A 43-year-old woman presents with fatigue, weight gain, and cold intolerance. TSH is 22 mU/L, free T4 is low. Anti-TPO antibodies are positive. She is trying to conceive. What is the TSH target?

$< 2.5 \mathrm{mU} / \mathrm{L}$

$< 1.0 \mathrm{mU} / \mathrm{L}$

$< 4.0 \mathrm{mU} / \mathrm{L}$

$< 6.0 \mathrm{mU} / \mathrm{L}$

$< 10.0 \mathrm{mU} / \mathrm{L}$

A 54-year-old woman who had a total abdominal hysterectomy with conservation of ovaries for fibroid-related menorrhagia 6 years ago presents with a 12-month history of troublesome vasomotor symptoms, mood disturbance, and poor concentration affecting her work as a teacher. She also reports reduced libido which is causing relationship difficulties. She has no other medical history, BMI is 24 kg/m², and she does not smoke. Her blood pressure is 118/76 mmHg. What is the most appropriate HRT regimen to address all her symptoms?

Transdermal estradiol patches with trial of testosterone supplementation if symptoms persist

Transdermal estradiol patches 50 mcg twice weekly

Oral estradiol 2 mg daily plus testosterone supplementation

Transdermal estradiol patches plus oral micronised progesterone

A 41-year-old parous woman requests contraception following the birth of her third child 4 weeks ago. She is not breastfeeding and is considering the combined oral contraceptive pill, which she used successfully between her previous pregnancies. She had an uncomplicated vaginal delivery with estimated blood loss of 400ml. She is a non-smoker with BMI of 26 kg/m² and no medical history of note. According to UKMEC criteria, when can she safely commence the combined oral contraceptive pill?

Immediately, as she is not breastfeeding

A 58-year-old woman with type 2 diabetes mellitus and a BMI of 31 kg/m² presents requesting continuation of her HRT. She was diagnosed with premature ovarian insufficiency at age 39 and has been taking continuous combined HRT (oral estradiol 2 mg with dydrogesterone 10 mg) since then. She currently has good glycaemic control (HbA1c 48 mmol/mol) on metformin alone and has no microvascular or macrovascular complications. She has no other cardiovascular risk factors and does not smoke. What is the most appropriate advice regarding HRT continuation?

Continue current HRT as benefits outweigh risks given her premature ovarian insufficiency

Switch to transdermal HRT as oral preparations are contraindicated in diabetes

Discontinue HRT immediately as she has now reached the age of natural menopause

Continue HRT but add aspirin for cardiovascular protection

Reduce to the lowest dose of HRT and plan to stop within 6 months

A 35-year-old woman with a history of previous ectopic pregnancy treated by laparoscopic salpingectomy 2 years ago presents requesting long-acting reversible contraception. She is in a new relationship and wishes to avoid pregnancy. She has regular periods, BMI of 25 kg/m², no other medical history, and is a non-smoker. She is particularly concerned about the risk of another ectopic pregnancy. What is the most appropriate contraceptive method to recommend?

52 mg levonorgestrel intrauterine system

Combined oral contraceptive pill

Depot medroxyprogesterone acetate injection

A 49-year-old woman commenced on sequential combined HRT (transdermal estradiol 50 mcg patches changed twice weekly plus oral micronised progesterone 200 mg for 14 days each month) 6 months ago for troublesome vasomotor symptoms. She reports good symptom control but has persistent irregular bleeding throughout the month, not just during the expected withdrawal bleed. Her last menstrual period before starting HRT was 14 months ago. Pelvic examination is normal. What is the most appropriate next step in management?

Arrange transvaginal ultrasound to assess endometrial thickness

Continue current regimen and reassure that irregular bleeding is expected in the first year

Switch to continuous combined HRT regimen

Stop HRT for 3 months then restart with a different preparation

Add tranexamic acid during bleeding episodes

A 28-year-old woman with well-controlled ulcerative colitis on mesalazine presents requesting contraception. She was recently started on azathioprine 150 mg daily by her gastroenterologist. She is in a stable relationship and desires highly effective contraception. She has regular menstrual cycles, BMI of 22 kg/m², and is a non-smoker with no other medical history. According to UKMEC criteria, which statement regarding contraceptive options is correct for this patient?

The combined oral contraceptive pill is UKMEC 1 with no restrictions

The etonogestrel implant is UKMEC 3 due to azathioprine interaction

The copper intrauterine device is UKMEC 3 due to immunosuppression

The levonorgestrel intrauterine system is UKMEC 2 due to increased infection risk

The depot medroxyprogesterone acetate injection is UKMEC 3 due to inflammatory bowel disease

A 52-year-old woman presents with troublesome vaginal dryness and dyspareunia. She went through natural menopause 3 years ago. She is reluctant to take systemic HRT as she had a previous venous thromboembolism 4 years ago related to prolonged immobilization following a fractured ankle. She has no other medical problems and takes no regular medications. Examination reveals vaginal atrophy with no other abnormalities. What is the most appropriate initial management?

Vaginal oestrogen therapy (estriol pessaries or estradiol tablets)

Systemic transdermal oestrogen-only HRT

Vaginal moisturizers and lubricants only

Systemic continuous combined oral HRT with low-dose oestrogen

Contraception for UKMLA AKT: High-Yield Women’s Health Lessons

Quick Overview

Contraception prevents unintended pregnancy through various mechanisms. NICE NG68 prioritizes Long-Acting Reversible Contraception (LARC) as first-line due to superior efficacy (failure rates <1% with typical use). Understanding UK Medical Eligibility Criteria (UKMEC) categories, quick-start protocols, and side effect management is essential for safe prescribing.

Core Facts & Concepts

UKMEC Categories:

UKMEC 1: No restriction (use method)
UKMEC 2: Advantages generally outweigh risks
UKMEC 3: Risks usually outweigh advantages (specialist input)
UKMEC 4: Unacceptable health risk (do NOT use)

Failure Rates (per 100 women-years):

LARC methods: IUS 0.2%, copper IUD 0.6%, implant 0.05%, depot injection 6%
Non-LARC: Combined pill 9%, POP 9%, condoms 18%, natural methods 24%

Figure 1: Diagram showing LARC contraceptive devices including IUD copper coil and hormonal IUS

Quick-Start Protocols (NICE NG68):

Start any time if reasonably certain not pregnant
Use 7-day bridging (condoms/abstinence) for CHC and POP
48-hour bridging for depot injection
Immediate protection: IUD inserted day 1-5 of cycle, or post-coitus as emergency contraception

Critical Numbers:

CHC: UKMEC 4 if >35 years + smoking ≥15/day, BMI ≥35, migraine with aura
Copper IUD: effective for 10 years (some models 5 years)
Levonorgestrel IUS (Mirena): 5 years licensed duration
Implant (Nexplanon): 3 years duration

⭐ Clinical Pearl: LARC methods are 20x more effective than user-dependent methods due to elimination of compliance issues.

Problem-Solving Approach

Step-by-Step Contraceptive Consultation:

Assess eligibility: Medical history (VTE risk, cardiovascular disease, migraine type, medications, BMI)
Pregnancy exclusion: LMP, recent unprotected intercourse, current contraception
Discuss LARC-first: Emphasize efficacy, cost-effectiveness, and convenience per NICE NG68
Address concerns: Bleeding patterns, hormonal vs non-hormonal options, STI protection needs
Initiate method: Apply quick-start if appropriate; arrange follow-up

Figure 2: Contraceptive implant insertion showing subdermal placement in upper arm

Managing Common Side Effects:

🚩 Unscheduled bleeding on hormonal contraception:

Exclude pregnancy, STIs, missed pills
Reassure: usually settles within 3 months
Consider switching progestogen type or adding CHC if on POP

🚩 Expulsion concerns (IUD/IUS):

Check threads monthly initially
Risk highest in first 3 months (5% expulsion rate)
Arrange scan if threads not palpable

Red Flags Requiring Immediate Action:

Severe abdominal pain (? ectopic pregnancy, perforation)
Heavy bleeding with signs of anemia
Chest pain/leg swelling on CHC (? VTE)
Severe headache with focal neurology (? stroke)

Analysis Framework

Method	UKMEC 4 Contraindications	Non-Contraceptive Benefits	Return to Fertility
CHC	Current VTE, migraine with aura, breast cancer, smoker >35y + ≥15/day	Regulates cycles, reduces dysmenorrhea/menorrhagia, ovarian/endometrial cancer protection	Immediate
Copper IUD	Pregnancy, unexplained vaginal bleeding, current PID, uterine cavity distortion	Emergency contraception (up to 5 days post-UPSI)	Immediate
LNG-IUS	Pregnancy, breast cancer, current PID	Treats menorrhagia (reduces bleeding 90%), endometrial protection	Immediate
Implant	Current breast cancer	Long-acting, no user error	Immediate
Depot injection	Current breast cancer, osteoporosis risk factors	Reduces sickle cell crises	Delayed (up to 12 months)

Quick Decision Rule:

Heavy periods → LNG-IUS (first-line per NICE)
BMI >35 → Avoid CHC; consider IUD/IUS/implant
Breastfeeding <6 weeks postpartum → Avoid CHC (UKMEC 4); POP safe from day 21

Visual Aid

Bridging Method Duration	Method
No bridging needed	Copper IUD (if day 1-5), POP if day 1-5
2 days	Depot injection
7 days	CHC, POP (if started after day 5), implant

Key Points Summary

✓ LARC-first approach per NICE NG68: failure rates <1% vs 9-18% for user-dependent methods

✓ UKMEC 4 absolute contraindications: CHC in migraine with aura, current VTE, breast cancer, smoker >35y + ≥15 cigarettes/day

✓ Quick-start anytime if reasonably certain not pregnant; use 7-day bridging for CHC/POP, 2-day for depot

✓ Copper IUD: most effective emergency contraception (up to 5 days post-UPSI), lasts 10 years, UKMEC 4 in active PID

✓ LNG-IUS: first-line for menorrhagia (90% reduction), lasts 5 years, return to fertility immediate

✓ Unscheduled bleeding: reassure settles in 3 months; exclude pregnancy/STIs before switching methods

✓ Red flags: severe abdominal pain (ectopic/perforation), chest pain/leg swelling on CHC (VTE), focal neurology (stroke)

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Contraception