Reproductive Health — MCQs
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A 52-year-old woman who has been taking sequential combined HRT for 14 months presents with a 10-day episode of vaginal bleeding that started on day 8 of her progestogen phase, which is earlier than her usual withdrawal bleed. The bleeding was heavier than normal. She has been compliant with her medication. Her last cervical screening 18 months ago was normal. Examination reveals a normal-sized, non-tender uterus. What is the most appropriate management?
A 31-year-old woman with body mass index of 39 kg/m² attends for review 6 weeks after insertion of a copper intrauterine device. She reports the device is working well with no problems. She asks when she needs to have the device changed. What is the licensed duration of use for the copper IUD for contraception in this patient?
A 48-year-old woman presents with an 8-month history of increasingly irregular menstrual cycles, hot flushes, and mood swings. Her last period was 4 months ago. She requests hormone replacement therapy. Her BMI is 23 kg/m², blood pressure is 124/78 mmHg, and she is a non-smoker. She has no significant medical history. Pelvic examination is normal. What is the most appropriate initial HRT regimen for this woman?
What is the maximum timeframe after the last menstrual period in a woman over 50 years of age during which ulipristal acetate can be used as emergency contraception?
A 29-year-old woman presents requesting removal of her etonogestrel contraceptive implant which was inserted 2 years ago. She reports a 4-month history of persistent irregular bleeding and has decided she would like to try for pregnancy. On examination, the implant cannot be palpated in the expected location in the upper arm. What is the most appropriate next step in management?
A 42-year-old nulliparous woman requests contraception. She has a history of focal epilepsy controlled on lamotrigine 200 mg daily. Her seizures have been well controlled for 3 years. She does not wish to become pregnant. What is the most important counselling point regarding combined oral contraceptive pill use in this patient?
A 54-year-old woman presents with severe vasomotor symptoms 18 months after her last menstrual period. She has a history of stage I endometrial cancer treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy 3 years ago. She is currently disease-free on surveillance. She requests hormone replacement therapy as lifestyle measures have been ineffective. What is the most appropriate management?
A 35-year-old woman with type 2 diabetes mellitus and a BMI of 34 kg/m² requests contraception. She has regular periods and is a non-smoker. Her blood pressure is 118/76 mmHg. She has tried oral contraceptive pills previously but frequently forgot to take them. She is interested in long-acting reversible contraception and particularly asks about the copper intrauterine device. What is the primary advantage of the copper IUD over the levonorgestrel intrauterine system for this patient?
A 55-year-old woman who experienced natural menopause at age 51 presents with vulvovaginal atrophy symptoms including severe vaginal dryness, dyspareunia, and urinary frequency. She declined systemic HRT 3 years ago due to concerns about breast cancer, as her sister was diagnosed with breast cancer at age 58. She has tried vaginal moisturisers with minimal benefit. What is the most appropriate management?
A 26-year-old woman presents for routine review. She had the etonogestrel contraceptive implant inserted 18 months ago. Since insertion, she has experienced frequent irregular bleeding, occurring approximately every 2-3 weeks for 5-7 days. She is otherwise well and wishes to continue with the implant due to its high efficacy, but the bleeding pattern is affecting her quality of life. What is the most appropriate management strategy?
Reproductive Health UK Medical PG Practice Questions and MCQs
Question 101: A 52-year-old woman who has been taking sequential combined HRT for 14 months presents with a 10-day episode of vaginal bleeding that started on day 8 of her progestogen phase, which is earlier than her usual withdrawal bleed. The bleeding was heavier than normal. She has been compliant with her medication. Her last cervical screening 18 months ago was normal. Examination reveals a normal-sized, non-tender uterus. What is the most appropriate management?
- A. Arrange transvaginal ultrasound to measure endometrial thickness
- B. Stop HRT for 3 months and reassess bleeding pattern
- C. Reassure and continue current HRT as breakthrough bleeding is common in the first year
- D. Switch to continuous combined HRT to reduce bleeding
- E. Arrange outpatient hysteroscopy and endometrial biopsy (Correct Answer)
Explanation: ***Arrange outpatient hysteroscopy and endometrial biopsy*** - In women on HRT for more than 6 months, any **unscheduled bleeding** or significant change in the withdrawal bleeding pattern requires urgent investigation to rule out **endometrial hyperplasia** or **malignancy**. - This patient’s bleeding is concerning because it is **heavier than normal**, lasted **10 days**, and occurred prematurely during the **progestogen phase** rather than after it. *Arrange transvaginal ultrasound to measure endometrial thickness* - While **transvaginal ultrasound** is a common first-line tool, it is less reliable for patients on HRT due to variations in **endometrial thickness** during the cycle. - **Hysteroscopy** and biopsy are preferred in this clinical scenario as they allow for **direct visualization** and histology, which is the gold standard for diagnosis. *Stop HRT for 3 months and reassess bleeding pattern* - Stopping HRT would delay the diagnosis of a potentially serious condition such as **endometrial cancer** and is not a recommended diagnostic strategy. - Management must focus on active investigation of the **abnormal bleeding** while the patient is still symptomatic. *Reassure and continue current HRT as breakthrough bleeding is common in the first year* - Breakthrough bleeding is common in the first **6 months**; however, this patient has been on HRT for **14 months**, making new bleeding patterns suspicious. - Reassurance is inappropriate because her bleeding started during the **progestogen phase**, which is not a normal physiological response to sequential HRT. *Switch to continuous combined HRT to reduce bleeding* - Switching to **continuous combined HRT** is only appropriate for women who are **postmenopausal** and have no suspicious bleeding symptoms. - Changing the formulation before excluding **endometrial pathology** is dangerous and could mask symptoms of an underlying malignancy.
Question 102: A 31-year-old woman with body mass index of 39 kg/m² attends for review 6 weeks after insertion of a copper intrauterine device. She reports the device is working well with no problems. She asks when she needs to have the device changed. What is the licensed duration of use for the copper IUD for contraception in this patient?
- A. 5 years as per standard licensing for all copper IUDs
- B. 10 years if the device contains ≥300 mm² copper (Correct Answer)
- C. 10 years regardless of copper content
- D. Indefinitely until menopause if inserted after age 40
- E. 5 years due to her obesity reducing device efficacy
Explanation: ***10 years if the device contains ≥300 mm² copper*** - Copper IUDs with a **copper surface area of 300 mm² or more** (e.g., T-Safe 380A) are licensed for **10 years** of use due to their sustained contraceptive efficacy. - The higher copper content ensures a consistent spermicidal and anti-implantation effect over a longer period, making them highly effective long-acting reversible contraception (LARC). *5 years as per standard licensing for all copper IUDs* - While some copper IUDs are indeed licensed for **5 years**, many newer or higher-copper-content devices have an **extended license of 10 years**. - The licensed duration is dependent on the specific **model and copper surface area** of the device, not a universal standard of 5 years for all. *10 years regardless of copper content* - The **amount of copper** in the device is a critical determinant of its licensed duration, with devices containing less copper generally having a shorter (e.g., 5-year) license. - Copper works by causing a local inflammatory reaction in the uterus, and a sufficient **surface area** is required to maintain this effect for an extended period. *Indefinitely until menopause if inserted after age 40* - This rule applies to copper IUDs inserted when a woman is **40 years or older**, allowing them to be kept until menopause for contraception. - However, the patient in this scenario is **31 years old**, meaning the device must be removed or replaced at the end of its licensed duration. *5 years due to her obesity reducing device efficacy* - The **efficacy of copper IUDs** is not affected by a woman's **body mass index (BMI)** or obesity, unlike some hormonal contraceptive methods. - Therefore, there is no medical reason to reduce the licensed duration of a copper IUD based on the patient's **BMI of 39 kg/m²**.
Question 103: A 48-year-old woman presents with an 8-month history of increasingly irregular menstrual cycles, hot flushes, and mood swings. Her last period was 4 months ago. She requests hormone replacement therapy. Her BMI is 23 kg/m², blood pressure is 124/78 mmHg, and she is a non-smoker. She has no significant medical history. Pelvic examination is normal. What is the most appropriate initial HRT regimen for this woman?
- A. Continuous combined HRT (estrogen and progestogen daily)
- B. Sequential combined HRT (estrogen daily with cyclical progestogen) (Correct Answer)
- C. Estrogen-only HRT with annual endometrial surveillance
- D. Tibolone as first-line therapy
- E. Progestogen-only preparation
Explanation: ***Sequential combined HRT (estrogen daily with cyclical progestogen)*** - This woman is **perimenopausal** (amenorrhea for less than 12 months) and has an **intact uterus**, thus requiring combined HRT to prevent **endometrial hyperplasia**. - The cyclical progestogen, administered for 10-14 days each month, ensures shedding of the uterine lining, leading to predictable **withdrawal bleeds** while managing symptoms. *Continuous combined HRT (estrogen and progestogen daily)* - This regimen is indicated for **postmenopausal women** who have been amenorrheic for at least **12 consecutive months**. - Initiating it during perimenopause often leads to high rates of **unscheduled or irregular breakthrough bleeding**, which is undesirable. *Estrogen-only HRT with annual endometrial surveillance* - **Estrogen-only HRT** is strictly reserved for women who have undergone a **hysterectomy**. - In a woman with an **intact uterus**, unopposed estrogen significantly increases the risk of developing **endometrial hyperplasia** and **endometrial carcinoma**. *Tibolone as first-line therapy* - **Tibolone** is a synthetic steroid with estrogenic, progestogenic, and androgenic properties, primarily used for **postmenopausal** symptoms and osteoporosis prevention. - Like continuous combined HRT, it is generally recommended only after **12 months of amenorrhea** to avoid unpredictable bleeding patterns. *Progestogen-only preparation* - **Progestogen-only** preparations are typically used for contraception or to manage heavy menstrual bleeding, not as primary therapy for **vasomotor symptoms**. - This regimen would not effectively alleviate the woman's **hot flushes** and other symptoms of estrogen deficiency.
Question 104: What is the maximum timeframe after the last menstrual period in a woman over 50 years of age during which ulipristal acetate can be used as emergency contraception?
- A. 72 hours
- B. 96 hours
- C. 120 hours (Correct Answer)
- D. 168 hours
- E. 144 hours
Explanation: ***120 hours*** - **Ulipristal acetate (UPA)** is a selective progesterone receptor modulator licensed for emergency contraception up to **120 hours** (5 days) after unprotected intercourse. - The timeframe remains the same regardless of age; women over **50 years** are still considered at risk of pregnancy until they are documented as **postmenopausal** (two years of amenorrhea if under 50, or one year if over 50). *72 hours* - This is the licensed timeframe for **Levonorgestrel (LNG)** emergency contraception, which is less effective than UPA between 72 and 120 hours. - While LNG works best within the first 24 hours, **Ulipristal acetate** maintains its efficacy throughout the entire 120-hour window. *96 hours* - **Levonorgestrel** may be used off-license up to 96 hours after intercourse, but its efficacy is significantly reduced at this point. - Research indicates that **Ulipristal acetate** is the preferred oral choice when the timeframe exceeds 72 hours due to its superior **ovulation delay** capabilities. *168 hours* - There is currently no oral emergency contraceptive pill licensed for use up to **168 hours** (7 days); both LNG and UPA are ineffective at this stage. - If more than 120 hours have passed, clinical assessment for a **Copper IUD** (which can be used up to 5 days after the earliest predicted ovulation) is required. *144 hours* - This duration exceeds the maximum **5-day therapeutic window** established for both Ulipristal acetate and the Copper IUD (post-intercourse). - Oral emergency contraception relies on **inhibiting ovulation**, which is statistically unlikely to be successful if the delay between intercourse and treatment is this long.
Question 105: A 29-year-old woman presents requesting removal of her etonogestrel contraceptive implant which was inserted 2 years ago. She reports a 4-month history of persistent irregular bleeding and has decided she would like to try for pregnancy. On examination, the implant cannot be palpated in the expected location in the upper arm. What is the most appropriate next step in management?
- A. Attempt removal under local anaesthetic using a small incision at the insertion site
- B. Arrange plain radiograph of the arm to locate the implant
- C. Arrange ultrasound scan of the arm to locate the implant (Correct Answer)
- D. Refer urgently to radiology for chest X-ray to exclude migration
- E. Reassure that the implant has dissolved and no further action is needed
Explanation: ***Arrange ultrasound scan of the arm to locate the implant***- **High-frequency ultrasound** (10-15 MHz) is the first-line investigation for a non-palpable **etonogestrel implant** as it is highly effective at identifying the device's location and depth.- Localization must be confirmed prior to any removal attempt to prevent **tissue damage** or a failed surgical procedure.*Attempt removal under local anaesthetic using a small incision at the insertion site*- **Blind exploration** is strictly contraindicated for non-palpable implants due to the risk of damaging underlying **nerves and vessels**.- It has a high failure rate and can lead to unnecessary **scarring** without guaranteeing the device is actually at that site.*Arrange plain radiograph of the arm to locate the implant*- Etonogestrel implants (Nexplanon/Implanon) are generally **not radio-opaque** enough for reliable detection on a standard **X-ray**.- Unlike the Jadelle system, these implants depend on **ultrasound or MRI** for visualization when they cannot be felt.*Refer urgently to radiology for chest X-ray to exclude migration*- **Migration** to the pulmonary vasculature is an extremely rare complication and is only considered if the implant is not found in the arm via **ultrasound or MRI**.- A **chest X-ray** is not the appropriate initial step for a patient presenting with an asymptomatic non-palpable device in the arm.*Reassure that the implant has dissolved and no further action is needed*- Contraceptive implants are made of **non-biodegradable** materials and do not dissolve in the body.- If the implant remains in situ, it may continue to release low levels of hormones, causing **irregular bleeding** and delaying the patient's desire for **pregnancy**.
Question 106: A 42-year-old nulliparous woman requests contraception. She has a history of focal epilepsy controlled on lamotrigine 200 mg daily. Her seizures have been well controlled for 3 years. She does not wish to become pregnant. What is the most important counselling point regarding combined oral contraceptive pill use in this patient?
- A. The COCP will reduce the effectiveness of lamotrigine requiring dose adjustment
- B. Lamotrigine will reduce the effectiveness of the COCP requiring additional contraception
- C. The COCP may reduce lamotrigine levels increasing seizure risk (Correct Answer)
- D. Both drugs interact causing increased risk of venous thromboembolism
- E. No significant interaction occurs between lamotrigine and the COCP
Explanation: ***The COCP may reduce lamotrigine levels increasing seizure risk***- The **ethinylestradiol** component of the COCP induces the liver enzyme **UDP-glucuronosyltransferase (UGT1A4)**, which significantly increases the metabolism and clearance of **lamotrigine**.- This interaction can cause a **50% or greater reduction** in serum lamotrigine concentrations, potentially leading to a loss of **seizure control** and requiring dose adjustment.*The COCP will reduce the effectiveness of lamotrigine requiring dose adjustment*- While this statement acknowledges the effect on lamotrigine, it is slightly less precise than the correct option which directly links the level reduction to the **clinical risk of seizures**.- It is important to note that because of this interaction, the **UKMEC** category for COCP use with lamotrigine is **Category 3**, suggesting the risks usually outweigh the benefits.*Lamotrigine will reduce the effectiveness of the COCP requiring additional contraception*- Unlike enzyme-inducing antiepileptics (e.g., carbamazepine), **lamotrigine** does not significantly induce the cytochrome P450 system and does not reduce the **contraceptive efficacy** of the COCP.- Patients do not need to take extra precautions to prevent pregnancy specifically because they are on lamotrigine; the concern is exclusively the **anti-epileptic's efficacy**.*Both drugs interact causing increased risk of venous thromboembolism*- While the COCP itself carries a baseline increased risk of **venous thromboembolism (VTE)**, there is no evidence that lamotrigine synergistically increases this specific risk.- The interaction between these medications is **pharmacokinetic** (metabolism-based) rather than **pro-thrombotic**.*No significant interaction occurs between lamotrigine and the COCP*- This is incorrect as a major **bidirectional interaction** exists; lamotrigine levels can drop during the active pill weeks and rise to toxic levels during the **pill-free interval**.- Clinicians must be aware of this interaction to avoid **toxic side effects** or **breakthrough seizures**, making monitoring and counselling essential.
Question 107: A 54-year-old woman presents with severe vasomotor symptoms 18 months after her last menstrual period. She has a history of stage I endometrial cancer treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy 3 years ago. She is currently disease-free on surveillance. She requests hormone replacement therapy as lifestyle measures have been ineffective. What is the most appropriate management?
- A. Prescribe continuous combined HRT with progestogen protection
- B. Offer cognitive behavioural therapy alone
- C. Prescribe estrogen-only HRT as she has had a hysterectomy
- D. Prescribe tibolone as it has weak estrogenic effects
- E. Offer selective serotonin reuptake inhibitors as first-line treatment (Correct Answer)
Explanation: ***Offer selective serotonin reuptake inhibitors as first-line treatment***- In patients with a history of **estrogen-dependent cancers** like endometrial cancer, **Hormone Replacement Therapy (HRT)** is generally contraindicated due to the risk of disease recurrence.- **SSRIs** or **SNRIs** (e.g., venlafaxine) are the first-line pharmacological non-hormonal alternatives proven to effectively reduce the frequency and severity of **vasomotor symptoms**.*Prescribe continuous combined HRT with progestogen protection*- While progestogens can counteract estrogenic effects on the endometrium, any form of systemic **estrogen** is avoided in survivors of **endometrial cancer** to minimize recurrence risk.- Combined therapy is usually reserved for women with an intact uterus; since this patient had a **hysterectomy**, combined HRT is not standard practice even in healthy individuals.*Offer cognitive behavioural therapy alone*- Although **CBT** can help manage the impact of menopausal symptoms, it is often insufficient as **monotherapy** for patients complaining of "severe" vasomotor symptoms.- Guidelines suggest combining lifestyle or behavioral interventions with **non-hormonal pharmacological** agents when symptoms significantly impact quality of life.*Prescribe estrogen-only HRT as she has had a hysterectomy*- Estrogen-only HRT is the standard for women post-hysterectomy, but it is strictly **contraindicated** here because her cancer was **estrogen-dependent**.- Even with Stage I disease and successful surgical resection (**TAH-BSO**), the potential risk of stimulating residual micrometastatic cells outweighs the benefits.*Prescribe tibolone as it has weak estrogenic effects*- **Tibolone** is a synthetic compound with estrogenic, progestogenic, and androgenic activity, making it unsuitable for women with a history of **hormone-sensitive malignancies**.- Its use is specifically discouraged in survivors of **breast or endometrial cancer** due to its estrogen receptor-stimulating properties.
Question 108: A 35-year-old woman with type 2 diabetes mellitus and a BMI of 34 kg/m² requests contraception. She has regular periods and is a non-smoker. Her blood pressure is 118/76 mmHg. She has tried oral contraceptive pills previously but frequently forgot to take them. She is interested in long-acting reversible contraception and particularly asks about the copper intrauterine device. What is the primary advantage of the copper IUD over the levonorgestrel intrauterine system for this patient?
- A. Lower risk of expulsion in obese women
- B. Shorter duration of action allowing more flexible fertility planning
- C. Non-hormonal method suitable for women with diabetes-related vascular complications (Correct Answer)
- D. Reduced menstrual blood loss compared to baseline
- E. Lower failure rate in overweight and obese women
Explanation: ***Non-hormonal method suitable for women with diabetes-related vascular complications***- The **copper intrauterine device (Cu-IUD)** is completely **non-hormonal**, making it an ideal choice for women with complex medical histories like diabetes where hormonal metabolic effects are a concern.- While progestogens are generally safe, a hormone-free method avoids any theoretical risk regarding **glucose metabolism** or **cardiovascular complications** associated with long-term steroid use.*Lower risk of expulsion in obese women*- There is no clinical evidence to suggest that the **Cu-IUD** has a lower **expulsion rate** compared to the **levonorgestrel intrauterine system (LNG-IUS)** based on BMI.- **Obesity** is generally not a risk factor for IUD expulsion; instead, factors like **age** and **parity** play a more significant role.*Shorter duration of action allowing more flexible fertility planning*- The **copper IUD** actually has a **longer duration of action** (approved for up to 10 years) compared to the LNG-IUS (approved for 5-8 years depending on the brand).- Both methods allow for an immediate **return to fertility** upon removal, so neither offers a specific advantage in planning flexibility.*Reduced menstrual blood loss compared to baseline*- This is incorrect as the **copper IUD** is well-known to potentially **increase menstrual blood loss** and cramping.- It is the **LNG-IUS**, not the copper IUD, that is the treatment of choice for reducing **menorrhagia** due to its local effect on the endometrium.*Lower failure rate in overweight and obese women*- Both the **Cu-IUD** and **LNG-IUS** are highly effective **Long-Acting Reversible Contraceptives (LARCs)** with failure rates of less than 1%.- Unlike some systemic hormonal methods (like the patch), the efficacy of **intrauterine devices** is not negatively impacted by a high **BMI**.
Question 109: A 55-year-old woman who experienced natural menopause at age 51 presents with vulvovaginal atrophy symptoms including severe vaginal dryness, dyspareunia, and urinary frequency. She declined systemic HRT 3 years ago due to concerns about breast cancer, as her sister was diagnosed with breast cancer at age 58. She has tried vaginal moisturisers with minimal benefit. What is the most appropriate management?
- A. Prescribe systemic continuous combined HRT as benefits outweigh risks at 4 years postmenopause
- B. Prescribe vaginal estradiol pessaries 10 mcg daily for 2 weeks then twice weekly maintenance (Correct Answer)
- C. Prescribe vaginal conjugated equine estrogens cream with cyclical progestogen for endometrial protection
- D. Prescribe ospemifene 60 mg daily as it is a selective estrogen receptor modulator
- E. Prescribe prasterone vaginal DHEA suppositories with concurrent systemic progestogen
Explanation: ***Prescribe vaginal estradiol pessaries 10 mcg daily for 2 weeks then twice weekly maintenance***- **Low-dose vaginal estrogen** is the **first-line medical treatment** for **Genitourinary Syndrome of Menopause (GSM)** when non-hormonal moisturizers fail.- It has **minimal systemic absorption**, making it safe for women with a family history of breast cancer and eliminates the need for **progestogen-mediated endometrial protection**.*Prescribe systemic continuous combined HRT as benefits outweigh risks at 4 years postmenopause*- The patient specifically **declined systemic HRT** due to safety concerns and her primary symptoms are localized to the vulvovaginal area.- While the "window of opportunity" (within 10 years of menopause) makes her a candidate for systemic therapy, **local treatment** is safer and more targeted for isolated atrophy.*Prescribe vaginal conjugated equine estrogens cream with cyclical progestogen for endometrial protection*- **Low-dose local estrogens** (like 10 mcg estradiol) do not require a **progestogen** because they do not cause significant endometrial proliferation.- **Conjugated equine estrogen (CEE)** creams are older formulations with potentially higher systemic absorption compared to modern low-dose estradiol pessaries.*Prescribe ospemifene 60 mg daily as it is a selective estrogen receptor modulator*- **Ospemifene** is an oral SERM indicated for dyspareunia, but **local vaginal estrogens** are generally preferred as first-line therapy due to direct action.- It carries a risk profile similar to other SERMs, including potential **thromboembolic events** and hot flushes, which makes local therapy a more conservative choice.*Prescribe prasterone vaginal DHEA suppositories with concurrent systemic progestogen*- **Prasterone (Vaginal DHEA)** is used for vulvovaginal atrophy but, like other local therapies, it does **not require systemic progestogen**.- While effective, low-dose estradiol pessaries are more established as the standard first-line local hormonal intervention.
Question 110: A 26-year-old woman presents for routine review. She had the etonogestrel contraceptive implant inserted 18 months ago. Since insertion, she has experienced frequent irregular bleeding, occurring approximately every 2-3 weeks for 5-7 days. She is otherwise well and wishes to continue with the implant due to its high efficacy, but the bleeding pattern is affecting her quality of life. What is the most appropriate management strategy?
- A. Remove the implant and insert a levonorgestrel intrauterine system
- B. Prescribe a short course of combined oral contraceptive pill to regulate bleeding (Correct Answer)
- C. Prescribe mefenamic acid to be taken during bleeding episodes
- D. Reassure that bleeding will settle by 2 years and no intervention is needed
- E. Remove the implant and insert a new one in the contralateral arm
Explanation: ***Prescribe a short course of combined oral contraceptive pill to regulate bleeding*** - A short course (usually 3 months) of the **combined oral contraceptive pill (COCP)** is a first-line management strategy to stabilize the **endometrium** and improve bleeding patterns in implant users. - This approach is suitable because the patient wishes to **retain the implant** for its high efficacy while needing a pharmacological intervention to improve her **quality of life**. *Remove the implant and insert a levonorgestrel intrauterine system* - While the **levonorgestrel intrauterine system (LNG-IUS)** typically results in lighter bleeding, the patient specifically stated a preference to **continue with the implant**. - Switching methods should be reserved for cases where **medical management** of bleeding fails or the patient no longer desires the current method. *Prescribe mefenamic acid to be taken during bleeding episodes* - **Mefenamic acid** (an NSAID) can reduce the volume and duration of bleeding episodes but is often less effective at **regulating the frequency** or unpredictability of bleeding compared to COCP. - It acts as a symptomatic treatment during active bleeding rather than **preventing future irregular episodes** by stabilizing the lining. *Reassure that bleeding will settle by 2 years and no intervention is needed* - While bleeding patterns can settle in early months, the patient has already had the implant for **18 months**, making spontaneous resolution unlikely at this stage. - Ignoring the patient's concerns about **quality of life** without offering an intervention increases the risk of **premature discontinuation** of a highly effective contraceptive. *Remove the implant and insert a new one in the contralateral arm* - Replacing the implant with a new one does not address the underlying **progestogen-induced endometrial changes** that cause the unscheduled bleeding. - This procedure is not an **evidence-based intervention** for managing irregular bleeding and would subject the patient to unnecessary minor surgery.
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