Reproductive Health — MCQs
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A 24-year-old woman attends for contraceptive advice. She has a history of recurrent cervical intraepithelial neoplasia (CIN), having had two large loop excisions of the transformation zone (LLETZ) procedures in the past 3 years, most recently 4 months ago. Histology from the most recent procedure showed complete excision of CIN 2 with clear margins. She is HPV-positive on recent follow-up testing. She is a non-smoker with a BMI of 24 kg/m². She requests reliable long-acting contraception. What is the most appropriate contraceptive method for this patient?
A 48-year-old woman presents with troublesome vasomotor symptoms affecting her quality of life and sleep. Her last menstrual period was 3 months ago and prior to that her cycles had been irregular for 8 months. She has a history of unprovoked deep vein thrombosis 6 years ago, for which she completed 6 months of anticoagulation. Thrombophilia screening at the time was negative. Her BMI is 27 kg/m² and blood pressure is 128/82 mmHg. What is the most appropriate management of her menopausal symptoms?
A 37-year-old woman presents for contraceptive advice. She has a history of breast cancer diagnosed at age 35, treated with lumpectomy, chemotherapy, and radiotherapy. She completed treatment 18 months ago and is currently taking tamoxifen. Recent scans show no evidence of recurrence. She is in a stable relationship and has two children. Her oncologist has confirmed she should avoid pregnancy. What is the most appropriate contraceptive recommendation?
A 54-year-old woman presents with recurrent urogenital symptoms including vaginal dryness, dyspareunia, and urinary frequency. She experienced natural menopause at age 51. She tried vaginal estrogen pessaries (estradiol 10 mcg) for 6 weeks but found them inconvenient and poorly tolerated. She has no significant past medical history and specifically wishes to avoid systemic hormone therapy. What is the most appropriate alternative management?
A 29-year-old woman with inflammatory bowel disease (Crohn's disease) predominantly affecting the terminal ileum and colon presents for contraceptive counselling. She underwent an ileocaecal resection 18 months ago and is currently in remission on azathioprine. She has no history of thromboembolism. Her BMI is 21 kg/m². She would like a highly effective contraceptive method. According to UKMEC criteria, which statement about contraceptive options is most accurate for this patient?
A 51-year-old woman commenced on continuous combined HRT (oral estradiol 1 mg with dydrogesterone 10 mg daily) 5 months ago for vasomotor symptoms. She presents with an episode of vaginal bleeding lasting 4 days which occurred 2 weeks ago and has now stopped. She has had no further bleeding since. Her last natural menstrual period was 16 months ago. She has no pain or other symptoms. What is the most appropriate initial management?
A 46-year-old woman presents with worsening heavy menstrual bleeding and pelvic pain. She has a history of multiple uterine fibroids documented on ultrasound 2 years ago, the largest measuring 6 cm. She has completed her family and requests effective contraception that might also help with her bleeding. Her BMI is 32 kg/m². She has no history of thromboembolism and her blood pressure is 132/78 mmHg. Pelvic examination reveals a bulky uterus consistent with fibroids. What is the most appropriate contraceptive method for this patient?
What is the recommended approach to progestogen therapy in women using estrogen-only hormone replacement therapy who have an intact uterus?
A 33-year-old woman presents 84 hours after unprotected sexual intercourse requesting emergency contraception. She has a regular 28-day menstrual cycle and estimates she is on day 14 of her cycle. She weighs 72 kg with a BMI of 26 kg/m². She takes no regular medications and has no contraindications to hormonal contraception. She has no previous history of ectopic pregnancy. What is the most appropriate emergency contraception to offer?
A 58-year-old woman presents for review of her hormone replacement therapy. She had a total hysterectomy for stage 1 endometrial carcinoma at age 55, treated with surgery alone. She has been taking estrogen-only HRT (transdermal estradiol 50 mcg patches) for 2 years for troublesome vasomotor symptoms which have now completely resolved. She is concerned about continuing HRT given her history. What is the most appropriate management?
Reproductive Health UK Medical PG Practice Questions and MCQs
Question 31: A 24-year-old woman attends for contraceptive advice. She has a history of recurrent cervical intraepithelial neoplasia (CIN), having had two large loop excisions of the transformation zone (LLETZ) procedures in the past 3 years, most recently 4 months ago. Histology from the most recent procedure showed complete excision of CIN 2 with clear margins. She is HPV-positive on recent follow-up testing. She is a non-smoker with a BMI of 24 kg/m². She requests reliable long-acting contraception. What is the most appropriate contraceptive method for this patient?
- A. Combined oral contraceptive pill should be avoided as it may increase risk of cervical cancer progression in HPV-positive women
- B. Depot medroxyprogesterone acetate injection is the most appropriate as it has protective effects against cervical neoplasia
- C. Copper intrauterine device is contraindicated until HPV status is negative
- D. Levonorgestrel intrauterine system is appropriate and can be offered as UKMEC 2 (Correct Answer)
- E. Etonogestrel subdermal implant should be avoided due to the association between progestogens and cervical neoplasia
Explanation: ***Levonorgestrel intrauterine system is appropriate and can be offered as UKMEC 2*** - According to **UK Medical Eligibility Criteria (UKMEC)**, cervical intraepithelial neoplasia (**CIN**) is classified as **UKMEC 2**, meaning the benefits of using an IUS generally outweigh the theoretical or proven risks. - The patient has had successful treatment of **CIN 2** with **clear margins**, and the presence of **HPV** does not contraindicate the placement of a long-acting reversible contraceptive (LARC) like the **LNG-IUS**. *Combined oral contraceptive pill should be avoided as it may increase risk of cervical cancer progression in HPV-positive women* - While some studies suggest a small increased risk of cervical cancer with **COCP** use over 5 years, it is still classified as **UKMEC 2** for women with **CIN**, not strictly contraindicated. - The patient specifically requested **long-acting contraception**, and the COCP is a daily method, not a LARC. *Depot medroxyprogesterone acetate injection is the most appropriate as it has protective effects against cervical neoplasia* - There is no clinical evidence to support the claim that **DMPA** has protective effects against the development or progression of **cervical neoplasia**. - While it is a reliable method, it requires repeated injections every 12-13 weeks rather than being a single-procedure **long-acting** device. *Copper intrauterine device is contraindicated until HPV status is negative* - A **Copper IUD** is actually classified as **UKMEC 1** or **2** for women with a history of **CIN**, and it is not contraindicated by **HPV-positive** status. - Routine **HPV follow-up** and cervical screening are required post-LLETZ regardless of the contraceptive method chosen, so HPV status does not impact IUD eligibility. *Etonogestrel subdermal implant should be avoided due to the association between progestogens and cervical neoplasia* - Progestogen-only methods like the **subdermal implant** are not associated with an increased risk of **cervical neoplasia** and are considered safe (**UKMEC 1**). - It is a highly effective **long-acting reversible contraceptive**, but the premise for avoiding it in the option is incorrect.
Question 32: A 48-year-old woman presents with troublesome vasomotor symptoms affecting her quality of life and sleep. Her last menstrual period was 3 months ago and prior to that her cycles had been irregular for 8 months. She has a history of unprovoked deep vein thrombosis 6 years ago, for which she completed 6 months of anticoagulation. Thrombophilia screening at the time was negative. Her BMI is 27 kg/m² and blood pressure is 128/82 mmHg. What is the most appropriate management of her menopausal symptoms?
- A. Transdermal estradiol with micronized progesterone as transdermal route has lower VTE risk than oral
- B. Low-dose combined oral contraceptive pill as she may still be fertile
- C. Venlafaxine as a non-hormonal alternative for vasomotor symptoms (Correct Answer)
- D. Continuous combined oral HRT as she is more than 6 months post-thrombosis
- E. Tibolone as it has a more favorable VTE risk profile
Explanation: ***Venlafaxine as a non-hormonal alternative for vasomotor symptoms*** - A history of **unprovoked deep vein thrombosis (VTE)** is generally considered a contraindication to standard **Hormonal Replacement Therapy (HRT)** because the risk of recurrence remains elevated.- **Venlafaxine**, an SNRI, is an effective **non-hormonal** treatment for moderate to severe **vasomotor symptoms** and provides a safe alternative for patients with VTE risk.*Transdermal estradiol with micronized progesterone as transdermal route has lower VTE risk than oral*- While **transdermal estrogen** does not increase VTE risk in the same way as oral estrogen, an **unprovoked VTE** is still a strong relative contraindication for any estrogen therapy in many clinical guidelines.- HRT should be avoided in this patient until she is reviewed by a **specialist** (Hematologist or Menopause clinic) to weigh risks against benefits.*Low-dose combined oral contraceptive pill as she may still be fertile*- The **Combined Oral Contraceptive Pill (COCP)** is strictly **UKMEC 4** (unacceptable health risk) for any patient with a history of VTE.- Although she is in the **perimenopause** and may be fertile, alternative non-hormonal contraception like a **Copper IUD** should be used instead.*Continuous combined oral HRT as she is more than 6 months post-thrombosis*- **Oral HRT** undergoes **first-pass metabolism** in the liver, which increases the production of clotting factors and significantly raises the risk of recurrent VTE.- The time elapsed since the event (6 years) does not eliminate the risk, especially since the initial event was **unprovoked**.*Tibolone as it has a more favorable VTE risk profile*- **Tibolone** is a synthetic compound with estrogenic, progestogenic, and androgenic properties that still carries an increased risk of **stroke** and **VTE**.- It is generally reserved for postmenopausal women (at least **one year** since the last period) and is not appropriate for someone with a high-risk thrombotic history.
Question 33: A 37-year-old woman presents for contraceptive advice. She has a history of breast cancer diagnosed at age 35, treated with lumpectomy, chemotherapy, and radiotherapy. She completed treatment 18 months ago and is currently taking tamoxifen. Recent scans show no evidence of recurrence. She is in a stable relationship and has two children. Her oncologist has confirmed she should avoid pregnancy. What is the most appropriate contraceptive recommendation?
- A. Levonorgestrel intrauterine system as it provides local rather than systemic hormone exposure
- B. Copper intrauterine device as it provides effective non-hormonal contraception (Correct Answer)
- C. Etonogestrel subdermal implant as progestogen-only methods are safe in breast cancer
- D. Barrier methods only due to absolute contraindication to all hormonal contraception
- E. Female sterilization as she has completed her family
Explanation: ***Copper intrauterine device as it provides effective non-hormonal contraception*** - The **Copper IUD** is the most appropriate choice because it is categorized as **UKMEC 1**, meaning there are no restrictions on its use in patients with a history of **breast cancer**. - It provides highly effective, **long-acting, reversible contraception (LARC)** without the risk of **hormonal stimulation** of potentially residual cancer cells. *Levonorgestrel intrauterine system as it provides local rather than systemic hormone exposure* - Any hormonal method, including the **LNG-IUS**, is classified as **UKMEC 4** (unacceptable health risk) for patients with current or recent (within 5 years) **breast cancer**. - Despite primarily local action, some **systemic absorption** occurs, which is contraindicated due to the risk of stimulating **hormone-sensitive malignant cells**. *Etonogestrel subdermal implant as progestogen-only methods are safe in breast cancer* - Progestogen-only methods are not considered safe in this context; they are strictly **contraindicated** (UKMEC 4) in the setting of active or recent **breast cancer**. - The implant releases **systemic hormones** that could interfere with the patient's recovery or interact with the management of **hormone-receptor-positive** disease. *Barrier methods only due to absolute contraindication to all hormonal contraception* - While barrier methods are non-hormonal, they have a higher **typical-use failure rate** (~18%), which is risky given the oncological advice to strictly avoid pregnancy. - This recommendation is incorrect because the **Copper IUD** is a far more reliable non-hormonal alternative available to this patient. *Female sterilization as she has completed her family* - **Sterilization** is an invasive surgical procedure that carries unnecessary risks compared to the highly effective and non-invasive **Copper IUD**. - At age 37, a reversible method is often preferred over a permanent one in case the patient's clinical situation or **life goals change** in the future.
Question 34: A 54-year-old woman presents with recurrent urogenital symptoms including vaginal dryness, dyspareunia, and urinary frequency. She experienced natural menopause at age 51. She tried vaginal estrogen pessaries (estradiol 10 mcg) for 6 weeks but found them inconvenient and poorly tolerated. She has no significant past medical history and specifically wishes to avoid systemic hormone therapy. What is the most appropriate alternative management?
- A. Vaginal estrogen cream (estriol 0.1%)
- B. Vaginal dehydroepiandrosterone (prasterone) pessaries (Correct Answer)
- C. Oral ospemifene
- D. Systemic continuous combined HRT with monitoring
- E. Vaginal moisturizers and lubricants alone
Explanation: ***Vaginal dehydroepiandrosterone (prasterone) pessaries*** - **Prasterone** is a synthetic **DHEA** that is converted intracellularly into **estrogens and androgens**, effectively treating **genitourinary syndrome of menopause (GSM)** without significant systemic absorption. - It is a suitable alternative for patients who find standard **estradiol pessaries** intolerable or ineffective and provides localized relief for both vaginal and **urinary symptoms**. *Vaginal estrogen cream (estriol 0.1%)* - While this is a **localized estrogen** therapy, the patient has already demonstrated intolerance to **estradiol pessaries**, making another form of vaginal estrogen less likely to be tolerated or preferred. - Creams are often perceived as **messier** and less convenient than other localized options, which may conflict with the patient's request for convenience. *Oral ospemifene* - Although **ospemifene** is a **selective estrogen receptor modulator (SERM)** specifically licensed for **dyspareunia**, it is an **oral medication** with systemic distribution. - The patient explicitly wishes to **avoid systemic therapy**, and this drug carries risks similar to HRT, such as an increased risk of **venous thromboembolism (VTE)**. *Systemic continuous combined HRT with monitoring* - This option contradicts the patient's specific preference to **avoid systemic hormone therapy** for her localized urogenital symptoms. - **Systemic HRT** is generally reserved for patients who also have vasomotor symptoms like **hot flashes**, which are not reported in this case. *Vaginal moisturizers and lubricants alone* - These are **non-hormonal** options that provide temporary relief for **dryness and dyspareunia** but do not treat the underlying **atrophy** of the vaginal and urethral tissues. - They are often insufficient for moderate-to-severe symptoms or **urinary frequency** associated with **vulvovaginal atrophy**.
Question 35: A 29-year-old woman with inflammatory bowel disease (Crohn's disease) predominantly affecting the terminal ileum and colon presents for contraceptive counselling. She underwent an ileocaecal resection 18 months ago and is currently in remission on azathioprine. She has no history of thromboembolism. Her BMI is 21 kg/m². She would like a highly effective contraceptive method. According to UKMEC criteria, which statement about contraceptive options is most accurate for this patient?
- A. Combined oral contraceptive pill may have reduced efficacy due to malabsorption from bowel disease and should be avoided
- B. The etonogestrel subdermal implant efficacy is unaffected by Crohn's disease and azathioprine therapy (Correct Answer)
- C. Depot medroxyprogesterone acetate is contraindicated due to concerns about bone density in inflammatory bowel disease
- D. The levonorgestrel intrauterine system is relatively contraindicated due to immunosuppression from azathioprine
- E. Progesterone-only pills are less effective in patients with inflammatory bowel disease affecting the small bowel
Explanation: ***The etonogestrel subdermal implant efficacy is unaffected by Crohn's disease and azathioprine therapy*** - The **etonogestrel implant** is a Long-Acting Reversible Contraceptive (LARC) that bypasses the gastrointestinal tract, ensuring efficacy is maintained despite **malabsorption** or **small bowel resection**. - It is classified as **UKMEC 1** for patients with inflammatory bowel disease (IBD) and its metabolism is not impacted by **azathioprine**. *Combined oral contraceptive pill may have reduced efficacy due to malabsorption from bowel disease and should be avoided* - While absorption can be a concern in severe disease or significant malabsorption, the **UKMEC** classifies combined oral contraceptives as **Category 2** (benefits outweigh risks) for IBD patients in remission without major malabsorption. - The primary concern for **COCP** in IBD is the potentially increased risk of **venous thromboembolism (VTE)** during active flares, not solely reduced efficacy from malabsorption, and they are not completely avoided in remission. *Depot medroxyprogesterone acetate is contraindicated due to concerns about bone density in inflammatory bowel disease* - Injectable progestogens like **Depot medroxyprogesterone acetate (DMPA)** are **UKMEC 2** (benefits generally outweigh risks), not contraindicated. While they can cause a reversible reduction in **bone mineral density**, they are not forbidden unless the patient has specific high-risk factors for **osteoporosis** that are not present here. - In this patient (young, in remission, normal BMI), DMPA is an acceptable choice, although not the most highly effective LARC. *The levonorgestrel intrauterine system is relatively contraindicated due to immunosuppression from azathioprine* - The **levonorgestrel intrauterine system (LNG-IUS)** is classified as **UKMEC 2** for patients on immunosuppression; there is a theoretical, slight increase in the risk of infection, but the clinical benefits generally outweigh this risk, making it an acceptable option. - Immunosuppressive therapy like **azathioprine** does not represent a contraindication to the use of intrauterine devices or systems, which are highly effective LARCs. *Progesterone-only pills are less effective in patients with inflammatory bowel disease affecting the small bowel* - Although there are theoretical concerns regarding absorption in severe **malabsorption syndromes** or significant small bowel disease, the **UKMEC** still classifies **progesterone-only pills (POPs)** as **Category 2** for IBD. - POPs are considered a safe option, but due to potential absorption variability and the need for strict adherence, LARCs like the implant or IUS are often preferred for higher efficacy and reliability in patients with previous **bowel resections** or IBD.
Question 36: A 51-year-old woman commenced on continuous combined HRT (oral estradiol 1 mg with dydrogesterone 10 mg daily) 5 months ago for vasomotor symptoms. She presents with an episode of vaginal bleeding lasting 4 days which occurred 2 weeks ago and has now stopped. She has had no further bleeding since. Her last natural menstrual period was 16 months ago. She has no pain or other symptoms. What is the most appropriate initial management?
- A. Reassure her that irregular bleeding is expected in the first 6 months of continuous combined HRT and review if bleeding persists beyond 6 months (Correct Answer)
- B. Arrange urgent transvaginal ultrasound scan to assess endometrial thickness
- C. Switch to sequential combined HRT regimen
- D. Arrange outpatient hysteroscopy and endometrial biopsy
- E. Stop HRT immediately and repeat assessment in 3 months
Explanation: ***Reassure her that irregular bleeding is expected in the first 6 months of continuous combined HRT and review if bleeding persists beyond 6 months*** - **Unscheduled bleeding** is a common and expected side effect in the initial **six months** of continuous combined HRT as the endometrium adapts to the constant hormone levels. - Given this is a single, self-limiting episode at 5 months into treatment and she is otherwise asymptomatic, **reassurance and observation** are the appropriate initial steps. *Arrange urgent transvaginal ultrasound scan to assess endometrial thickness* - While **transvaginal ultrasound (TVUS)** is a key investigation for **postmenopausal bleeding (PMB)**, it is generally not indicated for expected breakthrough bleeding within the first 6 months of HRT initiation. - An urgent scan would be considered if the bleeding was heavy, prolonged, or persisted beyond the initial adjustment period, none of which apply here. *Switch to sequential combined HRT regimen* - **Sequential combined HRT** is typically prescribed for **perimenopausal** women who have had a menstrual period within the last year, allowing for regular withdrawal bleeding. - This patient is 16 months post-menopause, making **continuous combined HRT** the appropriate regimen to avoid regular bleeds, and switching would likely reintroduce them. *Arrange outpatient hysteroscopy and endometrial biopsy* - **Hysteroscopy and endometrial biopsy** are invasive diagnostic procedures usually reserved for cases with persistent or abnormal bleeding, or when **TVUS** findings suggest endometrial pathology (e.g., endometrial thickness >4mm). - Performing these investigations for an isolated, self-limiting episode of bleeding within the expected adjustment phase of HRT is **premature and excessive**. *Stop HRT immediately and repeat assessment in 3 months* - Stopping HRT is unwarranted as the bleeding is likely a normal adjustment response, and she is benefiting from the treatment for her **vasomotor symptoms**. - Immediate cessation would lead to a likely return of her menopausal symptoms and does not align with current guidelines for managing initial HRT-related bleeding.
Question 37: A 46-year-old woman presents with worsening heavy menstrual bleeding and pelvic pain. She has a history of multiple uterine fibroids documented on ultrasound 2 years ago, the largest measuring 6 cm. She has completed her family and requests effective contraception that might also help with her bleeding. Her BMI is 32 kg/m². She has no history of thromboembolism and her blood pressure is 132/78 mmHg. Pelvic examination reveals a bulky uterus consistent with fibroids. What is the most appropriate contraceptive method for this patient?
- A. Etonogestrel subdermal implant
- B. Progesterone-only pill
- C. Combined oral contraceptive pill
- D. 52 mg levonorgestrel intrauterine system (Correct Answer)
- E. Copper intrauterine device
Explanation: ***52 mg levonorgestrel intrauterine system*** - The **levonorgestrel intrauterine system (LNG-IUS)** is highly effective for managing **heavy menstrual bleeding (HMB)**, often reducing blood loss by 90% or more and can induce **amenorrhea**. - It provides reliable, long-term contraception and can alleviate pelvic pain associated with fibroids, provided the **uterine cavity** is not significantly distorted by the fibroids. *Combined oral contraceptive pill* - While combined oral contraceptives (COCs) can reduce menstrual bleeding and regulate cycles, they are generally less effective than the **LNG-IUS** for severe **HMB** and do not directly address the mass effect of fibroids. - The patient's **BMI of 32 kg/m²** slightly increases potential cardiovascular risks with COCs, though her blood pressure is currently well-controlled. *Copper intrauterine device* - The **copper IUD** is contraindicated in patients with **heavy menstrual bleeding** as it is known to increase both menstrual blood loss and **dysmenorrhea**, which would worsen the patient's symptoms. - It offers only contraception and provides no therapeutic benefit for **fibroid-related bleeding** or pelvic pain. *Etonogestrel subdermal implant* - The implant offers effective contraception but its effect on **heavy menstrual bleeding** is variable; it can cause irregular bleeding or amenorrhea, but is less predictable than the **LNG-IUS** for significant flow reduction. - It does not exert the same localized **endometrial suppression** that is key to managing fibroid-related **menorrhagia** effectively. *Progesterone-only pill* - The **progesterone-only pill (POP)** provides contraception and may reduce bleeding for some, but it is less efficacious than the **LNG-IUS** for treating severe **HMB** associated with uterine fibroids. - It requires strict daily adherence and its impact on **pelvic pain** and fibroid growth is not as significant or consistent compared to the localized effect of the LNG-IUS.
Question 38: What is the recommended approach to progestogen therapy in women using estrogen-only hormone replacement therapy who have an intact uterus?
- A. Progestogen should be given for at least 10 days per month if using cyclical combined HRT (Correct Answer)
- B. Progestogen protection is not required if using transdermal estrogen
- C. Progestogen can be omitted if using low-dose estrogen therapy
- D. Progestogen is only required in the first year of HRT therapy
- E. Progestogen should be given continuously if more than 5 years post-menopause
Explanation: ***Progestogen should be given for at least 10 days per month if using cyclical combined HRT*** - In women with an **intact uterus**, systemic estrogen therapy without progestogen leads to **unopposed endometrial stimulation**, significantly increasing the risk of **endometrial hyperplasia** and **carcinoma**. - Guidelines recommend progestogen for at least **12-14 days** (with a minimum of **10 days**) per cycle to ensure effective shedding of the endometrial lining and minimize cancer risk. *Progestogen protection is not required if using transdermal estrogen* - Regardless of whether estrogen is administered **transdermally** or **orally**, the systemic levels reach the uterus and cause endometrial proliferation. - Progestogen remains mandatory for all forms of **systemic HRT** when the uterus is intact to prevent malignant transformation. *Progestogen can be omitted if using low-dose estrogen therapy* - Even **low-dose estrogen** can stimulate the endometrium enough to cause hyperplasia over time, making omission unsafe. - Only **vaginal low-dose estrogen** used for local atrophy symptoms typically does not require a progestogen; all **systemic doses** do. *Progestogen is only required in the first year of HRT therapy* - Endometrial protection must be maintained for the **entire duration** of systemic estrogen use, as the risk of hyperplasia persists as long as estrogen is taken. - Discontinuing progestogen while continuing estrogen at any point would leave the endometrium **unopposed** and vulnerable. *Progestogen should be given continuously if more than 5 years post-menopause* - While **continuous combined HRT** is often preferred in post-menopausal women to avoid withdrawal bleeds, it is not a requirement based strictly on a 5-year timeline. - The choice between **cyclical** and **continuous** regimens depends on the woman's preference and menopausal status, but progestogen is required in both for endometrial safety.
Question 39: A 33-year-old woman presents 84 hours after unprotected sexual intercourse requesting emergency contraception. She has a regular 28-day menstrual cycle and estimates she is on day 14 of her cycle. She weighs 72 kg with a BMI of 26 kg/m². She takes no regular medications and has no contraindications to hormonal contraception. She has no previous history of ectopic pregnancy. What is the most appropriate emergency contraception to offer?
- A. Ulipristal acetate 30 mg as a single dose
- B. Copper intrauterine device insertion (Correct Answer)
- C. Combined oral contraceptive (Yuzpe method)
- D. Levonorgestrel 1.5 mg as a single dose
- E. Levonorgestrel 3 mg (double dose) as a single dose
Explanation: ***Copper intrauterine device insertion***- The **copper IUD** is the most effective method of emergency contraception and can be inserted up to **120 hours (5 days)** after unprotected intercourse, or within 5 days of the earliest predicted **ovulation**.- Given the patient is at **84 hours** post-intercourse and likely in the **periovulatory period** (day 14), the IUD offers superior efficacy compared to hormonal methods that primarily delay ovulation.*Ulipristal acetate 30 mg as a single dose*- While effective for up to **120 hours**, its efficacy can be reduced if **ovulation** is already imminent or has occurred, which is a strong possibility on day 14 of a regular cycle.- It is generally less effective than the **copper IUD** and should not be offered as a first-line alternative when an IUD can be fitted.*Combined oral contraceptive (Yuzpe method)*- This method involves high doses of **estrogen and progestin**, and is significantly less effective and associated with a higher incidence of **nausea and vomiting** compared to newer options.- It is generally **outdated** and not recommended as a primary emergency contraception choice when more effective and better-tolerated methods are available.*Levonorgestrel 1.5 mg as a single dose*- This hormonal emergency contraceptive is licensed and most effective when taken within **72 hours (3 days)** of unprotected intercourse.- The patient has presented at **84 hours**, falling outside the recommended and most effective time window for **levonorgestrel**.*Levonorgestrel 3 mg (double dose) as a single dose*- A double dose of **levonorgestrel** (3 mg) is considered for women with a **BMI >26 kg/m²** or weight **>70 kg** due to potential reduced efficacy at standard doses, which applies to this patient (72kg, BMI 26).- However, similar to the standard dose, its efficacy is time-dependent and significantly reduced or absent when taken **84 hours** after intercourse, well past the **72-hour** window.
Question 40: A 58-year-old woman presents for review of her hormone replacement therapy. She had a total hysterectomy for stage 1 endometrial carcinoma at age 55, treated with surgery alone. She has been taking estrogen-only HRT (transdermal estradiol 50 mcg patches) for 2 years for troublesome vasomotor symptoms which have now completely resolved. She is concerned about continuing HRT given her history. What is the most appropriate management?
- A. Switch to continuous combined HRT for endometrial protection
- B. Discuss discontinuation of HRT given cancer history and symptom resolution (Correct Answer)
- C. Continue current HRT indefinitely as she has had a hysterectomy
- D. Add cyclical progesterone to current estrogen therapy
- E. Increase estradiol dose to 75 mcg patches for better symptom control
Explanation: ***Discuss discontinuation of HRT given cancer history and symptom resolution*** - This patient's **vasomotor symptoms** have completely resolved, eliminating the primary indication for HRT, which should always be used at the **lowest effective dose** for the shortest duration. - Given her history of **stage 1 endometrial carcinoma**, an **estrogen-sensitive malignancy**, continuing HRT introduces an unnecessary risk of recurrence that outweighs any benefit, making discontinuation the most appropriate management. *Switch to continuous combined HRT for endometrial protection* - The patient has undergone a **total hysterectomy**, meaning she no longer has a uterus or **endometrium**, so there is no need for progesterone to provide endometrial protection. - Adding progesterone would expose her to unnecessary medication and potential **side effects** without providing any therapeutic or protective benefit in this context. *Continue current HRT indefinitely as she has had a hysterectomy* - HRT, even estrogen-only, is associated with long-term risks such as **venous thromboembolism (VTE)** and possibly breast cancer, and should not be continued indefinitely without clear indication. - Indefinite HRT use is particularly cautioned in individuals with a history of **estrogen-dependent cancers**, regardless of hysterectomy status, due to increased risk. *Add cyclical progesterone to current estrogen therapy* - **Cyclical progesterone** is used to induce withdrawal bleeds and protect the endometrium in women with an intact uterus; it serves no purpose after a **total hysterectomy**. - Introducing progesterone would add potential **side effects** (e.g., bloating, mood changes) without offering any clinical benefit for this patient. *Increase estradiol dose to 75 mcg patches for better symptom control* - Increasing the dose is inappropriate as the patient's **vasomotor symptoms** have already completely resolved, indicating that the current dose is sufficient. - A higher dose of **transdermal estradiol** would unnecessarily increase systemic estrogen exposure, which is particularly concerning given her prior **estrogen-dependent endometrial carcinoma**.
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