Reproductive Health — MCQs
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A 46-year-old perimenopausal woman presents with increasing menstrual irregularity and requests contraception. She has a 6-month history of menstrual cycles ranging from 21 to 45 days. Her FSH level measured on day 3 of her cycle is 18 IU/L. She is a non-smoker with BMI 27 kg/m² and no significant medical history. Which contraceptive method would provide both reliable contraception and symptom relief for her perimenopausal symptoms?
A 23-year-old woman attends the sexual health clinic 48 hours after unprotected sexual intercourse. She is on day 18 of her regular 28-day menstrual cycle. Her BMI is 23 kg/m². She has no significant medical history and takes no regular medications. She requests emergency contraception. What is the most appropriate management?
A 39-year-old woman presents 76 hours after unprotected sexual intercourse requesting emergency contraception. She has a regular 28-day cycle and her last menstrual period started 12 days ago. She weighs 68 kg with BMI 25 kg/m². She takes no regular medications and has no significant medical history. She declines intrauterine contraception. Which pharmacological emergency contraception option is most appropriate?
A 54-year-old woman who had a hysterectomy for benign disease 10 years ago has been using oestrogen-only HRT (transdermal oestradiol 50 mcg patches) for 5 years. She reports well-controlled vasomotor symptoms but has recently read about risks of HRT and is concerned. She has no personal or family history of breast cancer or cardiovascular disease. Her BMI is 26 kg/m² and blood pressure is 128/78 mmHg. Which statement about continuing HRT represents the most accurate assessment of her risk-benefit profile?
A 25-year-old woman attends for removal and replacement of her etonogestrel contraceptive implant, which was inserted 3 years ago. She is very satisfied with the method. On examination, the implant is palpable but lies deeper than expected in the subcutaneous tissue of the upper arm. You make an attempt at removal but cannot visualise the implant clearly through the initial incision. What is the most appropriate immediate management?
A 51-year-old woman with a history of breast cancer treated 7 years ago presents requesting treatment for severe vasomotor symptoms affecting her quality of life and work. She is reluctant to use non-hormonal options. Examination is unremarkable. Recent mammography shows no evidence of recurrence. Which non-hormonal pharmacological treatment has the strongest evidence base for managing vasomotor symptoms in women with contraindications to HRT?
A 30-year-old woman with systemic lupus erythematosus (SLE) requests contraception. Her disease is well-controlled on hydroxychloroquine. She has no history of thrombosis, her antiphospholipid antibodies are negative, and her renal function is normal. She is a non-smoker with BMI 23 kg/m² and blood pressure 122/76 mmHg. According to UKMEC criteria, which statement regarding contraceptive options is correct?
A 49-year-old woman commenced continuous combined HRT 6 weeks ago for troublesome vasomotor symptoms. She now reports diffuse breast tenderness and bloating. Her symptoms are well-controlled otherwise. Examination reveals bilateral diffuse breast tenderness with no discrete masses. What is the most appropriate management approach?
A 36-year-old woman with a history of recurrent major depressive disorder, currently stable on sertraline 100 mg daily, requests contraceptive advice. She reports that her mood significantly deteriorates in the week before menstruation. She has no other medical history, is a non-smoker with BMI 25 kg/m² and blood pressure 116/72 mmHg. Which contraceptive method would be most beneficial for managing both contraception and her premenstrual mood symptoms?
A 44-year-old woman presents with increasingly irregular menstrual cycles over the past 8 months, with cycle length varying from 21 to 50 days. She reports mild hot flushes and sleep disturbance. She is sexually active and uses condoms for contraception but is concerned about contraceptive reliability due to irregular cycles. Her BMI is 24 kg/m² and blood pressure is 124/78 mmHg. She has no significant medical history. What is the most appropriate contraceptive recommendation?
Reproductive Health UK Medical PG Practice Questions and MCQs
Question 121: A 46-year-old perimenopausal woman presents with increasing menstrual irregularity and requests contraception. She has a 6-month history of menstrual cycles ranging from 21 to 45 days. Her FSH level measured on day 3 of her cycle is 18 IU/L. She is a non-smoker with BMI 27 kg/m² and no significant medical history. Which contraceptive method would provide both reliable contraception and symptom relief for her perimenopausal symptoms?
- A. Combined oral contraceptive pill containing ethinylestradiol 30 mcg and levonorgestrel 150 mcg (Correct Answer)
- B. Levonorgestrel intrauterine system 52 mg
- C. Progesterone-only pill containing desogestrel 75 mcg
- D. Etonogestrel subdermal implant 68 mg
- E. Copper intrauterine device
Explanation: ***Combined oral contraceptive pill containing ethinylestradiol 30 mcg and levonorgestrel 150 mcg***- The **combined oral contraceptive (COC)** is ideal for perimenopausal women under 50 because it provides both **reliable contraception** and **symptom relief** for vasomotor symptoms and irregular cycles.- In a healthy, non-smoking woman with a BMI under 30, the COC effectively stabilizes hormone levels and manages **menstrual irregularity** associated with an elevated **FSH** level.*Levonorgestrel intrauterine system 52 mg*- While excellent for **long-acting reversible contraception** and treating heavy menstrual bleeding, it does not provide systemic estrogen required to relieve **perimenopausal vasomotor symptoms**.- It would manage local uterine symptoms but would not address the systemic hormonal fluctuations indicated by the patient's **irregular cycle lengths**.*Progesterone-only pill containing desogestrel 75 mcg*- This method provides effective contraception but often causes **irregular bleeding patterns**, which can complicate the clinical assessment of perimenopausal bleeding.- Since it lacks an **estrogen component**, it offers no therapeutic benefit for the vasomotor symptoms or the underlying hormonal decline of **perimenopause**.*Etonogestrel subdermal implant 68 mg*- The implant is a highly effective contraceptive, but like other progestogen-only methods, it frequently leads to **unpredictable spotting** or amenorrhea.- It does not contain the **ethinylestradiol** necessary to regulate the menstrual cycle or alleviate symptoms caused by **estrogen deficiency**.*Copper intrauterine device*- This is a hormone-free contraceptive that provides no relief for **menstrual irregularity** and may actually **increase menstrual flow** and cramping.- It has no impact on **perimenopausal symptoms** or the hormonal fluctuations indicated by the rising **Day 3 FSH** levels.
Question 122: A 23-year-old woman attends the sexual health clinic 48 hours after unprotected sexual intercourse. She is on day 18 of her regular 28-day menstrual cycle. Her BMI is 23 kg/m². She has no significant medical history and takes no regular medications. She requests emergency contraception. What is the most appropriate management?
- A. Prescribe levonorgestrel 1.5 mg single dose
- B. Prescribe ulipristal acetate 30 mg single dose
- C. Insert copper intrauterine device (Correct Answer)
- D. Prescribe two doses of levonorgestrel 750 mcg 12 hours apart
- E. Reassure that emergency contraception is not required as conception is unlikely
Explanation: ***Insert copper intrauterine device*** - The **copper intrauterine device (Cu-IUD)** is the most effective form of emergency contraception, boasting a failure rate of less than **0.1%**. - It can be inserted up to **5 days (120 hours)** after unprotected sexual intercourse or up to 5 days after the earliest predicted ovulation, making it the **gold standard** regardless of the menstrual cycle day. *Prescribe levonorgestrel 1.5 mg single dose* - This medication is licensed for use up to **72 hours** post-intercourse but is significantly **less effective** than the Cu-IUD, especially in the fertile window or if ovulation has occurred. - Its efficacy decreases as the time from intercourse increases, and its primary mechanism of delaying ovulation may be less effective on day 18, which is typically post-ovulatory. *Prescribe ulipristal acetate 30 mg single dose* - While **ulipristal acetate** is more effective than levonorgestrel, particularly later in the fertile window, it still carries a higher failure rate compared to the **Cu-IUD**. - It can be used up to **120 hours** post-intercourse, but the Cu-IUD is generally recommended first due to its superior efficacy. *Prescribe two doses of levonorgestrel 750 mcg 12 hours apart* - This split-dose regimen of levonorgestrel is considered **obsolete** and has been largely replaced by the more convenient and equally effective **1.5 mg single dose**. - Current guidelines for emergency contraception no longer recommend this older practice. *Reassure that emergency contraception is not required as conception is unlikely* - Although ovulation typically occurs around day 14 in a 28-day cycle, unprotected sexual intercourse on day 18 still carries a **risk of pregnancy** due to variations in individual cycle lengths and potential for delayed ovulation. - It is medically inappropriate to dismiss a patient's request for emergency contraception, as any unprotected intercourse carries a risk, and patient autonomy in reproductive health decisions is paramount.
Question 123: A 39-year-old woman presents 76 hours after unprotected sexual intercourse requesting emergency contraception. She has a regular 28-day cycle and her last menstrual period started 12 days ago. She weighs 68 kg with BMI 25 kg/m². She takes no regular medications and has no significant medical history. She declines intrauterine contraception. Which pharmacological emergency contraception option is most appropriate?
- A. Levonorgestrel 1.5 mg single dose as she is within the 96-hour window
- B. Ulipristal acetate 30 mg as she is within the 120-hour window and likely near ovulation (Correct Answer)
- C. Levonorgestrel 3 mg double dose to increase efficacy
- D. No emergency contraception needed as she is not in her fertile window
- E. Combined oral contraceptive (Yuzpe regimen) as she is beyond the 72-hour window for levonorgestrel
Explanation: ***Ulipristal acetate 30 mg as she is within the 120-hour window and likely near ovulation*** - **Ulipristal acetate (UPA)** is the most effective oral emergency contraceptive when administered between **72 and 120 hours** after unprotected intercourse, making it suitable for this patient at 76 hours. - UPA can effectively delay ovulation even after the **LH surge** has commenced, which is crucial as the patient is on day 12 of a 28-day cycle, indicating she is likely in her **fertile window** approaching ovulation. *Levonorgestrel 1.5 mg single dose as she is within the 96-hour window* - The efficacy of **levonorgestrel** significantly diminishes when taken more than **72 hours** after unprotected intercourse, and this patient is at 76 hours. - Levonorgestrel primarily acts by inhibiting the **LH surge** and preventing ovulation, but it is less effective once the LH surge has already begun, which is probable on day 12 of a 28-day cycle. *Levonorgestrel 3 mg double dose to increase efficacy* - A **double dose** (3 mg) of levonorgestrel is generally considered for individuals with a **BMI > 26 kg/m²** or those on **enzyme-inducing medications**. - This patient has a **BMI of 25 kg/m²** and no relevant medication use, so a standard or double dose of levonorgestrel is not preferred over ulipristal acetate in this specific time frame and cycle phase. *No emergency contraception needed as she is not in her fertile window* - For a **regular 28-day cycle**, the **fertile window** typically encompasses the 5 days before ovulation and the day of ovulation, which is usually around day 14. - As her last menstrual period was **12 days ago**, she is precisely within her fertile window and at a high risk of conception, therefore emergency contraception is strongly indicated. *Combined oral contraceptive (Yuzpe regimen) as she is beyond the 72-hour window for levonorgestrel* - The **Yuzpe regimen** involves multiple high doses of combined oral contraceptives and is considered a **less effective** and **older method** compared to levonorgestrel or ulipristal acetate. - This regimen is associated with a much higher incidence of **side effects**, particularly severe nausea and vomiting, making it a less desirable option for emergency contraception.
Question 124: A 54-year-old woman who had a hysterectomy for benign disease 10 years ago has been using oestrogen-only HRT (transdermal oestradiol 50 mcg patches) for 5 years. She reports well-controlled vasomotor symptoms but has recently read about risks of HRT and is concerned. She has no personal or family history of breast cancer or cardiovascular disease. Her BMI is 26 kg/m² and blood pressure is 128/78 mmHg. Which statement about continuing HRT represents the most accurate assessment of her risk-benefit profile?
- A. She should stop HRT immediately as the risks outweigh benefits after 5 years of use
- B. Oestrogen-only HRT after hysterectomy is associated with increased breast cancer risk similar to combined HRT
- C. She can continue HRT as oestrogen-only HRT in women post-hysterectomy has a favourable risk profile with no increased breast cancer risk demonstrated (Correct Answer)
- D. She should switch to tibolone which has a lower risk profile than oestrogen-only HRT
- E. She should have annual mammography while continuing HRT due to significantly increased breast cancer risk
Explanation: ***She can continue HRT as oestrogen-only HRT in women post-hysterectomy has a favourable risk profile with no increased breast cancer risk demonstrated*** - Evidence, notably from the **Women's Health Initiative (WHI) study**, indicates that **oestrogen-only HRT** in women post-hysterectomy does not increase the risk of **breast cancer**. - This patient has well-controlled symptoms, no contraindications, and a favorable risk profile, supporting continued individualized use without a fixed time limit. *She should stop HRT immediately as the risks outweigh benefits after 5 years of use* - There is no **arbitrary time limit** for HRT use; continuation depends on persistent symptoms and a favorable risk-benefit assessment, not solely on duration. - Abruptly stopping HRT could lead to a recurrence of her **vasomotor symptoms**, negatively impacting her quality of life unnecessarily. *Oestrogen-only HRT after hysterectomy is associated with increased breast cancer risk similar to combined HRT* - **Combined HRT** (oestrogen plus progestogen) is associated with a slightly increased risk of **breast cancer**, primarily due to the progestogen component. - In contrast, **oestrogen-only HRT** in women without a uterus has not shown a similar increase in breast cancer risk and may even have a protective effect. *She should switch to tibolone which has a lower risk profile than oestrogen-only HRT* - **Tibolone** is a synthetic steroid that has a different risk profile and is not inherently safer than **transdermal oestradiol** for all women; it can carry its own risks including potential increased breast cancer recurrence or incidence in certain populations. - Given she is well-controlled on her current **oestrogen-only HRT** with a favorable risk profile, there is no clinical indication to switch. *She should have annual mammography while continuing HRT due to significantly increased breast cancer risk* - Current guidelines recommend that women on **oestrogen-only HRT** follow **standard national breast screening protocols**, not necessarily annual mammography, as their breast cancer risk is not significantly increased. - The absence of increased breast cancer risk with **oestrogen-only HRT** means that more intensive surveillance beyond routine screening is unwarranted.
Question 125: A 25-year-old woman attends for removal and replacement of her etonogestrel contraceptive implant, which was inserted 3 years ago. She is very satisfied with the method. On examination, the implant is palpable but lies deeper than expected in the subcutaneous tissue of the upper arm. You make an attempt at removal but cannot visualise the implant clearly through the initial incision. What is the most appropriate immediate management?
- A. Continue with deeper dissection until the implant is located and removed
- B. Insert a new implant in the contralateral arm and arrange specialist removal of the original implant
- C. Apply pressure to the distal end of the implant to make it more superficial, then attempt removal again
- D. Extend the incision and use forceps to grasp deeper tissue to locate the implant
- E. Abandon the procedure, apply pressure dressing, and refer for ultrasound localisation and specialist removal (Correct Answer)
Explanation: ***Abandon the procedure, apply pressure dressing, and refer for ultrasound localisation and specialist removal*** - When an **etonogestrel implant** cannot be easily visualised or removed through a small incision, further blind manipulation increases the risk of **neurovascular injury** to the median nerve or brachial artery. - **FSRH guidelines** recommend abandoning the procedure and referring to a specialist service where **ultrasound guidance** can be used to precisely locate and remove the deep implant. *Continue with deeper dissection until the implant is located and removed* - **Deep dissection** in the primary care setting is contraindicated as it lacks appropriate imaging and increases the risk of **permanent scarring** and tissue trauma. - Searching blindly for a non-visible implant can lead to further **displacement** of the device into deeper muscular compartments. *Insert a new implant in the contralateral arm and arrange specialist removal of the original implant* - Inserting a second implant before the first is removed would lead to an **excessive progestogen dose**, which is clinically inappropriate. - Specialist removal of the **expired implant** should be prioritised before a replacement is provided to ensure hormonal stability and patient safety. *Apply pressure to the distal end of the implant to make it more superficial, then attempt removal again* - This technique is generally used for **palpable, superficial implants**; if initial attempts failed, the implant is likely deeper than initially assessed. - Repeated pressure and manipulation of a **deeply placed implant** can cause it to migrate further or cause pain to the patient. *Extend the incision and use forceps to grasp deeper tissue to locate the implant* - Grasping deeper tissues blindly with **forceps** is dangerous due to the proximity of the **medial epicondyle** and associated nerves and vessels. - **Specialist tools** and imaging are required to ensure the implant is grasped specifically without damaging surrounding anatomical structures.
Question 126: A 51-year-old woman with a history of breast cancer treated 7 years ago presents requesting treatment for severe vasomotor symptoms affecting her quality of life and work. She is reluctant to use non-hormonal options. Examination is unremarkable. Recent mammography shows no evidence of recurrence. Which non-hormonal pharmacological treatment has the strongest evidence base for managing vasomotor symptoms in women with contraindications to HRT?
- A. Evening primrose oil 1000 mg twice daily
- B. Black cohosh 40 mg daily
- C. Venlafaxine 75 mg daily (Correct Answer)
- D. Gabapentin 900 mg daily in divided doses
- E. Vitamin E 800 IU daily
Explanation: ***Venlafaxine 75 mg daily***- **SNRIs** and **SSRIs** like venlafaxine have the strongest evidence base for reducing **vasomotor symptoms** (up to 60%) in women where **HRT** is contraindicated due to breast cancer.- It is effective in titration and does not have the significant **CYP2D6 inhibition** concerns that medications like paroxetine have when used alongside **tamoxifen**.*Evening primrose oil 1000 mg twice daily*- This is a complementary therapy that lacks robust clinical evidence for the management of **menopausal flushing**.- **NICE guidelines** do not recommend its use due to inconsistent results in systematic reviews.*Black cohosh 40 mg daily*- While widely used, there is limited and inconsistent evidence regarding the efficacy and long-term safety of **black cohosh** for **hot flushes**.- Concerns exist regarding potential **hepatotoxicity** and its unknown impact on **breast tissue** in cancer survivors.*Gabapentin 900 mg daily in divided doses*- Although **gabapentin** is an effective alternative to HRT, it is generally considered **second-line** to SNRIs/SSRIs.- Its use is often limited by a higher side-effect profile, including **somnolence** and **dizziness**, and the inconvenience of **three-times-daily dosing**.*Vitamin E 800 IU daily*- **Vitamin E** has shown only a marginal benefit in clinical trials, often no better than **placebo** for severe vasomotor symptoms.- High doses are not recommended for routine use as they do not provide the clinical relief required for **severe symptoms**.
Question 127: A 30-year-old woman with systemic lupus erythematosus (SLE) requests contraception. Her disease is well-controlled on hydroxychloroquine. She has no history of thrombosis, her antiphospholipid antibodies are negative, and her renal function is normal. She is a non-smoker with BMI 23 kg/m² and blood pressure 122/76 mmHg. According to UKMEC criteria, which statement regarding contraceptive options is correct?
- A. Combined oral contraceptive is UKMEC 2 (advantages generally outweigh risks) as her SLE is stable without organ involvement (Correct Answer)
- B. All combined hormonal contraceptives are absolutely contraindicated in SLE regardless of disease activity or antibody status
- C. Progesterone-only methods are UKMEC 3 (risks usually outweigh advantages) in SLE
- D. Copper intrauterine device is contraindicated due to increased infection risk in SLE
- E. Depot medroxyprogesterone acetate should be avoided due to concerns about bone density in women with SLE on corticosteroids
Explanation: ***Combined oral contraceptive is UKMEC 2 (advantages generally outweigh risks) as her SLE is stable without organ involvement*** - For women with **Systemic Lupus Erythematosus (SLE)**, combined hormonal contraception (CHC) is classified as **UKMEC 2** if their disease is stable and **antiphospholipid antibodies** are negative. - This classification reflects that the **advantages of preventing pregnancy** generally outweigh the potential risks, especially when there are no risk factors for **thromboembolism** like positive antiphospholipid antibodies or active disease. *All combined hormonal contraceptives are absolutely contraindicated in SLE regardless of disease activity or antibody status* - Combined hormonal contraceptives are classified as **UKMEC 4** (absolute contraindication) only in SLE patients with **positive antiphospholipid antibodies** or those with severe active lupus. - For women with stable, well-controlled SLE and negative antiphospholipid antibodies, CHCs are not absolutely contraindicated, as evidenced by the **UKMEC 2** categorization. *Progesterone-only methods are UKMEC 3 (risks usually outweigh advantages) in SLE* - Most **progesterone-only methods (POPs, implants, injectables)** are categorized as **UKMEC 1** for women with SLE, indicating no restrictions on their use. - Even in the presence of **positive antiphospholipid antibodies**, progesterone-only methods are generally considered **UKMEC 2**, making them a safer option for contraception in most SLE patients. *Copper intrauterine device is contraindicated due to increased infection risk in SLE* - The **Copper IUD** is classified as **UKMEC 1** for women with SLE, meaning it can be used without restriction and does not worsen disease activity or increase flare risk. - There is no increased risk of **pelvic inflammatory disease** in women with stable SLE using IUDs, even if on low-dose immunosuppression, contrary to this statement. *Depot medroxyprogesterone acetate should be avoided due to concerns about bone density in women with SLE on corticosteroids* - **Depot medroxyprogesterone acetate (DMPA)** is categorized as **UKMEC 2** for women with SLE, suggesting that advantages generally outweigh risks. - While DMPA can cause a **reversible reduction in bone mineral density**, it is not strictly contraindicated, especially in patients like this one who are on **hydroxychloroquine** and not long-term **corticosteroids**, which are more detrimental to bone health.
Question 128: A 49-year-old woman commenced continuous combined HRT 6 weeks ago for troublesome vasomotor symptoms. She now reports diffuse breast tenderness and bloating. Her symptoms are well-controlled otherwise. Examination reveals bilateral diffuse breast tenderness with no discrete masses. What is the most appropriate management approach?
- A. Reassure that symptoms commonly resolve within 3 months and review at 3 months (Correct Answer)
- B. Switch to sequential combined HRT to reduce progestogen exposure
- C. Discontinue HRT immediately and arrange urgent breast imaging
- D. Add danazol to reduce mastalgia while continuing current HRT
- E. Switch to transdermal oestrogen with cyclical progestogen
Explanation: ***Reassure that symptoms commonly resolve within 3 months and review at 3 months*** - Side effects such as **breast tenderness** and **bloating** are common during the first 3 months of **HRT initiation** as the body adjusts to the hormones. - Since her clinical examination is **reassuring** (no masses) and **vasomotor symptoms** are well-controlled, monitoring for the standard 3-month window is the first-line approach. *Switch to sequential combined HRT to reduce progestogen exposure* - Switching to **sequential HRT** is generally indicated if progestogen-related side effects persist beyond the initial 3-month trial period or if the patient is **perimenopausal**. - Changing the regimen too early prevents the assessment of whether the body would have tolerated the **continuous combined** regimen, which offers better **endometrial protection**. *Discontinue HRT immediately and arrange urgent breast imaging* - **Urgent imaging** is not indicated as there are no **red flags** such as discrete masses, skin changes, or nipple discharge; her tenderness is bilateral and diffuse. - Discontinuing HRT would lead to the immediate recurrence of her distressing **vasomotor symptoms** unnecessarily. *Add danazol to reduce mastalgia while continuing current HRT* - **Danazol** is not an appropriate or licensed treatment for HRT-induced breast tenderness and carries significant **androgenic side effects**. - Management of HRT side effects should focus on **dose adjustment** or route changes of the HRT itself rather than adding secondary systemic medications. *Switch to transdermal oestrogen with cyclical progestogen* - While **transdermal preparations** or changing the progestogen type can help with tenderness, these adjustments should only be considered if symptoms persist for more than **3 months**. - Initiating a **cyclical progestogen** would also induce **withdrawal bleeds**, which the patient may prefer to avoid if she is already established on a continuous regimen.
Question 129: A 36-year-old woman with a history of recurrent major depressive disorder, currently stable on sertraline 100 mg daily, requests contraceptive advice. She reports that her mood significantly deteriorates in the week before menstruation. She has no other medical history, is a non-smoker with BMI 25 kg/m² and blood pressure 116/72 mmHg. Which contraceptive method would be most beneficial for managing both contraception and her premenstrual mood symptoms?
- A. Cyclical combined oral contraceptive pill with 4-day hormone-free interval
- B. Continuous combined oral contraceptive pill regimen without breaks (Correct Answer)
- C. Etonogestrel subdermal implant
- D. Depot medroxyprogesterone acetate injection
- E. Copper intrauterine device
Explanation: ***Continuous combined oral contraceptive pill regimen without breaks*** - This regimen provides a **stable hormonal environment** by continuously delivering **estrogen and progestogen**, effectively suppressing **ovulation** and preventing the cyclical hormonal fluctuations that trigger **premenstrual mood symptoms**. - By eliminating the **hormone-free interval**, it avoids the abrupt **hormone withdrawal** that is often associated with the worsening of mood symptoms in the luteal phase and before menstruation, making it ideal for **Premenstrual Dysphoric Disorder (PMDD)** or severe **PMS**. *Cyclical combined oral contraceptive pill with 4-day hormone-free interval* - Even with a shorter 4-day hormone-free interval, there is still a significant **hormone drop** that can induce **withdrawal symptoms** and exacerbate **mood instability** in individuals sensitive to hormonal changes. - This method does not fully address the need for **continuous hormonal suppression** to prevent the cyclical mood symptoms experienced by the patient, unlike a continuous regimen. *Etonogestrel subdermal implant* - The **etonogestrel implant** is a **progestogen-only method** that often results in **irregular bleeding patterns** and can sometimes worsen or cause **mood changes** due to continuous progestogen exposure without the balancing effect of estrogen. - It may not reliably suppress the **hypothalamic-pituitary-ovarian axis** sufficiently to prevent all cyclical hormonal fluctuations, making it less effective for managing premenstrual mood symptoms compared to continuous combined hormonal contraception. *Depot medroxyprogesterone acetate injection* - **DMPA** is a **progestogen-only method** known for potential side effects including **weight gain** and **depressive mood changes**, especially in individuals with a history of depression. - While it can lead to amenorrhea, the **lack of estrogen** and the potential for **adverse mood effects** make it less suitable than continuous combined oral contraception for directly managing premenstrual mood exacerbations. *Copper intrauterine device* - The **copper IUD** is a **non-hormonal contraceptive method**, meaning it has no effect on the patient's **hormonal fluctuations** or **premenstrual mood symptoms**. - It often leads to **heavier and more painful periods**, which could potentially worsen the patient's overall experience and does not provide any therapeutic benefit for her chief complaint of premenstrual mood deterioration.
Question 130: A 44-year-old woman presents with increasingly irregular menstrual cycles over the past 8 months, with cycle length varying from 21 to 50 days. She reports mild hot flushes and sleep disturbance. She is sexually active and uses condoms for contraception but is concerned about contraceptive reliability due to irregular cycles. Her BMI is 24 kg/m² and blood pressure is 124/78 mmHg. She has no significant medical history. What is the most appropriate contraceptive recommendation?
- A. Continue condoms as she is likely perimenopausal and fertility is low
- B. Commence combined oral contraceptive pill which will also regulate her cycles and help vasomotor symptoms
- C. Recommend levonorgestrel intrauterine system for contraception and cycle control (Correct Answer)
- D. Advise that no contraception is needed once amenorrhoeic for 6 months given her age
- E. Measure FSH and LH levels to assess if contraception is still required
Explanation: ***Recommend levonorgestrel intrauterine system for contraception and cycle control*** - This woman is experiencing symptoms consistent with **perimenopause**, including irregular cycles, hot flushes, and sleep disturbance. The **levonorgestrel intrauterine system (LNG-IUS)** provides highly effective contraception (>99% efficacy). - The LNG-IUS is also highly effective at managing **irregular and heavy menstrual bleeding**, which is common in perimenopause, and can serve as the progestogen component for future hormone replacement therapy (HRT). *Continue condoms as she is likely perimenopausal and fertility is low* - While fertility declines with age, **ovulation can still occur unpredictably** during perimenopause, making reliable contraception necessary until menopause is confirmed. - **Condoms** have a higher typical-use failure rate (13-18%) compared to long-acting reversible contraceptives and do not address her irregular cycles or vasomotor symptoms. *Commence combined oral contraceptive pill which will also regulate her cycles and help vasomotor symptoms* - While **combined oral contraceptive (COC)** pills can regulate cycles and help vasomotor symptoms, they carry increased **thromboembolic risks** and cardiovascular risks in women over 35. - The LNG-IUS is generally preferred in perimenopausal women as it avoids the systemic side effects of estrogen while providing superior **endometrial protection** and contraception. *Advise that no contraception is needed once amenorrhoeic for 6 months given her age* - Clinical guidelines state that women aged under 50 require contraception for **24 months** after their last menstrual period to ensure the cessation of fertility. - Amenorrhea for only 6 months is **insufficient** to confirm the permanent cessation of ovarian function and the end of fertile potential in a 44-year-old. *Measure FSH and LH levels to assess if contraception is still required* - **Follicle-stimulating hormone (FSH)** levels fluctuate significantly during the perimenopause and are not a reliable indicator of contraceptive need or fertility status. - The diagnosis of the menopausal transition and the need for contraception are primarily **clinical** based on age and symptom profile; hormonal testing does not alter management in this context.
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