as she does not wish to use barrier contraception or long-acting reversible contraceptives (the injection, implant or intrauterine devices), leaving either the POP or combined-hormonal contraception (CHC) as options. This patient has migraines with aura, meaning that all CHC (i.e. the pill, patch or vaginal ring) is contraindicated due to the unacceptable risk of stroke. She therefore will have been prescribed the POP.

Question 34

What’s the most common side effect of POPs?

Answer 34

irregular vaginal bleeding

Question 35

An 18-year-old woman visits a family planning clinic to discuss methods of contraception. She has suffered from migraine with aura for the last eighteen months. Which one of the following contraceptive methods is classified by the UK Medical Eligibility Criteria as having no caution or contraindication to use in this condition?

A. Levonorgestrel-releasing intrauterine device

B. Combined oral contraceptive pill

C. Progestogen-only implant

D. Progestogen-only pill

E. Copper intrauterine device

Answer 35

E. Copper intrauterine device

Migraine with aura is a complete contraindication to using the combined oral contraceptive pill due to an increased risk of ischaemic stroke (UKMEC class 4). The progestogen-based methods of contraception and the levonorgestrel-releasing intrauterine device are classed as UKMEC 2 in patients who suffer from migraine with aura, indicating that ‘the advantages of using the method generally outweigh the theoretical or proven risks’. The only form of contraception that is recommended by the UKMEC as having no contraindication in this condition - i.e. UKMEC 1 - is the copper intrauterine device.

Question 36

what does COCP reduce the risk of?

Answer 36

Endometrial cancer
- Risk is reduced by at least 30%, with a greater risk reduction the longer oral contraceptives were used

Question 37

what does COCP increase risk of?

Answer 37

1. Breast (from oestrogen/progesterone)
2. cervical cancer (cervical ectropion)

Question 38

what red flags require cessation of COCP?

Answer 38

e.g. elevated blood pressure (>160mmHg), new onset headache or neurological symptoms, acute chest-pain / shortness of breath.

Question 39

what drugs, when given in combination with the combined oral contraceptive pill, would put a female at increased risk of pregnancy, namely reduce the effectiveness of the pill?

Answer 39

1. rifampicin
2. carbamezapine (anti-epileptics)
3. phenytoin (anti-epileptics)

Question 40

COCP contraindications (mnemonic)

Answer 40

Question 41

oestrogen & warfarin/steroids:

Answer 41

Oestrogens antagonise the effects of coumarins (warfarin) ie reduces effects of warfarin
-oestrogens increase plasma levels of steroids.

Question 42

Answer 42

The intrauterine system (Mirena)
vs laparoscopic tubal occlusion

Question 43

Answer 43

Irregular bleeding

Question 44

what are common side effects of contraceptive injection (unique to injection):

Answer 44

weight gain and osteoporosis

Question 45

A 36 year old female attends her GP practice to discuss contraception. She is 4 weeks post partum and is currently breast feeding. She has a past medical history of menorrhagia, she does not take any regular medication. She previously took a combined oral contraceptive pill (COCP).

Which of the following is most appropriate next step in managing this patient?

A. Restart the COCP

B. Intrauterine device (IUD)

C. Progesterone only pill (POP)

D. Reassure her that no contraception is needed when breastfeeding

E. Combined hormonal contraceptive patch

Answer 45

C. Progesterone only pill (POP)

The POP has no adverse affects on lactation or infant outcomes such as growth and development. Very small amounts of progesterone can be found in breast milk of those taking the POP.

Not D: Reassure her that no contraception is needed when breastfeeding

Contraception is not required for the first 21 days post partum, however, beyond that contraception is recommended even if still breastfeeding. Lactational amenorrhea is a temporary lack of fertility whilst breast feeding. Lactational amenorrhea method (LAM) is sometimes used as a form of ‘natural’ contraception. If used correctly it is effective with only 2 in 100 people becoming pregnant in the first 6 months post partum. However, it requires consistent and exclusive breast feeding and is only effective for the first 6 months. It is therefore recommended by the Faculty of Sexual and Reproductive Healthcare to implement contraception before 21 days.

Not A: Restart the COCP

The COCP is contraindicated less than 6 weeks post partum and breast feeding. There is an increased risk for VTE post-natally, this would be increased by use of COCP.

Not B: IUD

The IUD, also known as the copper coil, can commonly cause periods to be heavier. As this patient has a history of menorrhagia it is not a suitable option for her.

Not E: Combined hormonal contraceptive patch

Combined hormonal contraceptive patches such as Evra are contraindicated when less than 6 weeks post partum and breastfeeding. This is because of the increased risk for VTE postnatally which would be increased further with the use of a combined hormonal contraceptive patch.