Approach to methods of contraception

Individuals aged >35 years who smoke 15 or more cigarettes a day are contraindicated from oestrogen containing contraceptives. This is an absolute contraindication (BMJ Best Practice 2021 and UKMEC guidance) due to the risk of thromboembolic complications. Maria would be able to use copper or progesterone-based contraceptives or barrier methods such as condoms.

Periodic abstinence works by predicting ovulation via various method such as tracking basal body temperature, checking consistency of cervical mucus and charting menstrual cycles. Abstinence from intercourse 5 days before predicted day of ovulation to 2 days after ovulation. A benefit of this method is that it is respectful of religious and cultural beliefs and provides an individualised method, however it is labour intensive and requires self-control.

Contraception is not only about people with uteruses, but is also important for males too. A vasectomy provides a permanent, non-reversible protection against pregnancy and is 99% effective. Twelve weeks after the procedure, individuals should have semen analysis to confirm aspermia indicating the success of the procedure. Prior to this result, individuals are advised to use a back up method of contraception. (BMJ Best Practice 2021)

The vas deferens is a straight, thick, muscular tube that conveys sperm from the epididymus to the ejaculatory duct, from which sperm can then pass through to the prostatic urethra. The seminal vesicle duct combines with the vas deferens to create the ejaculatory duct. The vas deferens forms part of the spermatic cord during the progression through the inguinal canal.

This is a more challenging application question. There are 4 methods of emergency contraception: progesterone-only emergency contraception, oestrogen/progesterone emergency contraception, ulipristal and copper intrauterine device (BMJ Best Practice 2021). This immediately rules out progesterone intrauterine device. Next consider the time frame, oestrogen/progesterone emergency contraception is only effective within 72 hours (3 days) so this window is not available. In addition, this method is no longer commonly used in the UK as it has been demonstrated as inferior to other methods (see FRSH guidance (PDF)). Progesterone-only emergency contraception is not effective after 96 hours (4 days) ruling this out too. This leaves ulipristal and copper intrauterine device (IUD) as choices. Ulipristal is a selective progesterone-only modulator; when taken within 5 days of unprotected sexual intercourse it is 90% effective. The Copper IUD is the most effective emergency contraception with nearly 100% effective within 5 days. However, as Davina is being treated for an STI, insertion of an IUD increases the risk of pelvic inflammatory disease, thus, the most appropriate choice is ulipristal.

Individuals should wait 5 days after the use of ulipristal before starting hormonal contraception as this may decrease the effectiveness of ulipristal. The individual would also need to use back up methods of contraceptions within first 7 days of starting or resuming regular contraception. (BMJ Best Practice 2021)

Individual preferences play an important role in deciding upon contraception methods and this question tests your understanding of this. Condoms are ruled out as Davina is requesting a long term method. Banding of the fallopian tubes is a method of permanent contraception, Davina has requested her fertility preserved so this is not appropriate. Oestrogen/progesterone oral contraceptive is a pill., the stem states she does not want to take any tablets. The progesterone injection is not a great option for someone who has a phobia of needles! Thus, this leaves a progesterone intrauterine device which is localised hormones, long term and fertility preserving!

Lactational amenorrhoea is up to 98% effective. Individuals must breast feed exclusively, feeding every 4 hours in the day and 6 hours at night. When individuals have their first menstrual period, reach 6 months old and their infant feeds less often this method is no longer effective. (BMJ Best Practice)

The diaphragm and spermicide involves fitting a barrier at the cervix to prevent sperm from reaching the uterus and Fallopian tubes. An individual must be able to accurately locate their cervix to insert the diaphragm coated in spermicide prior to intercourse. The other answer choices relate to the rhythm/periodic abstinence method.

The use of spermicide may increase the risk of HIV transmission, so should be avoided in individuals living with HIV who are not viral load undetectable. Remember undetectable viral load = untransmissable! Condoms are the only method that provide STI protection, which includes HIV.