Reproductive Health — MCQs

A 19-year-old woman requests emergency contraception. She had unprotected sexual intercourse 36 hours ago, on day 11 of her regular 28-day cycle. She weighs 58 kg with a BMI of 22 kg/m². She has no significant medical history and takes no regular medications. What is the most effective emergency contraception method to offer?

Q162

A 52-year-old woman presents with hot flushes, night sweats, and mood disturbance for 8 months. Her last menstrual period was 14 months ago. She has a history of breast cancer treated with wide local excision and radiotherapy 3 years ago, currently on tamoxifen. She requests hormone replacement therapy for symptom control. What is the most appropriate initial management?

Q163

A 28-year-old nulliparous woman attends for contraceptive advice. She has a BMI of 34 kg/m² and smokes 15 cigarettes daily. Her blood pressure is 138/88 mmHg. She has no past medical history and takes no regular medications. She requests the combined oral contraceptive pill as she finds it convenient. What is the most appropriate management?

Reproductive Health UK Medical PG Practice Questions and MCQs

Question 161: A 19-year-old woman requests emergency contraception. She had unprotected sexual intercourse 36 hours ago, on day 11 of her regular 28-day cycle. She weighs 58 kg with a BMI of 22 kg/m². She has no significant medical history and takes no regular medications. What is the most effective emergency contraception method to offer?

A. Levonorgestrel 1.5 mg single dose
B. Ulipristal acetate 30 mg single dose
C. Copper intrauterine device insertion (Correct Answer)
D. Combined oral contraceptive pill (Yuzpe regimen)
E. Levonorgestrel 3 mg double dose

Explanation: ***Copper intrauterine device insertion*** - The **copper intrauterine device (Cu-IUD)** is the most effective method of emergency contraception, with a failure rate of approximately **0.1%**. - It can be inserted up to **5 days (120 hours)** after unprotected intercourse or within 5 days of the **earliest predicted ovulation**, significantly outperforming oral options in high-risk windows. *Levonorgestrel 1.5 mg single dose* - This method is only licensed for use up to **72 hours** after intercourse and its efficacy decreases as the time from intercourse increases. - It works by **delaying ovulation** and is less effective than both the Cu-IUD and ulipristal acetate, especially when taken close to the LH surge. *Ulipristal acetate 30 mg single dose* - While more effective than levonorgestrel and usable up to **120 hours**, it remains statistically inferior to the **Cu-IUD**. - It acts as a **progesterone receptor modulator** to delay ovulation but does not prevent implantation if fertilization has already occurred. *Combined oral contraceptive pill (Yuzpe regimen)* - This involves high doses of **ethinylestradiol and levonorgestrel** but is considered an outdated method due to lower efficacy and higher rates of side effects like nausea. - It is significantly **less effective** than modern single-dose hormonal regimens or mechanical methods. *Levonorgestrel 3 mg double dose* - A double dose of levonorgestrel is only indicated for patients with a **BMI > 26 kg/m²** or those taking **enzyme-inducing medications**. - Since this patient has a normal **BMI of 22 kg/m²**, a double dose is not clinically indicated and would not exceed the efficacy of a Cu-IUD.

Question 162: A 52-year-old woman presents with hot flushes, night sweats, and mood disturbance for 8 months. Her last menstrual period was 14 months ago. She has a history of breast cancer treated with wide local excision and radiotherapy 3 years ago, currently on tamoxifen. She requests hormone replacement therapy for symptom control. What is the most appropriate initial management?

A. Advise venlafaxine or another selective serotonin reuptake inhibitor (Correct Answer)
B. Prescribe tibolone as it has fewer breast cancer risks
C. Prescribe low-dose combined HRT preparation
D. Discontinue tamoxifen and commence HRT after appropriate washout period
E. Prescribe vaginal estrogen pessaries for symptom control

Explanation: ***Advise venlafaxine or another selective serotonin reuptake inhibitor*** - **Hormone replacement therapy (HRT)** is contraindicated in patients with a history of **breast cancer** due to the risk of stimulating tumor recurrence. - **Venlafaxine** (an SNRI) or certain SSRIs are first-line non-hormonal options for managing **vasomotor symptoms** (hot flushes) and mood disturbance in breast cancer survivors. *Prescribe tibolone as it has fewer breast cancer risks* - **Tibolone** is a synthetic steroid with estrogenic properties and is specifically contraindicated in women with a history of breast cancer due to increased **recurrence risk**. - While it may be used for osteoporosis or menopause in some populations, it does not provide a safe profile for **hormone-sensitive malignancies**. *Prescribe low-dose combined HRT preparation* - **Systemic HRT** is consistently avoided in breast cancer patients as it directly counteracts the therapeutic purpose of drugs like **Tamoxifen**. - Even low doses pose a significant theoretical and clinical risk for promoting the growth of latent **estrogen-receptor-positive** cells. *Discontinue tamoxifen and commence HRT after appropriate washout period* - Tamoxifen is a vital **adjuvant therapy** that reduces the risk of cancer recurrence; discontinuing it would compromise the patient's **oncological prognosis**. - Managing symptoms should never involve stopping life-prolonging **cancer treatment** when non-hormonal alternatives exist. *Prescribe vaginal estrogen pessaries for symptom control* - **Vaginal estrogen** is primarily indicated for **genitourinary syndrome of menopause** (vaginal dryness) rather than systemic symptoms like hot flushes or night sweats. - Although systemic absorption is low, it remains a second-line option after **non-hormonal lubricants** for breast cancer patients and does not treat mood disturbances.

Question 163: A 28-year-old nulliparous woman attends for contraceptive advice. She has a BMI of 34 kg/m² and smokes 15 cigarettes daily. Her blood pressure is 138/88 mmHg. She has no past medical history and takes no regular medications. She requests the combined oral contraceptive pill as she finds it convenient. What is the most appropriate management?

A. Prescribe combined oral contraceptive pill with advice about smoking cessation
B. Repeat blood pressure measurement and consider combined oral contraceptive pill if consistently below 140/90 mmHg
C. Advise that combined oral contraceptive pill is contraindicated and recommend progesterone-only pill (Correct Answer)
D. Prescribe combined oral contraceptive pill with low-dose aspirin for cardiovascular protection
E. Refer to specialist contraception clinic for further assessment

Explanation: ***Advise that combined oral contraceptive pill is contraindicated and recommend progesterone-only pill*** - The **combined oral contraceptive pill (COCP)** is generally avoided in patients with multiple risk factors; while she is under 35, her heavy smoking (≥15/day) and **obesity (BMI 34)** increase cardiovascular risks significantly. - The **progestogen-only pill (POP)** is a safer alternative as it does not carry the same **venous thromboembolism (VTE)** or stroke risks associated with the estrogen component of the COCP. *Prescribe combined oral contraceptive pill with advice about smoking cessation* - Prescribing the COCP despite multiple risk factors is unsafe; smoking ≥15 cigarettes/day and obesity are **UKMEC 3** criteria which means risks usually outweigh benefits. - Smoking cessation advice is essential but does not immediately mitigate the acute **cardiovascular and thrombotic risks** posed by current heavy smoking and high BMI. *Repeat blood pressure measurement and consider combined oral contraceptive pill if consistently below 140/90 mmHg* - Although her BP of 138/88 is borderline, even a normal BP would not resolve the contraindications posed by her **smoking status and BMI**. - Relying solely on BP monitoring ignores the additive risk of **arterial disease** and VTE inherent in her clinical profile. *Prescribe combined oral contraceptive pill with low-dose aspirin for cardiovascular protection* - **Aspirin** is not indicated or effective as a primary mitigation strategy for the specific thromboembolic risks introduced by the **estrogen** in COCP. - Adding aspirin does not change the **UKMEC category** of the COCP from unsafe to safe for use in this high-risk patient. *Refer to specialist contraception clinic for further assessment* - A specialist referral is unnecessary as the **UKMEC guidelines** provide clear criteria for primary care to manage this case. - The decision to switch to a **progestogen-only method** or a LARC (long-acting reversible contraceptive) can and should be made by the primary clinician based on existing evidence.

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