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Essay 288 - contraception

Essay 288 - contraception Posted by PAUL A.
A healthy 20 year old mother of three children has been referred to the gynaecology clinic because of problems with contraception and repeated unplanned pregnancies. (a) Which information would you obtain from the history? [6 marks] (b) What would you tell her about the advantages and disadvantages of depo-medroxyprogesterone acetate? [7 marks] (c) What would you tell her about the advantages and disadvantages of the levonorgestrel-releasing intra-uterine device? [7 marks].
Posted by S D.
a) Menstrual history regarding LMP, regularity of cycles and cycle length; any IMB, PCB or dyspareunia should be asked. Her current contraception and types of previous contraception used should be enquired. Type of problems encountered during previous contraception, her compliance and if the method was correctly followed should be asked. History of previous PID or STI\'s should caution to the use of intrauterine contraceptive devices because of the increased risk of infection. Any contraindications to hormonal methods such as focal migraine should be asked. Use of medications such as anti epileptics may influence the dose of oral contraceptive pills to be given. Mode of deliveries and time of last child birth and if she is breastfeeding is important as this influences the type of pill given. She should be asked whether she has multiple sexual partners as barrier contraception in addition to other contraception can be advised.
b) Depot provera can be given every 3 months, so compliance is better. It is user independent and is an effective contraceptive. It forms a protective mucus plug at the cervix and reduces the risk of PID. The risk of ectopic pregnancy is lower compared to non users of contraception. Fertility ultimately returns on discontinuation of method.
There is higher risk of irregular vaginal bleeding with this method. There is a risk of osteoporosis on long term use which disappears on discontinuation of the method but this has not been confirmed in RCT\'s. Acne, weight gain, mood changes, depression and headahes are transient and disappear with time. There is delay in return of fertility of 12-18 months after discontinuation of the method and women shouldbe informed about this. There is also a risk of amenorrhea which increases anxiety in some women. The injections can be painful.
c) Mirena IUS is as effective as sterilisation and can stay in for 5 years. Fertility returns immediately after removal of device. It acts by causing endometrial atrophy, so decreases menorrhagia and also dysmenorrhea. It is also effective in decreasing the symptoms of PMS. It also decreases the incidence of PID and ectopic pregnancy compared to non users of contraception.
It causes irregular vaginal bleeding in the first 4-6 months of use and woman should be thoroughly about this. If she perseveres, then usually the bleeding tends to settle by 9 months. Risk of perforation during insertion (1:1000); risk of PID especially in the first 3 weeks after insertion and PID after this period depends on the life style of the patient. Other side effects include nausea, tender breasts, acne, headaches which are usually transient.
Posted by clarice M.
a) I would enquire about her previous contraception, perceived reasons for failure and reasons for discontinuation.
Details about her menstrual cycle such as the last menstrual period, cycle length, regularity and blood flow will also be obtained.
The obstetric history should include mode of delivery, when her most recent delivery occurred and if she is currently breast feeding.

Relative and absolute contraindications to the various contraceptive methods available should be sought. For example, a history of migraine with aura or venous thromboembolism precludes the use of a combined contraceptive pill. Uterine anomalies such as a bicornuate uterus is a relative contraindication for siting an intrauterine device and caution should be exercised when it is inserted. Active liver disease is an absolute contraindication to progestogen only contraceptives, be it oral or long-acting.

I would obtain a history of sexual partners in the last 6 months, condom use and previous history of sexually transmitted infection to assess her risk for a sexually transmitted infection.

b) The advantages of depot-medroxprogesterone acetate (DMPA) are that it is reversible and has a low failure rate of 0.3-1/100 women years. To a certain extent, it is not user dependent and its efficacy is not affected by antibiotics. After 1 year of use it can cause amenorrhoea which will be beneficial to patients who have heavy menses.

The disadvantages are that it can cause irregular bleeding in the 1st 6 months of use. Weight gain of up to 2kg can occur particularly in the early stages of its use. Breast tenderness, bloating and pre-menstrual symptoms can also occur. It also reduces bone mineral density after 2 years of use. However this is reversible and there is no increased risk in fractures during this time. Another important disadvantage is a delay in return to fertility following cessation of DMPA. This can last from 6 months but in a minority of patients this can last upto 2 years.

C) The advantages of the IUS is that it is a reversible form of contraception and has a low failure rate of 0.1/100 women years. It lasts for 5 years duration and it is not user dependent. Its efficacy is unaffected by antibiotic use. It reduces the chances of developing an ectopic pregnancy compared with other types of contraception. It reduces menstrual flow in 40% of patients and another 40% may experience amenorrhoea. This will be useful in patients who have menorrhagia. If pregnancy is desired, there is no delay in conceiving once the IUS is removed.

The disadvantage is that it can cause irregular bleeding the 1st 6 months of use. Systemic side effects such as breast tenderness and premenstrual symptoms can also occur, but these are transient. When it is inserted, uterine perforation can occur. Pelvic inflammatory disease can also occur if there is undiagnosed infection at the time of insertion. However, this can be managed by screening the patient for sexually transmitted infections prior to insertion or administering antibiotic cover during its insertion.
Posted by dr neelangini G.
a) I would ask her any current method of contraception & problems she is facing. I would also like to know past contraceptive history & cause of discontinuation of the method. Her menstrual history , to know her LMP & to rule out possibility of early pregnancy. Her regularity of menstrual cycle & amount of bleeding is important in deciding type of contraception. Her Obstetric history including mode of deliveries. History of breast feeding is important to help her choose a contraception method . Any family history of breast cancer to be noted. Previous h/o DVT in pregnancies, past h/o PID to be taken into consideration.Her sexual history to be obtained to know he risk of STIs. Personal history of smoking, alcoholism to be considered.



b) I will tell her that DMPA is one of the most effective family planning method with less than 1 pregnancy per 100 users per year. Its advantages are once injected , it will give protection for 12 weeks. It refrains from need of taking daily pills. No oestrogenic side effects on cardiovascular system . Its noncontraception benefits are , prevention of anaemias as amount of blood loss is less. It is associated with less risk of ectopic pregnancy & CA endometrium than woman who do not use contraception. There is no permanent impairment of fertility. It is costeffective. It can be used by breast feeding women as it does not reduce lactation.
Its disadvantages are irregular menstrual cycle in initial one year of use & thereafter amenorrhoea lasting 3 months or more. There may be irregular bleeding , spotting pv. It is associated with weight gain of 1-2 kg per year . Women face slightly increased risk of breast cancer in the first five year of use. If she decides for further childbearing , return of fertility is delayed by 6 months after the last injection. Prolonged use is associated with reduced bone mineral density.

c) I will tell her that LNG IUs is an effective reversible method of contraception with failure rate of less than one pregnancy per 100 users per year. Its advantages are , it can be used by breast feeding woman. Once inserted , she will have contraceptive effect for 5 years. Risk of ectopic pregnancy is low. It can reduce menstrual blood loss by 90% therefore useful in menorrhagea patients. Rapid return of fertility occurs after removal of the device within 4 -12months. It does not have adverse impact on BMD .
I will tell her the disadvantages of LNG IUS are , small increase in risk of PID after insertion . It is associated with altered pattern of menstrual bleeding , like prolonged bleeding & amenorrhoea. There is increased risk of ovarian cyst formation. It has few hormaonal effects like acne, headache, breast tenderness .Its risk of expulsion is 1 in 20. There is also a risk of perforation .
Posted by clarice M.
a) I would enquire about her previous contraception, perceived reasons for failure and reasons for discontinuation.
Details about her menstrual cycle such as the last menstrual period, cycle length, regularity and blood flow will also be obtained.
The obstetric history should include mode of delivery, when her most recent delivery occurred and if she is currently breast feeding.

Relative and absolute contraindications to the various contraceptive methods available should be sought. For example, a history of migraine with aura or venous thromboembolism precludes the use of a combined contraceptive pill. Uterine anomalies such as a bicornuate uterus is a relative contraindication for siting an intrauterine device and caution should be exercised when it is inserted. Active liver disease is an absolute contraindication to progestogen only contraceptives, be it oral or long-acting.

I would obtain a history of sexual partners in the last 6 months, condom use and previous history of sexually transmitted infection to assess her risk for a sexually transmitted infection.

b) The advantages of depot-medroxprogesterone acetate (DMPA) are that it is reversible and has a low failure rate of 0.3-1/100 women years. To a certain extent, it is not user dependent and its efficacy is not affected by antibiotics. After 1 year of use it can cause amenorrhoea which will be beneficial to patients who have heavy menses.

The disadvantages are that it can cause irregular bleeding in the 1st 6 months of use. Weight gain of up to 2kg can occur particularly in the early stages of its use. Breast tenderness, bloating and pre-menstrual symptoms can also occur. It also reduces bone mineral density after 2 years of use. However this is reversible and there is no increased risk in fractures during this time. Another important disadvantage is a delay in return to fertility following cessation of DMPA. This can last from 6 months but in a minority of patients this can last upto 2 years.

C) The advantages of the IUS is that it is a reversible form of contraception and has a low failure rate of 0.1/100 women years. It lasts for 5 years duration and it is not user dependent. Its efficacy is unaffected by antibiotic use. It reduces the chances of developing an ectopic pregnancy compared with other types of contraception. It reduces menstrual flow in 40% of patients and another 40% may experience amenorrhoea. This will be useful in patients who have menorrhagia. If pregnancy is desired, there is no delay in conceiving once the IUS is removed.

The disadvantage is that it can cause irregular bleeding the 1st 6 months of use. Systemic side effects such as breast tenderness and premenstrual symptoms can also occur, but these are transient. When it is inserted, uterine perforation can occur. Pelvic inflammatory disease can also occur if there is undiagnosed infection at the time of insertion. However, this can be managed by screening the patient for sexually transmitted infections prior to insertion or administering antibiotic cover during its insertion.
Posted by Neelam A.
NA
A detailed history should be obtained to find out type of contraception used in the past, adverse effects, failure rate with any particular methods or poor compliance with pills. Obstetric history is also important to know age of children, number of terminations and type of deliveries and whether she is breast feeding. An enquiry should also be made to know details of gynaecological problems in form of menorrhagia, premenstrual syndrome, pelvic inflammatory disease (PID) or fibroids. Personal or family history of thromboembolism, or osteoporosis and breast cancer should also be asked. Medical history of diabetes, hypertension migraine liver disease or epilepsy should be asked. A note should be made to know about medications use especially liver enzyme inducer and antibiotic which would affect the efficacy of contraception. Fertility plans and completion of family should also be enquired. Sexual history should also be obtained to know about stable relationship or multiple partners. Personal history of smoking is also important. Cervical smear status should also be noted down. Body mass index should also be recorded. Pros and cons of all available reversible and permanent contraceptive methods should be discussed in addition to vasectomy option and informed decision should be made. Information leaflets should be provided.
Advantages of depo-medroxyprogesterone are:
One injection lasts 3 months. Efficacy rate are .20-0.5 per 100 women year. As it does inhibit ovulation, its use will be beneficial in endrometriosis, and dysmenorrhoea. It would also result amenorrhoea in about one third women, therefore ferritin level would go up in anaemic women. It can be used in breast feeding women or where there is contraindication for the use of combined oral contraceptive pills. It also reduces chances of PID.
Disadvantages of depo-medroxyprogesterone are:
Its use is associated with menstrual irregularities especially amenorrhoea. Incidence of ectopic pregnancy is higher compared to use of COCP. Other adverse effects are weight gain, breast tenderness, mood swings, acne and ovarian cysts. Long term use is associated with reduced bone mineral density. Delay in return of fertility following its discontinuation.
Advantages of levonorgestrel-releasing intra-uterine device:
Besides contraceptive effect, its use is also associated with reduction in amount of blood loss. 12 months use results 95% reduction in blood loss and amenorrhoea in about one-third. It can also reduce blood loss in fibroids. Its efficacy has been proved to reduce pain in endometriosis and dysmenorrhoea. It can also be used along with transdermal oestrogen in premenstrual syndrome. Its use is associated with less number of ectopic compared to other intrauterine devices. It is a popular long term contraception, lasts for 5 years. Its efficacy has been shown to equivalent to sterilization, although it is a reversible contraception.
Disadvantages of levonorgestrel-releasing intra-uterine device:
Insertion of this device needs proper training and sterilized instrument set. She should be counselled for menstrual irregularities for initial 6 months followed by period of amenorrhoea. Adverse progesterogenic side effects can be seen in form of breast tenderness, weight gain, mood swings or ovarian cyst. Expulsion rate are around 5% initially in a year time. Improper technique and unhygienic condition may be associated with perforation and infection (3 weeks after insertion).

Posted by Manoj Babu  R.

a) Which information would you obtain from the history? [6 marks]

A detailed marital and obstetric history should include the duration since marriage, no of pregnancies and their outcomes, time since last delivery and whether she is breast feeding or not. Enquire about future child birth plans.

Contraceptive history should include the type of contraceptives used, current contraception and possible causes of failure should be explored based on the type of contraception used. An enquiry about current partners is important to assess the risk of STIs.

Menstrual history should include the LMP, history of menorrhagia or irregularity of cycles, dysmenorrhoea and premenstrual syndromes.

(b) What would you tell her about the advantages and disadvantages of depo-medroxyprogesterone acetate? [7 marks]

Depomedroxtprogesterone (DMPA) is an injectable progesterone only contraception which is coitus independent. The failure rate is only 4 in 1000 over 2 years and does not need any further motivation other than repeat injections every 12 weeks. It can be used during breast feeding and does not affect lactation. It can be injected any time after first and second trimester termination of pregnancy. It does not cause progestrogenic side effects like acne, depression or headache and can be used in women who have contraindications for estrogen use. It does not increase the risks of STIs and may reduce the frequency of seizures in those with epilepsy.

Disadvantages of DMPA include delay in return of fertility for up to I year after stopping, but will need alternative contraception immediately after stopping if pregnancy is not needed. Most common reason for discontinuing is irregular and unpredictable bleeding. It can cause weight gain for up to 2-3 kg after 1 year of use. It does not protect against STIs and may cause slight reduction in bone mineral density. But this is usually reversible after stoppage does not increase the risk of fractures. Need for repeated injection may not be acceptable for some women. She should be provided with written information explaining all these.

(c) What would you tell her about the advantages and disadvantages of the levonorgestrel-releasing intra-uterine device? [7 marks].

Levonorgestrel releasing intrauterine system (IUS) is one of long acting reversible contraception with very low failure rate of about 10 in 1000. Once inserted it has to be replaced only after 5 years and there is no evidence of delay in fertility after removal. It does not cause increase in weight gain and the risk of ectopic pregnancy is less than those using no contraception. It can used during breast feeding and it can used safely in women with contraindications for estrogen. It reduces bleeding in about 90% women and may cause amenorrhea in some. Other non contraceptive benefits include possible reduction of dysmenorrhoea and reduction in size of any fibroids.

Disadvantages include the need for an invasive procedure for insertion and the possible risk of perforation in about 1 in 1000. There is risk of PID but it is only in the first 20 days after insertion and decreases thereafter. It can cause acne in some but there is only minimal effect on mood and libido. Cause of failure is due to expulsion which can occur in 1 in 20 women and she should check for the IUS thread to make sure that it is in situ. If pregnancy occurs, up to 1 in 20 can be ectopic. It can cause irregular bleeding and dysmenorrhoea in some women but usually in the initial months only. She should be provided with written information explaining all these.

Posted by Farzana N.
Deatailed menstrual history is taken regarding her LMP, length of cycle and regularity.Enquiry should be made about any intermenstrual or post coital bleeding
Contraception history is taken regarding type of contraception and most important is her compliance.Non compliance is the most important factor in case of failure of contraception,especially in young females..
Obstetric history -parity ,age of youngest child ,if she is breast feeding.
History of any ectopic pregnancy.
Sexual history is taken –multiple sexual partners puts her at risk of STIs.
b) Advantages of DMPA are they provide effective contraception,with failure rate
0.25-0.5/100 women yrs.Risk of ectopic pregnancy is lower as compared to POP.
Minimal adverse effects are seen on coagulation and and lipid profiles.Thus there is no increased risk of VTE or HTN.It has no impact on milk production and can be used in lactating mothers
Non contraceptive benefits include protection against PID,endometrial cancer and vaginal candidiasis.Menstrual blood loss is reduced .It is cost effective than COCP even at 1yr of use.
Disadvantages are that woman may experience ammenorrhoea and irregular bleeding which may cause her anxiety.She may have weight gain.Return of fertility may be delayed.It may take as long as 7-8months.Small loss in BMD ,but it is largely recovered
after stopping DMPA
c)Advantages of IUS are that it provides effective contraception ,with failure rate of <1in 100women over 5yrs.It is licensed for contraception for 5yrs. No evidence of delay in fertility. Expulsion occurs in less than 1 in 20 women
Non contraceptive benefits are reduction in menstrual bleeding. Upto 97% at the end of 1yr and increase in Hb concentrations.Risk of PID is reduced.
Disadvantages of IUS are that she may experience irregular bleeding. and pain.
Risk of ectopic pregnanacy is less than in women with no contraception.,but if she does become pregnant with IUS in situ,risk of ectopic pregnancy is 1 in 20. She should seek medical advice.She may experience change in mood or libido, or increase in acne.
No evidence of effect on weight gain .
Posted by S M.
a) I would find out what type of contraceptives she knows of and her wishes on which contraceptive she should use now. I would enquire on the types of contraceptives she has used and which problems she has had with them such as irregular bleeding. I would try to determine whether she has used them correctly for example whether she missed any pills to account for an unplanned pregnancy. I would find out whether she wishes to have more children in the future and if she is in a stable relationship. If in a stable relationship, her partner could be offered a vasectomy. If not in a stable relationship she could be offered condoms for contraception and to reduce her risk of sexually transmitted infections. The date of her last delivery and whether she is breastfeeding needs to be known since this will affect the type of contraceptive she should begin now.

b) I would tell her that advantages include a low failure rate of 4 in 1000 if the depo-medroxyprogesterone acetate injection is given every 12 weeks. It avoids having to remember to take a pill every day as in the case of the combined oral contraceptive pill.
The disadvantages include a delay in return of fertility. This delay can be up to 1 year. This contraceptive can also cause irregular bleeding or the absence of periods. It can also cause weight gain. I would provide her with written information.

C) I would tell her that advantages include long term use. The levonorgestrel-releasing intra-uterine device (LNG-IUS) can be used for 5 years before it needs to be changed. The LNG-IUS is safe. It is an effective contraceptive with 99% success rate. After removal, there is no delay in fertility returning. If she has heavy menstrual periods, another advantage of the LNG-IUS is that it can significantly reduce menstrual blood loss. The disadvantages of the LNG-IUS are that it needs to be inserted into the cavity of the uterus which may be uncomfortable or painful. It carries a small risk of infection within the first 20 days of insertion. It carries a small risk of expulsion and she must check vaginally for the strings attached to the LNG-IUS every month to ensure that it has not been expelled. I would provide her with written information.
Posted by Dr Dyslexia V.
X

a. I would take history of previous contraception usage, the reason of failure, such as low compliance or, inadequate knowledge wrong application. Other history include her planned family size and her future pregnancy plan. Her last menstrual period and regularity of cycle is also important to determine undiagnosed pregnancy . Any history of uterine pathology should be taken as it could be inappropriate for IUCD insertion. History of sexual frequency, partner and exposure to sexually transmitted disease ( STI) should also be illicited.


b. The advantages of depo medroxyprogesterone acetate include the low failure rate of 0.4 per 100 users over 2 years. It is easily administrable for 3 monthly duration does not require high degree of compliance and tedious usage of daily pills. It could be used during breastfeeding. The disadvantages include irregular cycle, and ocaasionally amenorrhea. There is associated increased duration of return to fertility which could last up to 2 years. It is associated with weight gain in long term use. There is a decrease in bone density but not associated with fractures. It could also not be used to patient with needle phobia and it could cause pain if administered wrongly. It does not confer against STI. It is also associated with presence of functional ovarian cyst.
c. The advantage of the levonegesteral intrauterine system ( LNG IUS) include a low failure rate of 1 in 100 users over 5 years. This could also be used for a period of 5 years without change and earns a good compliance rate once applied. It is also cost effective compared to usage of other methods of long term reversible contraception. It has added advantage of improving symptoms of dysfuntional uterine bleeding. The device is also could be used on patient who are breastfeeding. It is associated with a risk of uterine perforation about 1 in 1000 users and associated risk of expulsion about 1 : 20 users over the period o 5 years. There is also a relative risk slight increase with pelvic inflammatory disease. It could also cause occurrence of ectopic pregnancy. It does not offer protection against STI . There is also association with menstrual irregularities which are usually for the the first 6 month of usage and occasionally amenorrhea.
Posted by Mark D.
=============
mark

a)
I will ask which methods of contraception has she used in the past ,the problems associated with each of them and if she was taking them as per instructions. I will ask her current method of contraception and its problems and confirm the compliance with it.
I will enquire her menstrual history- age of menarche, regularity flow and LMP.
I will enquire about her past gynecoligical history like PID,STIs, ectopics,endometriosis, chronic pelvic pain and any treatments for them .
I will enquire about her obstetric history the mode of deliveries and age of last child birth.i will ask her future fertility intensions and what kind of method would she like to use –oral or injectable or implant , hormonal or nonhormonal.


b)
The advantages of Inj DMPA are it is non-oral method so not associated with nausea or gastric symptoms. It does not need to remember and take a tablet daily.it has to betaken once in three months so less number of visits to clinic.it decreases the menstrual blood flow and and particularly useful if she has heavy menstrual loss.
It reduced endometriosis associated pain if she has endometriosis.It has a low failure rate of 0.5/100 woman years.
The disadvantage it it gives trouble some side effects like mastalgia, bloating, weight gain due to progestogens.It does not provide protection against STIs. It gives poor cycle control and is associated with unpredictable break through bleeding.She may find it difficult to come to the clinic every 3 monthly leaving behind 3 children at home.it reduces bome mineral density if used for long term.It may also cause functional ovarian cysts although most ofthem are asymptomatic and don’t require any treatment.it causes delay in return to fertility of 9 months from the last injection and not suitable if she wants pregnancy immediately after stopping the method.
I will provide written information .


c)The advantage of LNG IUS are very low failure rate 0.2/100 woman years .Once inserted it is effective for 5 years.there is no need to fiollow up routinely after the first followup after 3-4 weeks. In woman with heavy periods it is particularly useful as it decreases the menstrual blood loss by 60% in 3-4 months and 30% women become amenorric in 1 year of use.it also reduces endometriosis associated pain.

The disadvantage of it is it gives bothersome irregular breakthrough bleeding in the first 3-6 months of use.it has to be fited by a medical personel. It is associated with complications like expulsion (1/20 ), perforation (1/200), and infection in first 3 weeks ( 1%) .She will need to be screened for chlamydia before insertion. If found positive she will need antibiotics and referal to GUM clinic. It gives mild progestogenic side effects due to systemic absorption and like mastagia and breast tenderness. I wll provide witten information to her .
Posted by Manoj M.
a) Her desire and need for contraception should be ellicited as she may not need any contraception.
A history of cause of problems with use of previous contraception should be ellicited to exclude compliance issue and side effects.
Her recent contraceptive use should be ellicited and a need for emergency contraception should be excluded.
Her menstrual history including last menstrual period should be taken to exclude any current pregnancy prior to prescribing contraceptions.
A family history of risk for thrombosis, breast cancer should be taken to exclude her risk factors for contraception with combined pills.
History of smoking should be excluded as smoking more than 15 cigarettes/ day will be a containdication for combined oral contrceptive pills.
Details of her pregnancy and last child birth should be taken including brest feeding history to decide her contraceptive choice.
History of previous ectopic pregnancy and pelvic infections/ history of sexually transmitted infection should be ellicited so that further testing (including chlamydia) and treatment / referral to genitourinary medicine could be offered.
Her sexual history should be taken with regards to more than 2 partners in the last 6 months, she should be offered testing for STI/ referred to genitourinary medicine and safer sex advice provided.

b)Contraceptive advantages of depot medoxy progesterone acetate(DMPA) is very effective contraceptive method with failure rate of fewer than 0.4 in 100 over 2yrs period.
It is user friendly and lesser compliance issue compared to oral contraceptive pill as it is once intra muscular injection every 12 weeks. It does not interfere with sexual intercourse compared with condoms.
Non contraceptive advantages like amenorhoea is common with DMPA and lesser menstrual loss if affected with heavy menstrual bleeding.
DMPA provides reduction in pelvic inflammatory disease compared to non user of contraception, but safer sex with barrier methods should be advised if high risk.
No evidence of affect of DMPA on depression, acne or headache.
It can be used with underlying risk factors like family history of thrombosis / breast cancer.
Disadvantages of DMPA are increase in weight gain of 2-3 kg over one year period which may not be acceptable with the patient as may impair her body image.
Most common reason for discontinuation is irregular bleeding pattern with DMPA which may not be acceptable for the patient.
DMPA is assocated with loss of bone mineral density loss over 2 year use and this almost fully recovers with stopping DMPA, but no increased risk of fracture of bones.
There may be a delay of fertility of up to 1 year with stopping DMPA but if continued contraception is needed alternative methods of contraception should be employed immediately.
Return for injection every 3 months may be disadvantage with child care and other issues.

c) Contraceptive advantages of Levonorgesterol intra uterine system is it is a very effective contraceptive method with failure rate of fewer than 1 in 100 over 5 year period.
It is user friendly and no compliance issue after insertion compared to oral pills and need to be changed only 5 years and does not interfere with sexual intercourse compared to condoms.
There is no delay of fertility on removal of the coil.
Non contraceptive advantages are, it reduces menstual bleeding more commonly, which may give better compliance for patient if affected with heavy menstrual bleeding.
It will provide better protection against ectopic pregnancy compared to non user of contraception.
No evidence of increase in body weight.
Disadvantages are risk of preforation with insertion which is 1 in 1000, along with risk of pain associated with insertion.
There is a risk of expulsion which is 1 in 20 over 5 year period and she should be advised regarding coil thread checking.
Irregular bleeding pattern is common reason to discontinue but she should be explained about this & in most of women will achieve much less bleeding pattern in a year time.
Regarding changes of mood and libido are small effect and silimar to intra uterine coil.
There is a small chances of acne with IUS and uncommon for changing the device for this reason.





Posted by Priti T.
prt

a] The patient should be asked regarding details of her sexual history and menstrual hx.Date of LMP is asked to exclude pregnancy before prescribing contraceptives.
Details of obstetric hx is asked to know the number of CS and vaginal delivery as it would help in deciding the type of contraceptive.Previous contraception used should be enquired into.
Hx of menorrhagia and dysmenorrhoea is elicted.She should be asked about any further desire for children &the expected family size.History of more than one sexual partner in the last year should be asked as patient is only 20 years old;she should be referred to genitourinary medicine to rule out sexually transmitted infections if she has been changing partners.
Family hx of osteoporosis,thromboembolism and breast cancer should be asked .
She should be asked about the smoking,alcohol intake or any drug abuse in the personal hx.Any hx of migraine,liver disease or associated drug intake needs to be noted.

b] Advantages of depot Medroxy Progesterone Acetate[DMPA] is that it is a long acting reversible contraceptive which needs to be taken every 12 weeks.The patient should be told that it has a good efficacy with a pearl index of 0.25-0.5/100 women years.
It does not needs to be taken daily and does not interfere with sexual intercourse.
It is associated with lower risk of Pelvic inflammatory Disease,ectopic pregnancy and endometrial cancer
Menstrual blood flow is reduced and hence it reduces iron deficiency anaemia .This method is especially suitable if the woman is breast feeding or a smoker.In case the patient is diabetic or hypertensive, it avoids the oestrogenic effects of COCPs.
Patient should be told that the efficacy of DMPA is not reduced by the antibiotics and liver inducing enzymes.She can continue the injection at the usual interval of 12 weeks.

Patient should be informed about the various disadvantages of DMPA that the menstrual irregularity is common.Amenorrhoea is more likely with repeated doses;30% with the first dose and 55% after the fourth dose.Upto 50% of the women may discontinue DMPA at the end of one year due to unacceptable bleeding pattern.
It is associated with a delayed return of fertility ,of about 8 months from the last injection and may be as long as 24 months.
There may be weight gain of upto 2 kg in the first year which may not be acceptable to many patients.
There is an evidence that DMPA causes significant reduction in the bone mineral density.This may be important if the woman has a family hx of osteoporosis.But this may revert to normal on discontinuation.Verbal as well as written information should be given to the patient.


c] The patient should be told the advantages of LNG-IUS[Levonorgestral Intrauterine system] that it has a good efficacy of less than 1/100 pregnancy rate and it is licensed for use for 5 years.It has a ready reversibility and return of endometrial morphology and menstruation with in 30 days.
It has the advantage of treating associated menorrhagia and reducing blood loss upto 97 % after 12 months of use;with increase in serum ferritin and Haemoglobin concentration.
Dysmenorrhoea may be improved.
It has a lower ectopic pregnancy rate 0.02/100 women years compared to nova T users and sexually active women not using contraceptives.
It protects against PID by thickening the cervical mucus,inactivation of endometrium and reduced bleeding.
The disadvantages of LNG-IUS is that there may be difficulty in insertion due to its thick stem.Patient may need analgesia or cervical dilatation for the insertion.
There is increased incidence of irregular bleeding and it may take 3 months for the endometrium to atrophy.Patient should be told about it.
There is increased incidence of functional ovarian cysts compared to copper IUDs .Patients needs to be counselled properly about amenorrhoea as many women regard it as abnormal.Various progestogenic adverse effects like oedema,headache and breast tenderness should be told to the patient and written information given for the same.There is increased likelihood of developing acne due to progestogen ,but few women discontinue IUS due to this.
IUS is expensive and is not cost effective to NHS as only contraceptive.Around 60% of women discontinue the use of IUS due to unacceptable bleeding profile and this should be told to the patient.
There is risk of perforation albeit small 1:100 at the time of insertion.If women becomes pregnant with IUS in situ then the risk of ectopic pregnancy is 1:20 and woman should be told to exclude ectopic pregnancy.Written information is given for all the above details.
Posted by syeda sajida M.
(a) I will enquire about the previous method of contraception and her compliance as there is a chance that her previous unplanned pregnancies were due to user failure. I will also ask her what is her preference now, whether implants, intrauterine devices, injections pills after giving her all information about these methods and is she aware of emergency contraception.
Mode of previous deliveries and age of her last child and whether she is breastfeeding will also be enquired. Regarding her menstrual history, it is important to know the regularity, amount of flow, any dysmenorrhea. Her LMP should be recorded as well. Any family history of osteoporosis should also be sought.
(B) I will inform her that DPMA is a form of long acting reversible contraception in injection form that needs to be taken every 84-90days. It is easy to use in the sense that the patient needs just one injection every 3 months unlike the pills which need to be taken regularly and any failure of their compliance would result in an unplanned pregnancy. The failure rate is less than 0.4/100 women years. There is less risk of ectopic pregancy and PID. Menstrual blood loss may also reduce with time and there is improvement with Hb. It will not interfere with her breastfeeding.
As far as disadvantages are concerned, there is chance of weight gain of about 2-3kg, especially during 1st year of use. There can be irregular bleeding per vaginum for some time but there is also 30% chance of amenorrhea after 1 injection and 55% after 4 injections. There may be a delay in return of fertility from 8 months to 24 months. This method can\'t be used for more than 2 years as there is a chance of small loss of bone mineral density which will recover when DPMA is stopped and there is no risk of fractures. I will also provide the patient with the information leaflet.
(c) Levonorgestral Intrauterine system is another method of long acting reversible contraception. It is very effective with failure rate of less than 1 in 100 women years. It can be kept for 5 years. No patient compliance needed and fertility is returned back as soon as it is removed. No effect on her breastfeeding and menorrhagia will also improve.
The disadvantage of this method is there is risk of irregular bleeding, spotting and pain for the first 6 months but by the end of 1 year oligomenorrhea or amenorrhea occurs in about 95%, so she needs proper counselling. There is a small chance of having acne and change in mood but no risk of weight gain. There is a low risk of PID and ectopic pregnancy but overall rates are lower than no contraception. If anytime she feels she is pregnant, she should get medical advice. There is a risk of uterine perforation at the time of insertion and increased chances of infection for the first 2-3 weeks. Also there is a small risk of expulsion. I will give her information leaflets.
Posted by A S.
Am
a) I will take details of menstrual history, LMP for possibility of current pregnancy, regularity of the cycle , amount of bleeding and for how many days she bleed per month. Contraception history incluing current contraception, previous methods used and causes of failure like irregular pill taking . Sexual history is important , last intercourse and if she is using any barrier methods . Previous or current pelvic pains ,vaginal discharge or previous attacks of PID and when was the last attack . Obstetric history including when was her last delivery ? is she breast feeding ?

b) Advantages of depomedroxy progesterone acetate are numerous . Easy administration , only IM injection every 12 weeks . For a busy mother like her it is user independent , she don t have to remember to do anything except to take the injection on time . The method is indepedant of intercourse. Long acting method and can be used safely for 2 years . It has very low failure rate ( less than 1 /100 women year) . No follow up visits are needed except if she has any concern or want to change the method . However the disadvantages include possible decrease in bone mineral density if used for more than 2 years . The method don’t protect against STIs so she must use a barrier method as well (double ditch ) . She may experience irregular periods and treatment of these irregularities may entail taking another hormone tablets to stop persistent bleeding . She may gain about 2-3 Kg in the 2 years .
Return of fertility after stopping the method may take few months . I will provide her with written information.

c) Regarding the advantages of levonorgestrel IUS it can be used for 5 years . It is also user and intercourse independent . I t will reduce the amount of her monthly bleeding . Minimal systemic side effects like mood swings, acne and usually no one will stop using the method because of them.
Pregnancy rates are very low ,less than 1/100 year .Return of fertility is immediate after removal of the device . On the other hand the method has some disadvantages . It needs application through the vagina which may be painful . The expulsion rate is 1/20 . it doesn’t protect against STIs . Irregular bleeding in the first 6 month but it will reduce overtime and some women will be amenorrhic after I year . There is risk of perforation (1/1000) which may necissates other interference or surgery to retrieve it . She should have a follow up visit after 3 weeks to check correct placement of the device . Removal is done through the vagina .
Posted by A H.
ah
a)A menstrual history will be taken. The date of her last menstual period, as well as associated dysmenorrhoea, and menorrhagia as well as her cycle length and frequency will be asked. If cycle control is necessary appropriate hormonal contraception will be advised
The type of contraception used as well as duration of use will be enquired. Her compliance and any difficulties she has with compliance will also be sought.
THe age of her last child as well as if she is breastfeeding will be asked to determine type of contraception and time to start hormonal contraception.
A medical and drug history will be taken to determine if there are contraindications to, especially hormonal contraception. Certain drugs like anti-epileptics which induce liver enzymes will also reduce efficacy of the combined oral contraceptive pill.
A family history of breast or genital tract malignancy will be taken as this may cause anxiety and reduce compliance of hormonal contraception.

b)medroxyprogestene acetate is available for contraception as a long acting injectable given by deep intramuscular injection every twelve weeks.
The advantages are that it is highly effective with a failure rate of .25 to 1 per 100 women years. It is not user-dependent nor coitus dependent and therefore compliance or efficacy is not affected unless she is unable to attend for the injection.
Non contraceptive benefits include its usefulness for relief of premenstrual syndrome and dysnenorrhoea,and it protects against pelvic inflammatoy disease, endometrial cancer and ectopic pregnancy.
It has minimal metabolic effects and reduces menstrual blood loss thereby reducing the risk of iron-deficiency anaemia.
The disadvantages include menstrual irregularities and unpredictable vaginal bleeding which can interfere with sexual activity. About 30 percent experience amenorrhoea after the first injection and 55 percent after the the fourth; this may be unacceptable for young women as they will be concerned that this may be due to pregnancy.
There can be a long delay of return to fertility of about 8 months to 24 months.
Other side-effects include weight gain, breast tenderness and decrease in bone density which is partially reversible after stopping treatment and ovarian activity resumes.

c) The advantages of the levonorgestrel-intrauterine system(LNG-IUS) are that it is highly efficacious and this lasts for five years. Menstrual blood loss decreases by about 97 percent after the first year and therefore it is a cost-effective alternative to treat menorrhagia.
It protects against pelvic inflammatory disease by its effect of thickening cervical mucus. Is associated with a lower rate of ectopic pregnancy compared with copper containing IUCDs and there might be a reduced incidence and growth of uterine fibroids.
The disadvantages of the LNG-IUS are that it may be difficult to insert due to its size. and a paracervical block may be necessary. It may be expelled in the first few months. Uterine perforation may occur in 1.2 per 1000 insertions.
Irregular bleeding is experienced in the first few months and amenorrhoea may be experinced by about 35 percent of users. This may be unacceptable in young women.
There is an increased risk of functional cysts. Other side-effects include headache, breast tenderness and acne which may subside in the first few months.
Posted by Ron C.
Rnz
A.
Ask regarding methods of contraception used so far and method being currently used. Ask regarding her preferences and reasons for previous failure of contraception. Obstetric history including miscarriages and terminations. I’ll try to find out whether there is riskful sexual behaviour, whether she is in a stable relationship and what her plans for possible future children are. Social background and potential for abuse needs to be assessed. I will enquire regarding her cycle, LMP, dysmenorrhea, menorrhagia. I’ll ask for medical problems, family history and smoking behaviour.

B.
Main advantage is ease of use, once in 3 months only and therefore low potential to forget. It is very reliable with Pearl index more than 99. it will not interfere with for example smoking or most medical problems. Disadvantages are the potential for erratic period bleeds being unpredictable and sometimes heavy. Side-effects may be weight gain, fluid retention, acne. Long use will also affect the bone mass. After stopping it may take several months for fertility to regain.

C.
Again the ease of the method where compliance does not pose a problem is an important advantage. After introduction there is no need for change until after 5 years and after removal fertility returns without delay. Additional benefit is the reduction of period bleeds in 90% after 1 year, whilst about one third remains amneorrhoeic. Disadvantage is that it requires speculum examination for introduction. The first 3-4 months the cycle can temporarily turn erractic, but thereafter usually normalise. Though the hormones only act locally, some women do experience side-effects and ovarian cysts are more common. There is also a slightly increased risk for STD, especially in riskful behaviour.
Posted by Ahmad A.
I would ask about her menstrual history, if she had regular cycle or not. I would ask about other unplanned pregnancies ended by termination of pregnancy and method of deliveries and date of last delivery, breast feeding or not. . Also, about her marital life if it is stable or not, about possibility of multiple partners. Her past contraception history should be obtained and the methods used. Also, if she got pregnant on top of one of the methods used. I would ask about her work type and if she is not keen to take daily hormonal pills. I would ask about previous un tolerated side effects of different kinds and if there is contraindication in her history to use COCP, like family history of DVT or breast cancer?. Her family was completed or not and if she is willing to have permanent method for contraception or partner sterilization as an alternative option.


Depot Medroxyprogestrone acetate (DMPA) is one of the long acting reversible, reliable contraception. Its pearl index is less than 0.5:100. It can be used once every 1 or 3 months. It can be used for breast feeding mother without alteration of milk production. Also, it can be used for hypertensive or diabetic mothers. Its efficacy was not altered by other pharmaceuticals like antibiotics, and other enzymatic inducers like antifungal (Griseovalvin) and anti convulsive, antiepileptic (Phenotoin). As it was given by parentral use its absorption was not affected by vomiting and diarrhoea. It can be useful for cases of Menorrhagia, uterine fibroids and Endometriosis. So, it can effective in endometrial cancer protection.
DMPA disadvantages, increase incidence of cycle irregularities, break through bleeding and amenorrhoea. There is increase incidence of mood changes, blues, weigt gain, breast pain and bloating. Not protective against sexually transmitted disease and PID. The regular ovulation may return after quite long time up to one year after discontinuation of DMPA. Patients\' information leaflet should be provided.


Levonorgestyl releasing intrauterine system (LR-IUS) is another method of long acting reversible contraception. Its pearl index about < 0.5/100.can be used up to 5 years. It may be used for cases of Menorrhagia with highly efficacy of reducing the menstrual blood flow. It may induce amenorrhoea. The fertility will return after short period of time after removal. It may reduce the incidence of PID and ectopic pregnancy. It may also reduce the size of uterine fibroids. It can give protection against endometrial cancer.
LR-IUS disadvantages, may cause discomfort during its insertion so nonestroidal antinflammatory or local anaethesia may be used. It may cause continuous break through bleeding for 3-6 months. One of the side effects of IUDs is perforation of the uterine wall. . Patients\' information leaflet, also should be provided.
Posted by J P.
a.History regarding the type of contraception used and the specific problems faced like menstrual irregularity [with DMPA],compliance difficulties,acne,weight gain problems will be enquired.Detailed menstrual history including LMP,any menstrual irregularity,menorrhagia will be enquired since IUS,OCP may decrease menstrual blood loss.Histpry of recent PID,sexually transmitted diseases which are contraindications to IUCD will also be looked into.Her compliance in use of regular tablets like OCP will be noted.Any contrindications to pills like focal migraine,liver disease,persoal history of thrombosis ,breast and endometrial cancer will be enquired.Any use of enzyme inducing drugs like broad spectrum antibiotics,antiepileptics will be enquired since this may necessitate drug modification.Her sexual history whether she is in stable relationship will be enquired since this may necessitate condom usage if not in stable relationship.Obstetric history ellicitation and whether she is breast feeding now and time since last child birth isa important since minipills can be started by 3 weeks postpartum,but injectables to be started after 6 weeks in breast feeding women.Finally her wishes should be taken into account.
b.The advantages of medroxy progesterone acetate injection are it can be given once in 12 weeks ,hence better compliance.Can be used in breast feeding women,diabetics.Pearl index is 0.2-0.4/HWY. Associated with the lower risk of PID and ectopic pregnancy compared to POP. It also decreases menstrual blood loss.The disadvantages are it may cause menstrual irregularity and even amenorrhea with repeated doses..There is weight gain, progestogenic side effects.Resumption of ovulation may be delayed after discontinuation to upto 8 months.There is evidence to suggest it may cause decreased bone density and osteoporosis if used for a long time particularly adolescents.Injection may be painful.Needs frequency modification if used with enzyme inducers.
c.IUS once fitted can remain for 5 years, better comliance.Failure rate is low..Avoids systemic progestogenic effects.Can be of use in menorrhagia,PMS , dysmenorrhea and endometriosis also.It is of therapeutic use in endometrial hyperplasia also.There is decreased incidence of ectopic pregnancy compared to non users.The incidence of PID is also decreased in the long term due to the thickening of cervical mucus.The disadvantages are it may cause menstrual irregularity and even amenorrhea which needs proper counselling.There is increased incidence of PID in the first 20 days due to insertion.During insertion there may be pain ,discomfort,difficulty in insertion and,risk of expulsion .There is also increased incidence of functional ovarian cysts compared to copper IUCD.

Posted by G. K.
History should be taken regarding the duration and the type of use of contraception i.e combined pill (COC), progeterone only pill (POP), estrogen patches, condoms or diaphragm with or without spermicide.Try to establish the problem with the use of the above
mentioned methods which could include missing pills altogether or not taking them within a specified time period . For example a POP should be taken within at the same3 hour period everday otherwise it\'s efficacy is reduced. Simililarly patient should be asked about the proper application of estrogen patches and any probem with compliance with regards to their use.
Any history of nausea vomiting associated with the intake of pill
should be inquired.
Personal history should be sought regarding alcohol and drug intake.She should be asked if the pregnancies were in a stable relationship or if were the result of chance encounters leading to one night stands. She should be inquired whether she was under the influence ofalcohol at the time or not.

The advantages of medroxyprogesterone acetate include adminstration of the contraceptive injection 3 monthly by her GP.It is easy to comply with and it can make heavy periods lighter if that is a concern with her as well. Breast feeding is possible since it doesn\'t effect the quality or quantity of breast milk. Also it cause thickening of cervical mucous leading to some degree of protection from sexuallly transmitted diseases.

Disadvantages of this method include delivery by injection which is painful and may not be acceptable to the patient. Otherproblems likeirregular vaginal bleeding, acne, weight gain, breast tenderness and mood changes can occur. Their is also a risk of osteoporosis with prolonged use especially if combined with breast feeding.Also there may be a delay in return of fertility by upto 18 months in case she decides to stop using contraception in order to conceive.It can cause increase in the incidence of ovarian cysts with it\'s sequlae of haemorrhage, torsion and rupture etc.

The advantages of a levonorgestrel inta uterine system include prolonged contraception fo 5 years. Immediete return of fertility upon removal of the device. Lightening of periods if heavy periods are a concern. Thickening of cervical mucous leading to some degree of protection from STDs. Progesterogenic side effects such as acne, wight gain, depressive moods are very slight since very little hormone is released into the system and most of it remains locally in the uterus.
The disadvantages include lower abdominal cramps which can be severe and persistent in a minority of patients after insertion, which itself can be very painful necessitating insertion of same under general anasthesia and it\'s associated risks.
Increase risk of infection in the first few weeks of insertion. Irregular bleeding for prolonged periods which may not be acceptable to her. There is a risk of expulsion in the first few weeks after insertion leaving her vulnerable to yet another unwanted pregnancy. Other rare risks include perforation of uterus and entry to abdominal cavity, necessitating removal via laparoscopy or more rarely via laparotomy if causing symptoms of pain.
Posted by Arun J.
a-I would ask about its impact on her quality of life, its social impact and the reasons for her unplanned pregnancy like missed pill, condom failure etc.Her awareness about emergency contraception assessed. Obstetric history obtained to know the number and mode of deliveries and previous MTP\'s.Her wishes for future fertility and contraception (permanent or temporary)assessed.Her attitude ,knowledge and preferences of contraceptives assessed. Intake of enzyme inducing drugs like rifampicin and non liver enzyme inducing drugs like ampicillin enquired as they reduce the contraceptive efficacy of contraceptive pills. Smoking ,alcohol intake and use of addictive drugs like cocaine ,heroin enquired as their use can influence her to skip her contraceptive pills and put her at high risk for unplanned pregnancies and STI\'s.
b-I would tell her that it is a long acting reversible contraceptive. It is effective for 12 wks once injected.So it is not coital dependent and has no problems with compliance as with oral pills.It is efficacious in preventing pregnancy,pearl index being 0.25-0.50/100 women years.Effective even when enzyme inducing drugs are used.However,it causes irregular bleeding in the first few wks, ammenorrhoea,delay in return of fertility after its use and loss of bone mineral density if used for long.I also would provide her with written information.

c-I would tell her that it is a long acting reversible contraceptive.It is effective for 5 yrs.So not coital dependent and no problems with complance as with oral pills.It is efficacious ,pearl index being,<0.18/100 women yrs.Return of fertility is rapid after removal.It has noncontraceptive benefits like reduced incidence of PID,ectopic pregnancies,and menorrhagia.However it needs special technique for insertion under anaesthesia,and has problems of spotting, amennorrhoea,premenstrual symptoms, functional ovarian cysts and expulsion. It cannot be used as an emergency contraceptive and it is costly when compared to other contraceptives.I would also provide her with written information.
Posted by PAUL A.
a) Menstrual history (1) regarding LMP, regularity of cycles and cycle length; any IMB, PCB or dyspareunia should be asked. Her current contraception and types of previous contraception used should be enquired. Type of problems encountered during previous contraception (1) , her compliance and if the method was correctly followed should be asked. History of previous PID or STI\'s should caution to the use of intrauterine contraceptive devices because of the increased risk of infection. Any contraindications to hormonal methods such as focal migraine healthy woman should be asked. Use of medications such as anti epileptics healthy may influence the dose of oral contraceptive pills to be given. Mode of deliveries and time of last child birth (1) and if she is breastfeeding is important as this influences the type of pill given. She should be asked whether she has multiple sexual partners as barrier contraception (1) in addition to other contraception can be advised. Family Hx of VTE / osteoporosis; social Hx – lifestyle, alcohol / illegal drug use which may contribute to problems with contraception
b) Depot provera can be given every 3 months, so compliance is better. It is user independent (1) less user dependent – still have to attend every 12 weeks and is an effective contraceptive how effective? Every contraceptive is effective to some extent . It forms a protective mucus plug at the cervix and reduces the risk of PID. The risk of ectopic pregnancy is lower compared to non users of contraception. Fertility ultimately returns on discontinuation of method.
where do your advantages stop and disadvantages begin? There is higher risk of irregular vaginal bleeding with this method. There is a risk of osteoporosis (1) on long term use which disappears on discontinuation of the method but this has not been confirmed in RCT\'s. Acne, weight gain, mood changes, depression and headahes are transient and disappear with time (1) . There is delay in return of fertility of 12-18 months (1) after discontinuation of the method and women shouldbe informed about this. There is also a risk of amenorrhea which increases anxiety in some women. The injections can be painful ? written info .
c) Mirena IUS is as effective as sterilisation you are assuming that the woman knows how effective sterilisation is and can stay in for 5 years. Fertility returns immediately after removal of device. It acts by causing endometrial atrophy, so decreases menorrhagia and also dysmenorrhea (1) . It is also effective in decreasing the symptoms of PMS. It also decreases the incidence of PID and ectopic pregnancy compared to non users of contraception (1) .
It causes irregular vaginal bleeding in the first 4-6 months (1) is this an advantage or disadvantage? of use and woman should be thoroughly about this. If she perseveres, then usually the bleeding tends to settle by 9 months. Risk of perforation (1) during insertion (1:1000); risk of PID especially in the first 3 weeks after insertion and PID after this period depends on the life style of the patient. Other side effects include nausea, tender breasts, acne, headaches which are usually transient risk of expulsion, functional ovarian cysts, potential difficulties with insertion, written info .
Posted by PAUL A.
a) I would enquire about her previous contraception (1) , perceived reasons for failure and reasons for discontinuation.
Details about her menstrual cycle (1) such as the last menstrual period, cycle length, regularity and blood flow will also be obtained.
The obstetric history should include mode of delivery, when her most recent delivery occurred and if she is currently breast feeding (1) .

Relative and absolute contraindications to the various contraceptive methods available should be sought. For example, a history of migraine with aura or venous thromboembolism healthy precludes the use of a combined contraceptive pill. Uterine anomalies such as a bicornuate uterus is a relative contraindication for siting an intrauterine device and caution should be exercised when it is inserted. Active liver disease is an absolute contraindication to progestogen only contraceptives, be it oral or long-acting.

I would obtain a history of sexual partners in the last 6 months, condom use (1) and previous history of sexually transmitted infection to assess her risk for a sexually transmitted infection. Family Hx of VTE / osteoporosis; social Hx – lifestyle, alcohol / drug abuse

b) The advantages of depot-medroxprogesterone acetate (DMPA) are that it is reversible and has a low failure rate (1) of 0.3-1/100 women years. To a certain extent, it is not user dependent (1) and its efficacy is not affected by antibiotics. After 1 year of use it can cause amenorrhoea which will be beneficial to patients who have heavy menses (1) .

The disadvantages are that it can cause irregular bleeding (1) in the 1st 6 months of use. Weight gain of up to 2kg can occur particularly in the early stages of its use. Breast tenderness, bloating and pre-menstrual symptoms can also occur . It also reduces bone mineral density after 2 years of use (1) . However this is reversible and there is no increased risk in fractures during this time. Another important disadvantage is a delay in return to fertility following cessation of DMPA. This can last from 6 months but in a minority of patients this can last upto 2 years (1) written info .

C) The advantages of the IUS is that it is a reversible form of contraception and has a low failure rate of 0.1/100 women years (1) . It lasts for 5 years duration and it is not user dependent (1) . Its efficacy is unaffected by antibiotic use. It reduces the chances of developing an ectopic pregnancy compared with other types of contraception. It reduces menstrual flow in 40% of patients and another 40% may experience amenorrhoea. This will be useful in patients who have menorrhagia (1) . If pregnancy is desired, there is no delay in conceiving once the IUS is removed.

The disadvantage is that it can cause irregular bleeding (1) the 1st 6 months of use. Systemic side effects such as breast tenderness and premenstrual symptoms can also occur, but these are transient. When it is inserted, uterine perforation can occur (1) . Pelvic inflammatory disease can also occur if there is undiagnosed infection at the time of insertion. However, this can be managed by screening the patient for sexually transmitted infections prior to insertion or administering antibiotic cover during its insertion woman might not like amenorrhoea, risk of expulsion, functional ovarian cysts, written info

Good & systematic answer
.
Posted by PAUL A.
a) I would ask her any current method of contraception & problems she is facing. I would also like to know past contraceptive history (1) & cause of discontinuation of the method. Her menstrual history (1) , to know her LMP & to rule out possibility of early pregnancy. Her regularity of menstrual cycle & amount of bleeding is important in deciding type of contraception. Her Obstetric history including mode of deliveries. History of breast feeding (1) is important to help her choose a contraception method . Any family history of breast cancer to be noted VTE, osteoporosis . Previous h/o DVT in pregnancies, past h/o PID to be taken into consideration.Her sexual history to be obtained to know he risk of STIs. Personal history of smoking, alcoholism (1) to be considered.



b) I will tell her that DMPA is one of the most effective family planning method with less than 1 pregnancy per 100 users per year (1) . Its advantages are once injected , it will give protection for 12 weeks. It refrains from need of taking daily pills. No oestrogenic side effects (1) on cardiovascular system . Its noncontraception benefits are , prevention of anaemias as amount of blood loss is less. It is associated with less risk of ectopic pregnancy & CA endometrium than woman who do not use contraception. There is no permanent impairment of fertility. It is costeffective. It can be used by breast feeding women (1) as it does not reduce lactation.
Its disadvantages are irregular menstrual cycle (1) in initial one year of use & thereafter amenorrhoea lasting 3 months or more. There may be irregular bleeding , spotting pv. It is associated with weight gain of 1-2 kg per year . Women face slightly increased risk of breast cancer in the first five year of use. If she decides for further childbearing , return of fertility is delayed by 6 months (1) after the last injection. Prolonged use is associated with reduced bone mineral density (1) written information.

c) I will tell her that LNG IUs is an effective reversible method of contraception with failure rate of less than one pregnancy per 100 users per year (1) . Its advantages are , it can be used by breast feeding woman. Once inserted , she will have contraceptive effect for 5 years. Risk of ectopic pregnancy is low. It can reduce menstrual blood loss by 90% therefore useful in menorrhagea patients (1) . Rapid return of fertility occurs after removal of the device within 4 -12months. It does not have adverse impact on BMD .
I will tell her the disadvantages of LNG IUS are , small increase in risk of PID after insertion . It is associated with altered pattern of menstrual bleeding , like prolonged bleeding & amenorrhoea (1) irregular bleeding in fkrst 3 months . There is increased risk of ovarian cyst formation. It has few hormaonal effects like acne, headache, breast tenderness (1) .Its risk of expulsion is 1 in 20. There is also a risk of perforation (1) written informatiom

Good answer
.
Posted by PAUL A.
NA
A detailed history should be obtained to find out type of contraception used in the past (1) , adverse effects, failure rate with any particular methods or poor compliance with pills. Obstetric history is also important to know age of children, number of terminations and type of deliveries and whether she is breast feeding (1) . An enquiry should also be made to know details of gynaecological problems in form of menorrhagia (1) menstrual Hx including LMP , premenstrual syndrome, pelvic inflammatory disease (PID) or fibroids. Personal or family history of thromboembolism, or osteoporosis (1) family Hx as she is HEALTHY and breast cancer should also be asked. Medical history of diabetes, hypertension migraine liver disease or epilepsy should be asked. A note should be made to know about medications use especially liver enzyme inducer and antibiotic which would affect the efficacy of contraception HEALTHY . Fertility plans and completion of family should also be enquired. Sexual history should also be obtained to know about stable relationship or multiple partners (1) . Personal history of smoking is also important. Cervical smear status will you expect a 20 year old to have had a smear?? should also be noted down. Body mass index should also be recorded do you get BMI from Hx?? . Pros and cons of all available reversible and permanent contraceptive methods should be discussed in addition to vasectomy option and informed decision should be made. Information leaflets should be provided waste of time & space – you were asked about Hx .
Advantages of depo-medroxyprogesterone are:
One injection lasts 3 months. Efficacy rate are .20-0.5 per 100 women year is this failure rate or efficacy?? . As it does inhibit ovulation, its use will be beneficial in endrometriosis, and dysmenorrhoea. It would also result amenorrhoea in about one third women, therefore ferritin level would go up in anaemic women (1) . It can be used in breast feeding women or where there is contraindication for the use of combined oral contraceptive pills (1) . It also reduces chances of PID.
Disadvantages of depo-medroxyprogesterone are:
Its use is associated with menstrual irregularities (1) especially amenorrhoea. Incidence of ectopic pregnancy is higher compared to use of COCP. Other adverse effects are weight gain, breast tenderness, mood swings, acne and ovarian cysts. Long term use is associated with reduced bone mineral density (1) . Delay in return of fertility following its discontinuation what is length of delay? .
Advantages of levonorgestrel-releasing intra-uterine device:
Besides contraceptive effect, its use is also associated with reduction in amount of blood loss (1) . 12 months use results 95% reduction in blood loss and amenorrhoea in about one-third. It can also reduce blood loss in fibroids. Its efficacy has been proved to reduce pain in endometriosis and dysmenorrhoea. It can also be used along with transdermal oestrogen in premenstrual syndrome. Its use is associated with less number of ectopic compared to other intrauterine devices. It is a popular long term contraception, lasts for 5 years (1) therefore less user-dependent . Its efficacy has been shown to equivalent to sterilization are you assuming the woman knows how effective sterilisation is? , although it is a reversible contraception.
Disadvantages of levonorgestrel-releasing intra-uterine device:
Insertion of this device needs proper training and sterilized instrument set. She should be counselled for menstrual irregularities (1) for initial 6 months followed by period of amenorrhoea. Adverse progesterogenic side effects can be seen in form of breast tenderness, weight gain, mood swings or ovarian cyst (1) . Expulsion rate are around 5% initially in a year time. Improper technique and unhygienic condition if perforation / infection occurs, will it be because of poor technique or unhygienic conditions? may be associated with perforation and infection (3 weeks after insertion).

See good answers above
Posted by PAUL A.
a) Which information would you obtain from the history? [6 marks]

A detailed marital You definitely do not want to start with this. Whether she is married or not is irrelevant and obstetric history should include the duration since marriage, no of pregnancies and their outcomes, time since last delivery and whether she is breast feeding or not (1) . Enquire about future child birth plans (1) .

Contraceptive history (1) should include the type of contraceptives used, current contraception and possible causes of failure should be explored based on the type of contraception used. An enquiry about current partners is important to assess the risk of STIs.

Menstrual history (1) should include the LMP, history of menorrhagia or irregularity of cycles, dysmenorrhoea and premenstrual syndromes.

(b) What would you tell her about the advantages and disadvantages of depo-medroxyprogesterone acetate? [7 marks]

Depomedroxtprogesterone (DMPA) is an injectable progesterone only contraception which is coitus independent. The failure rate is only 4 in 1000 over 2 years is this how you quote the failure rate of a contraceptive? and does not need any further motivation other than repeat injections every 12 weeks (1) less user-dependent . It can be used during breast feeding and does not affect lactation (1) . It can be injected any time after first and second trimester termination of pregnancy. It does not cause progestrogenic side effects how is this possible given that it is a systemic progestogen??? like acne, depression or headache and can be used in women who have contraindications for estrogen use. It does not increase the risks of STIs and may reduce the frequency of seizures in those with epilepsy.

Disadvantages of DMPA include delay in return of fertility for up to I year after stopping (1) , but will need alternative contraception immediately after stopping if pregnancy is not needed. Most common reason for discontinuing is irregular and unpredictable bleeding (1) . It can cause weight gain for up to 2-3 kg is this not a progestogenic side-effect? after 1 year of use. It does not protect against STIs and may cause slight reduction in bone mineral density (1) . But this is usually reversible after stoppage does not increase the risk of fractures. Need for repeated injection may not be acceptable for some women. She should be provided with written information (1) explaining all these.

(c) What would you tell her about the advantages and disadvantages of the levonorgestrel-releasing intra-uterine device? [7 marks].

Levonorgestrel releasing intrauterine system (IUS) is one of long acting reversible contraception with very low failure rate of about 10 in 1000 over 1 month or 2 years? How will the woman be able to compare failure rates? (-1) . Once inserted it has to be replaced only after 5 years (1) and there is no evidence of delay in fertility after removal. It does not cause increase in weight gain and the risk of ectopic pregnancy is less than those using no contraception. It can used during breast feeding and it can used safely in women with contraindications for estrogen. It reduces bleeding in about 90% (1) women and may cause amenorrhea in some. Other non contraceptive benefits include possible reduction of dysmenorrhoea and reduction in size of any fibroids.

Disadvantages include the need for an invasive procedure for insertion and the possible risk of perforation in about 1 in 1000 (1) . There is risk of PID but it is only in the first 20 days after insertion and decreases thereafter. It can cause acne in some but there is only minimal effect on mood and libido. Cause of failure is due to expulsion (1) which can occur in 1 in 20 women and she should check for the IUS thread to make sure that it is in situ. If pregnancy occurs, up to 1 in 20 can be ectopic is the risk of ectopic increased? . It can cause irregular bleeding and dysmenorrhoea there is some evidence that dysmenorrhoea is reduced in some women but usually in the initial months only. She should be provided with written information (1) explaining all these.

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Posted by PAUL A.
Deatailed menstrual history (1) is taken regarding her LMP, length of cycle and regularity.Enquiry should be made about any intermenstrual or post coital bleeding
Contraception history (1) is taken regarding type of contraception and most important is her compliance.Non compliance is the most important factor in case of failure of contraception,especially in young females..
Obstetric history -parity ,age of youngest child ,if she is breast feeding (1) .
History of any ectopic pregnancy.
Sexual history is taken –multiple sexual partners puts her at risk of STIs (1) use of barrier contraception; Family Hx of VTE / osteoporosis, lifestyle – smoking / alcohol / drug abuse .
b) Advantages of DMPA are they provide effective contraception,with failure rate
0.25-0.5/100 women yrs (1) .Risk of ectopic pregnancy is lower as compared to POP.
Minimal adverse effects are seen on coagulation and and lipid profiles.Thus there is no increased risk of VTE or HTN.It has no impact on milk production and can be used in lactating mothers (1)
Non contraceptive benefits include protection against PID,endometrial cancer and vaginal candidiasis.Menstrual blood loss is reduced (1) .It is cost effective than COCP even at 1yr of use.
Disadvantages are that woman may experience ammenorrhoea and irregular bleeding (1) which may cause her anxiety.She may have weight gain.Return of fertility may be delayed.It may take as long as 7-8months (1) .Small loss in BMD ,but it is largely recovered (1) written info
after stopping DMPA
c)Advantages of IUS are that it provides effective contraception ,with failure rate of <1in 100women over 5yrs how will she be able to compare this with 0.25-0.5/100 woman years? Can you?? .It is licensed for contraception for 5yrs. No evidence of delay in fertility. Expulsion occurs in less than 1 in 20 women is this an advantage?
Non contraceptive benefits are reduction in menstrual bleeding (1) . Upto 97% at the end of 1yr and increase in Hb concentrations.Risk of PID is reduced.
Disadvantages of IUS are that she may experience irregular bleeding for how long? . and pain.
Risk of ectopic pregnanacy is less than in women with no contraception is this a disadvantage? .,but if she does become pregnant with IUS in situ,risk of ectopic pregnancy is 1 in 20. She should seek medical advice.She may experience change in mood or libido, or increase in acne.
No evidence of effect on weight gain . ? written information

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Posted by Maayka ..
nellie

a) I would ask about the LMP and regularity of cycles or lack of such. A gynae history to determine if there are also associated menorraghia and dysmenorrhoea or abnormal pv bleeding which may need investigation before commencing a contraceptive method. Her sexual history with particular reference to previous STDs and recent infection. Her family history of cardiovascular disease and VTE. I would ask about her use of any drugs like antibiotics or enzyme inducing medications. If she smokes and uses alcohol should be ascertained. As she has 3 children I would ask how long ago was the last delivery and if she is presently breastfeeding. A few questions should address her past contraceptive use – the methods tried, were they used appropriately and were there side effects and were any discontinued and why and if she been using any recently .Has there been unprotected intercourse with the possibility of an early pregnancy.

b) The advantages of depo- medroxy progesterone acetate (DMPA) are that it has a failure rate of 0.25- 0.5 per women years. It works primarily by inhibiting ovulation so most women, about 50%, will be amenorrhoeic. It is administered as an injectable once every 3 months and is effective if given within first 5 days of LMP with immediate contraception, otherwise additional contraption will be required for 7 days. It is administered by a G.P office or at a family planning clinic.
The disadvantages is that there is associated abnormal bleeding patterns with its use and this is usually the main reason for discontinuing by most women. Its use over a 2yr period is associated with reduced bone mineral density but is reversible once stopped. There is a delay in return to fertility by as much as 1 year. I would provide her with an information leaflet on progestogen only injectables, namely DMPA, to peruse before making her decision.

c) The advantages of the levonorgestrel- releasing intrauterine device ( LNG-IUS) are it is also associated with a low failure rate of less than 1 in 1000 women years and when fitted , it is effective for up to 5 years . There is no need for follow up in interim if no problems. There is great advantage in women who also have menorrhagia because it works primarily at the level of the endometrium and causes significant reduction in blood loss with menses. There is no effect on loss of bone density and no delay in return to fertility.
The disadvantages are it requires insertion sometimes with local anaesthetic or there is some discomfort felt by the patient. The rate of expulsion is 1 in 1000. The risk of infection is greatest within the first 3 weeks of insertion. Some will also experience abnormal bleeding for the first 6 months of use. I will provide her with a leaflet on the LNG-IUS and, if available, show her a sample of the device to be fitted.



Posted by PAUL A.
a) I would find out what type of contraceptives she knows of and her wishes on which contraceptive she should use now. I would enquire on the types of contraceptives she has used (1) contraceptive Hx and which problems she has had with them such as irregular bleeding. I would try to determine whether she has used them correctly for example whether she missed any pills to account for an unplanned pregnancy. I would find out whether she wishes to have more children in the future (1) and if she is in a stable relationship. If in a stable relationship, her partner could be offered a vasectomy. If not in a stable relationship she could be offered condoms for contraception and to reduce her risk of sexually transmitted infections. The date of her last delivery and whether she is breastfeeding needs (1) to be known since this will affect the type of contraceptive she should begin now. how do you define a ‘stable’ relationship? Family Hx of VTE / osteoporosis; lifestyle including alcohol use

b) I would tell her that advantages include a low failure rate of 4 in 1000 is this how you quote the failure rate of a contraceptive? Is this every month, 12 months or what? if the depo-medroxyprogesterone acetate injection is given every 12 weeks. It avoids having to remember to take a pill every day as in the case of the combined oral contraceptive pill (1) less user-dependent .
The disadvantages include a delay in return of fertility. This delay can be up to 1 year (1) . This contraceptive can also cause irregular bleeding or the absence of periods (1) . It can also cause weight gain. I would provide her with written information (1) .

C) I would tell her that advantages include long term use. The levonorgestrel-releasing intra-uterine device (LNG-IUS) can be used for 5 years before it needs to be changed (1) . The LNG-IUS is safe what does this mean? Are there no risks associated with its use?? . It is an effective contraceptive with 99% success rate ? MEANING?? Do 1% of women get pregnant every month??? . After removal, there is no delay in fertility returning. If she has heavy menstrual periods, another advantage of the LNG-IUS is that it can significantly reduce menstrual blood loss (1) . The disadvantages of the LNG-IUS are that it needs to be inserted into the cavity of the uterus which may be uncomfortable or painful. It carries a small risk of infection within the first 20 days of insertion (1) . It carries a small risk of expulsion and she must check vaginally for the strings attached to the LNG-IUS every month to ensure that it has not been expelled. I would provide her with written information (1) irregular bleeding in first 3-4 months, amenorrhoea, risk of perforation, systemic side-effects, functional ovarian cysts .
Posted by PAUL A.
X

a. I would take history of previous contraception usage (1) , the reason of failure, such as low compliance or, inadequate knowledge wrong application. Other history include her planned family size and her future pregnancy plan (1) . Her last menstrual period and regularity of cycle (1) is also important to determine undiagnosed pregnancy . Any history of uterine pathology should be taken as it could be inappropriate for IUCD insertion. History of sexual frequency, partner and exposure to sexually transmitted disease ( STI) should also be illicited. FHx of VTE / osteoporosis, lifestyle; breastfeeding


b. The advantages of depo medroxyprogesterone acetate include the low failure rate of 0.4 per 100 users over 2 years is this how you quote the failure rate of a contraceptive?? . It is easily administrable for 3 monthly duration does not require high degree of compliance and tedious usage of daily pills (1) . It could be used during breastfeeding (1) . The disadvantages include irregular cycle, and ocaasionally amenorrhea (1) . There is associated increased duration of return to fertility which could last up to 2 years (1) . It is associated with weight gain in long term use. There is a decrease in bone density (1) but not associated with fractures. It could also not be used to patient with needle phobia and it could cause pain if administered wrongly. It does not confer against STI. It is also associated with presence of functional ovarian cyst. written info
c. The advantage of the levonegesteral intrauterine system ( LNG IUS) include a low failure rate of 1 in 100 users over 5 years is this how you quote the failure rate of a contraceptive? How is she expected to be able to compare 0.4/100 over 2 years with 1 per 100 over 5 years?? . This could also be used for a period of 5 years without change and earns a good compliance (1) rate once applied. It is also cost effective compared to usage of other methods of long term reversible contraception. It has added advantage of improving symptoms of dysfuntional uterine bleeding (1) . The device is also could be used on patient who are breastfeeding. It is associated with a risk of uterine perforation about 1 in 1000 users and associated risk of expulsion about 1 : 20 users over the period o 5 years (1) ARE THESE ADVANTAGES???. There is also a relative risk slight increase ? meaning?? with pelvic inflammatory disease. It could also cause occurrence of ectopic pregnancy. It does not offer protection against STI . There is also association with menstrual irregularities which are usually for the the first 6 month of usage and occasionally amenorrhea is amenorrhoea just an occasional occurrence??

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Posted by PAUL A.
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mark

a)
I will ask which methods of contraception (1) has she used in the past ,the problems associated with each of them and if she was taking them as per instructions. I will ask her current method of contraception and its problems and confirm the compliance with it.
I will enquire her menstrual history (1) - age of menarche, regularity flow and LMP.
I will enquire about her past gynecoligical history like PID,STIs, ectopics,endometriosis, chronic pelvic pain and any treatments for them .
I will enquire about her obstetric history the mode of deliveries and age of last child birth.i will ask her future fertility intensions (1) and what kind of method would she like to use –oral or injectable or implant , hormonal or nonhormonal. breastfeeding, FHx of VTE / osteoporosis, lifestyle


b)
The advantages of Inj DMPA are it is non-oral method so not associated with nausea or gastric symptoms. It does not need to remember and take a tablet daily.it has to betaken once in three months (1) so less number of visits to clinic.it decreases the menstrual blood flow (1) and and particularly useful if she has heavy menstrual loss.
It reduced endometriosis associated pain if she has endometriosis.It has a low failure rate of 0.5/100 woman years (1) .
The disadvantage it it gives trouble some side effects like mastalgia, bloating, weight gain due to progestogens (1) .It does not provide protection against STIs. It gives poor cycle control and is associated with unpredictable break through bleeding (1) .She may find it difficult to come to the clinic every 3 monthly leaving behind 3 children at home.it reduces bome mineral density if used for long term.It may also cause functional ovarian cysts although most ofthem are asymptomatic and don’t require any treatment.it causes delay in return to fertility of 9 months (1) from the last injection and not suitable if she wants pregnancy immediately after stopping the method.
I will provide written information (1) .


c)The advantage of LNG IUS are very low failure rate 0.2/100 woman years (1) .Once inserted it is effective for 5 years (1) .there is no need to fiollow up routinely after the first followup after 3-4 weeks. In woman with heavy periods it is particularly useful as it decreases the menstrual blood loss (1) by 60% in 3-4 months and 30% women become amenorric in 1 year of use.it also reduces endometriosis associated pain.

The disadvantage of it is it gives bothersome irregular breakthrough bleeding in the first 3-6 months (1) of use.it has to be fited by a medical personel. It is associated with complications like expulsion (1/20 ), perforation (1/200), and infection in first 3 weeks ( 1%) (1) .She will need to be screened for chlamydia before insertion. If found positive she will need antibiotics and referal to GUM clinic. It gives mild progestogenic side effects due to systemic absorption and like mastagia and breast tenderness. I wll provide witten information to her (1)

Good answer
.
Posted by PAUL A.
a) Her desire and need for contraception should be ellicited as she may not need any contraception.
A history of cause of problems with use of previous contraception should be ellicited to exclude compliance issue and side effects.
Her recent contraceptive (1) use should be ellicited and a need for emergency contraception should be excluded.
Her menstrual history including include regularity, menstrual loss last menstrual period should be taken to exclude any current pregnancy prior to prescribing contraceptions.
A family history of risk for thrombosis (1) , breast cancer should be taken to exclude her risk factors for contraception with combined pills.
History of smoking should be excluded as smoking more than 15 cigarettes/ day will be a containdication for combined oral contrceptive pills not in a 20 year old .
Details of her pregnancy and last child birth should be taken including brest feeding (1) history to decide her contraceptive choice.
History of previous ectopic pregnancy and pelvic infections/ history of sexually transmitted infection should be ellicited so that further testing (including chlamydia) and treatment / referral to genitourinary medicine could be offered.
Her sexual history (1) should be taken with regards to more than 2 partners in the last 6 months, she should be offered testing for STI/ referred to genitourinary medicine and safer sex advice provided.

b)Contraceptive advantages of depot medoxy progesterone acetate(DMPA) is very effective contraceptive method with failure rate of fewer than 0.4 in 100 over 2yrs period is this how you quote the failure rate of a contraceptive?? .
It is user friendly and lesser compliance issue compared to oral contraceptive pill as it is once intra muscular injection every 12 weeks (1) . It does not interfere with sexual intercourse compared with condoms.
Non contraceptive advantages like amenorhoea is common with DMPA and lesser menstrual loss (1) if affected with heavy menstrual bleeding.
DMPA provides reduction in pelvic inflammatory disease compared to non user of contraception, but safer sex with barrier methods should be advised if high risk.
No evidence of affect of DMPA on depression, acne or headache.
It can be used with underlying risk factors like family history of thrombosis / breast cancer.
Disadvantages of DMPA are increase in weight gain of 2-3 kg over one year period which may not be acceptable with the patient as may impair her body image.
Most common reason for discontinuation is irregular bleeding pattern (1) with DMPA which may not be acceptable for the patient.
DMPA is assocated with loss of bone mineral density loss (1) over 2 year use and this almost fully recovers with stopping DMPA, but no increased risk of fracture of bones.
There may be a delay of fertility of up to 1 year (1) with stopping DMPA but if continued contraception is needed alternative methods of contraception should be employed immediately.
Return for injection every 3 months may be disadvantage with child care and other issues. written info

c) Contraceptive advantages of Levonorgesterol intra uterine system is it is a very effective contraceptive method with failure rate of fewer than 1 in 100 over 5 year period is this how you quote failure rate? How is she supposed to compare this with 0.4 in 100 over 2 years?? .
It is user friendly and no compliance issue after insertion compared to oral pills and need to be changed only 5 years (1) and does not interfere with sexual intercourse compared to condoms.
There is no delay of fertility on removal of the coil.
Non contraceptive advantages are, it reduces menstual bleeding (1) more commonly, which may give better compliance for patient if affected with heavy menstrual bleeding.
It will provide better protection against ectopic pregnancy compared to non user of contraception.
No evidence of increase in body weight.
Disadvantages are risk of preforation with insertion which is 1 in 1000 (1) , along with risk of pain associated with insertion.
There is a risk of expulsion (1) which is 1 in 20 over 5 year period and she should be advised regarding coil thread checking.
Irregular bleeding pattern is common reason to discontinue but she should be explained about this & in most of women will achieve much less bleeding pattern in a year time (1) .
Regarding changes of mood and libido are small effect and silimar to intra uterine coil.
There is a small chances of acne with IUS and uncommon for changing the device for this reason. written information

Although you have written a good answer, suggest you look at other good answers above to see how you could have obtained the same marks without spending as much time on the question
Posted by PAUL A.
prt

a] The patient should be asked regarding details of her sexual history and menstrual hx why address these in the same sentence? .Date of LMP is asked to exclude pregnancy before prescribing contraceptives where is the sexual Hx? That is what happens when you address two issues simultaneously. You also need more detail about menstrual Hx .
Details of obstetric hx is asked to know the number of CS and vaginal delivery as it would help in deciding the type of contraceptive (1) ? breast feeding, reproductive intentions.Previous contraception used should be enquired into what about it?? .
Hx of menorrhagia and dysmenorrhoea is elicted is this not part of menstrual Hx? .She should be asked about any further desire for children (1) &the expected family size. History of more than one sexual partner in the last year should be asked this is sexual Hx which you mentioned in your first sentence as patient is only 20 years old;she should be referred to genitourinary medicine to rule out sexually transmitted infections if she has been changing partners.
Family hx of osteoporosis,thromboembolism (1) and breast cancer should be asked .
She should be asked about the smoking,alcohol intake or any drug abuse in the personal hx (1) .Any hx of migraine,liver disease healthy woman or associated drug intake needs to be noted. suggest you look at good answers above to see how you could have earned more marks while using less time / space

b] Advantages of depot Medroxy Progesterone Acetate[DMPA] is that it is a long acting reversible contraceptive which needs to be taken every 12 weeks.The patient should be told that it has a good efficacy with a pearl index of 0.25-0.5/100 women years (1) .
It does not needs to be taken daily and does not interfere with sexual intercourse.
It is associated with lower risk of Pelvic inflammatory Disease,ectopic pregnancy and endometrial cancer
Menstrual blood flow is reduced (1) and hence it reduces iron deficiency anaemia .This method is especially suitable if the woman is breast feeding (1) or a smoker. In case the patient is diabetic or hypertensive read the question - HEALTHY , it avoids the oestrogenic effects of COCPs.
Patient should be told that the efficacy of DMPA is not reduced by the antibiotics and liver inducing enzymes.She can continue the injection at the usual interval of 12 weeks.

Patient should be informed about the various disadvantages of DMPA that the menstrual irregularity is common (1) .Amenorrhoea is more likely with repeated doses;30% with the first dose and 55% after the fourth dose.Upto 50% of the women may discontinue DMPA at the end of one year due to unacceptable bleeding pattern.
It is associated with a delayed return of fertility (1) ,of about 8 months from the last injection and may be as long as 24 months.
There may be weight gain of upto 2 kg in the first year which may not be acceptable to many patients.
There is an evidence that DMPA causes significant reduction in the bone mineral density (1) .This may be important if the woman has a family hx of osteoporosis.But this may revert to normal on discontinuation.Verbal as well as written information (1) should be given to the patient.


c] The patient should be told the advantages of LNG-IUS[Levonorgestral Intrauterine system] that it has a good efficacy of less than 1/100 pregnancy rate is this per cycle or per year?? and it is licensed for use for 5 years.It has a ready reversibility and return of endometrial morphology and menstruation with in 30 days.
It has the advantage of treating associated menorrhagia (1) and reducing blood loss upto 97 % after 12 months of use;with increase in serum ferritin and Haemoglobin concentration.
Dysmenorrhoea may be improved.
It has a lower ectopic pregnancy rate 0.02/100 women years compared to nova T users and sexually active women not using contraceptives.
It protects against PID (1) by thickening the cervical mucus,inactivation of endometrium and reduced bleeding.
The disadvantages of LNG-IUS is that there may be difficulty in insertion due to its thick stem.Patient may need analgesia or cervical dilatation for the insertion.
There is increased incidence of irregular bleeding and it may take 3 months (1) for the endometrium to atrophy.Patient should be told about it.
There is increased incidence of functional ovarian cysts compared to copper IUDs .Patients needs to be counselled properly about amenorrhoea (1) as many women regard it as abnormal.Various progestogenic adverse effects like oedema,headache and breast tenderness should be told to the patient and written information given should be at the end for the same.There is increased likelihood of developing acne due to progestogen ,but few women discontinue IUS due to this.
IUS is expensive and is not cost effective to NHS as only contraceptive. Around 60% of women discontinue the use of IUS do you mean 60% of women who have it inserted will have it removed because of irregular bleeding?? This is incorrect due to unacceptable bleeding profile and this should be told to the patient.
There is risk of perforation albeit small 1:100 at the time of insertion (1) .If women becomes pregnant with IUS in situ then the risk of ectopic pregnancy is 1:20 and woman should be told to exclude ectopic pregnancy.Written information is given for all the above details

Although your answer contains most of the required information, it has not been presented in a manner which reflects a systematic approach to clinical problems. Suggest you look at good answers above. You could have saved 25% of the time / space spent and earned more marks .
Posted by PAUL A.
(a) I will enquire about the previous method of contraception (1) and her compliance as there is a chance that her previous unplanned pregnancies were due to user failure. I will also ask her what is her preference now, whether implants, intrauterine devices, injections pills after giving her all information you were asked about Hx about these methods and is she aware of emergency contraception.
Mode of previous deliveries and age of her last child and whether she is breastfeeding (1) will also be enquired. Regarding her menstrual history (1) , it is important to know the regularity, amount of flow, any dysmenorrhea. Her LMP should be recorded as well. Any family history of osteoporosis should also be sought (1) VTE .
(B) I will inform her that DPMA is a form of long acting reversible contraception in injection form that needs to be taken every 84-90days. It is easy to use in the sense that the patient needs just one injection every 3 months (1) unlike the pills which need to be taken regularly and any failure of their compliance would result in an unplanned pregnancy. The failure rate is less than 0.4/100 women years (1) . There is less risk of ectopic pregancy and PID. Menstrual blood loss may also reduce with time and there is improvement with Hb. It will not interfere with her breastfeeding (1) .
As far as disadvantages are concerned, there is chance of weight gain of about 2-3kg, especially during 1st year of use. There can be irregular bleeding (1) per vaginum for some time but there is also 30% chance of amenorrhea after 1 injection and 55% after 4 injections. There may be a delay in return of fertility from 8 months (1) to 24 months. This method can\'t be used for more than 2 years as there is a chance of small loss of bone mineral density (1) this does not mean it CANNOT be used beyond 2 years – you need to look at risks and benefits for a particular woman which will recover when DPMA is stopped and there is no risk of fractures. I will also provide the patient with the information leaflet (1) .
(c) Levonorgestral Intrauterine system is another method of long acting reversible contraception. It is very effective with failure rate of less than 1 in 100 women years. It can be kept for 5 years (1) . No patient compliance needed and fertility is returned back as soon as it is removed. No effect on her breastfeeding and menorrhagia will also improve (1) .
The disadvantage of this method is there is risk of irregular bleeding, spotting and pain for the first 6 months (1) but by the end of 1 year oligomenorrhea or amenorrhea occurs in about 95%, so she needs proper counselling. There is a small chance of having acne and change in mood but no risk of weight gain. There is a low risk of PID and ectopic pregnancy but overall rates are lower than no contraception is this a disadvantage?? . If anytime she feels she is pregnant, she should get medical advice. There is a risk of uterine perforation at the time of insertion and increased chances of infection for the first 2-3 weeks (1) . Also there is a small risk of expulsion (1) . I will give her information leaflets (1)

Good answer
.
Posted by PAUL A.
Am
a) I will take details of menstrual history (1) , LMP for possibility of current pregnancy, regularity of the cycle , amount of bleeding and for how many days she bleed per month. Contraception history (1) incluing current contraception, previous methods used and causes of failure like irregular pill taking . Sexual history (1) is important , last intercourse and if she is using any barrier methods . Previous or current pelvic pains ,vaginal discharge or previous attacks of PID and when was the last attack . Obstetric history including when was her last delivery ? is she breast feeding (1) do not ask the examiner questions?

b) Advantages of depomedroxy progesterone acetate are numerous . Easy administration , only IM injection every 12 weeks . For a busy mother like her it is user independent (1) less user-dependent , she don t have to remember to do anything except to take the injection on time . The method is indepedant of intercourse. Long acting method and can be used safely for 2 years . It has very low failure rate ( less than 1 /100 women year) (1) . No follow up visits are needed except if she has any concern or want to change the method . However the disadvantages include possible decrease in bone mineral density (1) if used for more than 2 years . The method don’t protect against STIs so she must use a barrier method as well (double ditch ) do not write it unless you are sure you will be accurate . She may experience irregular periods (1) and treatment of these irregularities may entail taking another hormone tablets to stop persistent bleeding . She may gain about 2-3 Kg in the 2 years .
Return of fertility after stopping the method may take few months how many? . I will provide her with written information (1) .

c) Regarding the advantages of levonorgestrel IUS it can be used for 5 years . It is also user and intercourse independent (1) . I t will reduce the amount of her monthly bleeding (1) . Minimal systemic side effects like mood swings, acne and usually no one will stop using the method because of them is this an advantage? Are you sure that no woman has discontinued IUS because of acne?? .
Pregnancy rates are very low ,less than 1/100 year .Return of fertility is immediate after removal of the device . On the other hand the method has some disadvantages . It needs application through the vagina which may be painful . The expulsion rate is 1/20 (1) . it doesn’t protect against STIs . Irregular bleeding in the first 6 month but it will reduce overtime and some women will be amenorrhic after I year (1) . There is risk of perforation (1/1000) (1) which may necissates other interference or surgery to retrieve it . She should have a follow up visit after 3 weeks to check correct placement of the device . Removal is done through the vagina written info .
Posted by PAUL A.
ah
a)A menstrual history will be taken (1) . The date of her last menstual period, as well as associated dysmenorrhoea, and menorrhagia as well as her cycle length and frequency will be asked. If cycle control is necessary appropriate hormonal contraception will be advised
The type of contraception (1) used as well as duration of use will be enquired. Her compliance and any difficulties she has with compliance will also be sought.
THe age of her last child as well as if she is breastfeeding (1) will be asked to determine type of contraception and time to start hormonal contraception.
A medical healthy and drug history will be taken to determine if there are contraindications to, especially hormonal contraception. Certain drugs like anti-epileptics which induce liver enzymes will also reduce efficacy of the combined oral contraceptive pill.
A family history VTE, osteoporosis of breast or genital tract malignancy will be taken as this may cause anxiety and reduce compliance of hormonal contraception.

b)medroxyprogestene acetate is available for contraception as a long acting injectable given by deep intramuscular injection every twelve weeks.
The advantages are that it is highly effective with a failure rate of .25 to 1 per 100 women years (1) . It is not user-dependent nor coitus dependent and therefore compliance or efficacy is not affected unless she is unable to attend for the injection (1) .
Non contraceptive benefits include its usefulness for relief of premenstrual syndrome ? evidence and dysnenorrhoea,and it protects against pelvic inflammatoy disease, endometrial cancer and ectopic pregnancy.
It has minimal metabolic effects and reduces menstrual blood loss (1) thereby reducing the risk of iron-deficiency anaemia.
The disadvantages include menstrual irregularities (1) and unpredictable vaginal bleeding which can interfere with sexual activity. About 30 percent experience amenorrhoea after the first injection and 55 percent after the the fourth; this may be unacceptable for young women as they will be concerned that this may be due to pregnancy.
There can be a long delay of return to fertility (1) of about 8 months to 24 months.
Other side-effects include weight gain, breast tenderness and decrease in bone density which is partially reversible after stopping treatment and ovarian activity resumes (1) written information .

c) The advantages of the levonorgestrel-intrauterine system(LNG-IUS) are that it is highly efficacious and this lasts for five years (1) . Menstrual blood loss decreases by about 97 percent after the first year and therefore it is a cost-effective alternative to treat menorrhagia (1) .
It protects against pelvic inflammatory disease by its effect of thickening cervical mucus. Is associated with a lower rate of ectopic pregnancy compared with copper containing IUCDs and there might be a reduced incidence and growth of uterine fibroids.
The disadvantages of the LNG-IUS are that it may be difficult to insert due to its size. and a paracervical block may be necessary. It may be expelled in the first few months (1) . Uterine perforation may occur in 1.2 per 1000 insertions (1) .
Irregular bleeding (1) is experienced in the first few months and amenorrhoea may be experinced by about 35 percent of users. This may be unacceptable in young women written information .
There is an increased risk of functional cysts. Other side-effects include headache, breast tenderness and acne which may subside in the first few months.
Posted by PAUL A.
Rnz
A.
Ask regarding methods of contraception (1) used so far and method being currently used. Ask regarding her preferences and reasons for previous failure of contraception. Obstetric history including miscarriages and terminations ? breastfeeding . I’ll try to find out whether there is riskful sexual behaviour how will you find this out? , whether she is in a stable relationship what is a ‘stable’ relationship? and what her plans for possible future children are (1) . Social background and potential for abuse needs to be assessed. I will enquire regarding her cycle, LMP, dysmenorrhea, menorrhagia (1) . I’ll ask for medical problems healthy , family history FHx of what?? and smoking behaviour.

B.
Main advantage is ease of use (1) , once in 3 months only and therefore low potential to forget. It is very reliable with Pearl index more than 99 NO – Pearl index is number of pregnancies per 100 woman years . it will not interfere with for example smoking or most medical problems. Disadvantages are the potential for erratic period bleeds (1) being unpredictable and sometimes heavy. Side-effects may be weight gain, fluid retention, acne. Long use will also affect the bone mass in what way? Increase or reduce?? . After stopping it may take several months for fertility to regain how many is several?? .

C.
Again the ease of the method where compliance does not pose a problem is an important advantage. After introduction there is no need for change until after 5 years (1) and after removal fertility returns without delay. Additional benefit is the reduction of period bleeds in 90% after 1 year (1) , whilst about one third remains amneorrhoeic. Disadvantage is that it requires speculum examination for introduction. The first 3-4 months the cycle can temporarily turn erractic (1) , but thereafter usually normalise. Though the hormones only act locally, some women do experience side-effects and ovarian cysts are more common. There is also a slightly increased risk for STD this is incorrect , especially in riskful behaviour.

You need a more detailed answer. See good answers above
Posted by PAUL A.
I would ask about her menstrual history, if she had regular cycle or not LMP, menstrual loss, dysmen . I would ask about other unplanned pregnancies ended by termination of pregnancy and method of deliveries and date of last delivery, breast feeding or not (1) . . Also, about her marital life did the question say she was married? How do you determine if her marital life is stable?? if it is stable or not, about possibility of multiple partners. Her past contraception history should be obtained and the methods used (1) what more do you want to know about previous contraception??. Also, if she got pregnant on top of one of the methods used. I would ask about her work type and if she is not keen to take daily hormonal pills. I would ask about previous un tolerated side effects of different kinds and if there is contraindication in her history to use COCP, like family history of DVT (1) osteoporosis or breast cancer?. Her family was completed (1) or not and if she is willing to have permanent method for contraception or partner sterilization as an alternative option.


Depot Medroxyprogestrone acetate (DMPA) is one of the long acting reversible, reliable contraception. Its pearl index is less than 0.5:100. ?? per 100 woman years It can be used once every 1 or 3 months NO – it is given every 12 weeks and NEVER given every month (-1) . It can be used for breast feeding mother (1) without alteration of milk production. Also, it can be used for hypertensive or diabetic mothers HEALTHY . Its efficacy was not altered by other pharmaceuticals like antibiotics, and other enzymatic inducers like antifungal (Griseovalvin) and anti convulsive, antiepileptic (Phenotoin) ? relevance to this woman . As it was given by parentral use its absorption was not affected by vomiting and diarrhoea. It can be useful for cases of Menorrhagia, uterine fibroids and Endometriosis. So, it can effective in endometrial cancer protection.
DMPA disadvantages, increase incidence of cycle irregularities (1) , break through bleeding and amenorrhoea. There is increase incidence of mood changes, blues, weigt gain, breast pain and bloating (1) . Not protective against sexually transmitted disease and PID. The regular ovulation may return after quite long time up to one year after discontinuation of DMPA (1) . Patients\' information leaflet (1) should be provided.


Levonorgestyl releasing intrauterine system (LR-IUS) is another method of long acting reversible contraception. Its pearl index about < 0.5/100 woman years .can be used up to 5 years (1) . It may be used for cases of Menorrhagia with highly efficacy of reducing the menstrual blood flow (1) . It may induce amenorrhoea. The fertility will return after short period of time after removal. It may reduce the incidence of PID and ectopic pregnancy. It may also reduce the size of uterine fibroids. It can give protection against endometrial cancer.
LR-IUS disadvantages, may cause discomfort during its insertion so nonestroidal antinflammatory or local anaethesia may be used. It may cause continuous break through bleeding for 3-6 months (1) . One of the side effects of IUDs is perforation of the uterine wall (1) ? incidence. . Patients\' information leaflet (1) , also should be provided.

SEE GOOD ANSWERS ABOVE
Posted by Priti T.
Dear Dr Paul,
Even though I try to write SAQs with in 20 minutes ,inthe end I check the percentages n figures.Up to 60 % of womem stop using IUS within 5 years.It is correct and the source is from NICE guideline on Long acting reversible Contraceptives[LARC] issued Oct 2005 page 17 and also page 44 has a table which compares other LARC.Thanks.waiting for yr reply.
Dr Priti
Posted by PAUL A.
Dear Dr Paul,
Even though I try to write SAQs with in 20 minutes ,inthe end I check the percentages n figures.Up to 60 % of womem stop using IUS within 5 years.It is correct and the source is from NICE guideline on Long acting reversible Contraceptives[LARC] issued Oct 2005 page 17 and also page 44 has a table which compares other LARC.Thanks.waiting for yr reply.
Dr Priti

Did the NICE guidelines say 60% of women stop using the IUS BECAUSE OF ABNORMAL BLEEDING? That is what you wrote in your essay. Without even knowing what the figure is, this statement has to be incorrect. The IUS will not be useful if 60% of women discontinued it because of a single side-effect
Posted by PAUL A.
a.History regarding the type of contraception used (1) and the specific problems faced like menstrual irregularity [with DMPA],compliance difficulties,acne,weight gain problems will be enquired.Detailed menstrual history (1) including LMP,any menstrual irregularity,menorrhagia will be enquired since IUS,OCP may decrease menstrual blood loss.Histpry of recent PID,sexually transmitted diseases which are contraindications to IUCD will also be looked into.Her compliance in use of regular tablets like OCP will be noted. Any contrindications to pills like focal migraine,liver disease,persoal history of thrombosis ,breast and endometrial cancer will be enquired READ THE QUESTION!!! . Any use of enzyme inducing drugs like broad spectrum antibiotics,antiepileptics READ THE QUESTION!!! Waste of your time & space will be enquired since this may necessitate drug modification.Her sexual history whether she is in stable relationship will be enquired since this may necessitate condom usage if not in stable relationship how do you assess the stability of her relationship? .Obstetric history ellicitation and whether she is breast feeding (1) now and time since last child birth isa important since minipills can be started by 3 weeks postpartum,but injectables to be started after 6 weeks in breast feeding women.Finally her wishes should be taken into account.
b.The advantages of medroxy progesterone acetate injection are it can be given once in 12 weeks ,hence better compliance.Can be used in breast feeding women (1) , diabetics ? relevance to this woman?? .Pearl index is 0.2-0.4/HWY do not recognise these units . Associated with the lower risk of PID and ectopic pregnancy compared to POP. It also decreases menstrual blood loss (1) .The disadvantages are it may cause menstrual irregularity (1) and even amenorrhea with repeated doses..There is weight gain, progestogenic side effects.Resumption of ovulation may be delayed after discontinuation to upto 8 months (1) .There is evidence to suggest it may cause decreased bone density and osteoporosis if used for a long time particularly adolescents (1) .Injection may be painful. Needs frequency modification if used with enzyme inducers ? relevance to the question .
c.IUS once fitted can remain for 5 years, better compliance (1) .Failure rate is low how high is low? ..Avoids systemic progestogenic effects are systemic side-effects AVOIDED??? .Can be of use in menorrhagia,PMS , dysmenorrhea and endometriosis also. It is of therapeutic use in endometrial hyperplasia also ? relevance to this healthy 20 year old woman .There is decreased incidence of ectopic pregnancy compared to non users.The incidence of PID is also decreased in the long term due to the thickening of cervical mucus.The disadvantages are it may cause menstrual irregularity (1) and even amenorrhea which needs proper counselling.There is increased incidence of PID in the first 20 days due to insertion.During insertion there may be pain ,discomfort,difficulty in insertion and,risk of expulsion (1) perforation.There is also increased incidence of functional ovarian cysts compared to copper IUCD (1) ? written information

You were specifically asked about a healthy 20 year old woman
.
Posted by PAUL A.
History should be taken regarding the duration and the type of use of contraception i.e combined pill (COC), progeterone only pill (POP), estrogen patches, condoms or diaphragm with or without spermicide waste of time & space – why did you list these options? Is there any reason whi there could not have been problems with IUCD, IUS, DMPA…? . Try to establish the problem with the use of the above
mentioned methods which could include missing pills altogether or not taking them within a specified time period . For example a POP should be taken within at the same3 hour period everday otherwise it\'s efficacy is reduced. Simililarly patient should be asked about the proper application of estrogen patches and any probem with compliance with regards to their use.
Any history of nausea vomiting associated with the intake of pill
should be inquired
see comment above .
Personal history should be sought regarding alcohol and drug intake (1) .She should be asked if the pregnancies were in a stable relationship or if were the result of chance encounters leading to one night stands this is an inappropriate and judgemental question that will lead many women to tell you to mind your own business. How do you assess stability of a relationship? . She should be inquired whether she was under the influence ofalcohol at the time or not obstetric Hx, breastfeeding, family Hx .

The advantages of medroxyprogesterone acetate include adminstration of the contraceptive injection 3 monthly by her GP.It is easy to comply (1) with and it can make heavy periods lighter if that is a concern with her as well. Breast feeding is possible (1) since it doesn\'t effect the quality or quantity of breast milk. Also it cause thickening of cervical mucous leading to some degree of protection from sexuallly transmitted diseases.

Disadvantages of this method include delivery by injection which is painful and may not be acceptable to the patient. Otherproblems likeirregular vaginal bleeding (1) , acne, weight gain, breast tenderness and mood changes can occur. Their is also a risk of osteoporosis (1) with prolonged use especially if combined with breast feeding.Also there may be a delay in return of fertility by upto 18 months (1) in case she decides to stop using contraception in order to conceive.It can cause increase in the incidence of ovarian cysts with it\'s sequlae of haemorrhage, torsion and rupture etc.
written info
The advantages of a levonorgestrel inta uterine system include prolonged contraception fo 5 years (1) . Immediete return of fertility upon removal of the device. Lightening of periods (1) if heavy periods are a concern. Thickening of cervical mucous leading to some degree of protection from STDs. Progesterogenic side effects such as acne, wight gain, depressive moods are very slight since very little hormone is released into the system and most of it remains locally in the uterus.
The disadvantages include lower abdominal cramps which can be severe and persistent in a minority of patients after insertion, which itself can be very painful necessitating insertion of same under general anasthesia and it\'s associated risks.
Increase risk of infection in the first few weeks of insertion (1) . Irregular bleeding for prolonged periods first 3-4 months which may not be acceptable to her. There is a risk of expulsion (1) in the first few weeks after insertion leaving her vulnerable to yet another unwanted pregnancy. Other rare risks include perforation (1) of uterus and entry to abdominal cavity, necessitating removal via laparoscopy or more rarely via laparotomy if causing symptoms of pain. written info
Posted by PAUL A.
a-I would ask about its impact on her quality of life ? relevance?? , its social impact and the reasons for her unplanned pregnancy need contraceptive Hx like missed pill, condom failure etc how does the examiner know that you know everything else that is included in etc? .Her awareness about emergency contraception assessed. Obstetric history obtained to know the number and mode of deliveries and previous MTP\'s what is this? You use abbreviations at your peril .Her wishes for future fertility (1) and contraception (permanent or temporary)assessed.Her attitude ,knowledge and preferences of contraceptives assessed. Intake of enzyme inducing drugs like rifampicin READ THE QUESTION!!! and non liver enzyme inducing drugs like ampicillin enquired as they reduce the contraceptive efficacy of contraceptive pills. Smoking ,alcohol (1) intake and use of addictive drugs like cocaine ,heroin enquired as their use can influence her to skip her contraceptive pills and put her at high risk for unplanned pregnancies and STI\'s.
b-I would tell her that it is a long acting reversible contraceptive. It is effective for 12 wks once injected.So it is not coital dependent and has no problems with compliance (1) as with oral pills.It is efficacious in preventing pregnancy,pearl index being 0.25-0.50/100 women years (1) .Effective even when enzyme inducing drugs are used.However,it causes irregular bleeding (1) in the first few wks, ammenorrhoea,delay in return of fertility after its use FOR HOW LONG? and loss of bone mineral density if used for long how long is long? .I also would provide her with written information (1) .

c-I would tell her that it is a long acting reversible contraceptive.It is effective for 5 yrs.So not coital dependent and no problems with complance (1) as with oral pills.It is efficacious ,pearl index being,<0.18/100 women yrs (1) .Return of fertility is rapid after removal.It has noncontraceptive benefits like reduced incidence of PID,ectopic pregnancies,and menorrhagia (1) .However it needs special technique for insertion under anaesthesia,and has problems of spotting in first 3-4 months , amennorrhoea,premenstrual symptoms, functional ovarian cysts and expulsion (1) you are likely to have earned more marks if you addressed these individually . It cannot be used as an emergency contraceptive and it is costly when compared to other contraceptives.I would also provide her with written information (1)

You were asked about a HEALTHY 20 year old woman
.
Posted by PAUL A.
nellie

a) I would ask about the LMP (1) and regularity of cycles or lack of such. A gynae history to determine if there are also associated menorraghia and dysmenorrhoea or abnormal pv bleeding which may need investigation before commencing a contraceptive method. Her sexual history with particular reference to previous STDs (1) and recent infection. Her family history of cardiovascular disease and VTE (1) osteoporosis . I would ask about her use of any drugs like antibiotics or enzyme inducing medications HEALTHY . If she smokes and uses alcohol should be ascertained. As she has 3 children I would ask how long ago was the last delivery and if she is presently breastfeeding (1) . A few questions should address her past contraceptive (1) use – the methods tried, were they used appropriately and were there side effects and were any discontinued and why and if she been using any recently .Has there been unprotected intercourse with the possibility of an early pregnancy.

b) The advantages of depo- medroxy progesterone acetate (DMPA) are that it has a failure rate of 0.25- 0.5 per women years (1) . It works primarily by inhibiting ovulation so most women, about 50%, will be amenorrhoeic why is this an advantage? . It is administered as an injectable once every 3 months and is effective if given within first 5 days of LMP with immediate contraception, otherwise additional contraption will be required for 7 days where is the advantage? . It is administered by a G.P office or at a family planning clinic ? advantage?? So are all other contraceptives .
The disadvantages is that there is associated abnormal bleeding (1) patterns with its use and this is usually the main reason for discontinuing by most women. Its use over a 2yr period is associated with reduced bone mineral density (1) but is reversible once stopped. There is a delay in return to fertility (1) by as much as 1 year. I would provide her with an information leaflet (1) on progestogen only injectables, namely DMPA, to peruse before making her decision.

c) The advantages of the levonorgestrel- releasing intrauterine device ( LNG-IUS) are it is also associated with a low failure rate of less than 1 in 1000 ??? women years and when fitted , it is effective for up to 5 years . There is no need for follow up in interim if no problems (1) less user-dependent. There is great advantage in women who also have menorrhagia because it works primarily at the level of the endometrium and causes significant reduction in blood loss (1) with menses. There is no effect on loss of bone density and no delay in return to fertility.
The disadvantages are it requires insertion sometimes with local anaesthetic or there is some discomfort felt by the patient. The rate of expulsion is 1 in 1000 (1) . The risk of infection is greatest within the first 3 weeks of insertion. Some will also experience abnormal bleeding for the first 6 months of use (1) . I will provide her with a leaflet (1) on the LNG-IUS and, if available, show her a sample of the device to be fitted.
Posted by PAUL A.
A good candidate should
(a)

History
• Menstrual Hx - LMP, cycle length and regularity; age at menarche; menstrual loss (1)
• Obstetric Hx - date of last delivery, feeding method ? breastfeeding; fertility wishes (1)
• Contraceptive Hx - current method; previous methods and problems encountered (1)
• Family Hx of VTE and osteoporosis (1)
• Sexual Hx - number of sexual partners, use of barrier methods (1)
• Social Hx - occupation (shift work), support network, use of alcohol / illegal drugs (1)

(b)

Advantages of depo medroxyprogesterone acetate (3)

• Highly effective contraceptive - Pearl index
• Less user-dependent than oral contraceptives. Infrequent doses – every 12 weeks
• May induce amenorrhoea which will be beneficial if Low Hb or heavy menstrual loss
• Can be administered to breast-feeding women and shortly after delivery
• Not associated with oestrogenic side-effects such as DVT risk

Disadvantages (4)

• Associated with irregular vaginal bleeding and amenorrhoea. The woman might think she is pregnant
• Associated with progestogenic side-effects like weight gain and mood changes
• Associated with delay in return to normal fertility of ~8 months but may be up to 24 months
• Associated with reduction in bone mineral density with prolonged use (> 2 years)
• Provide written informastion

(c)

Advantages of levonorgestrel IUS (3)


• Highly effective contraceptive - Pearl index
• Less user dependent as effective for 5 years
• Associated with reduced menstrual loss therefore of value if heavy periods
• Associated with reduced incidence of painful periods
• May reduce risk of PID and ectopic pregnancy

Disadvantages (4)

• Insertion might be difficult although this is less likely in a multip
• Associated with irregular bleeding in the first 3-4 months
• Associated with amenorrhoea which the woman might not want
• Associated with progestogenic side-effects and increased risk of functional ovarian cysts
• May be expelled leading to failure
• Insertion associated with risk of uterine perforation and an increased risk of PID in the first 3 weeks following insertion
• Provide written information
sssssssss Posted by PAUL A.

sss