Reproductive Health Practice Questions

Q: According to the UK Medical Eligibility Criteria (UKMEC), which of the following clinical scenarios represents a UKMEC 4 (unacceptable health risk) for the copper intrauterine device?

Current pelvic inflammatory disease. ***Current pelvic inflammatory disease*** - Insertion of a **Copper IUD** in the presence of an active infection can facilitate **ascending infection**, significantly increasing the risk of worsening the condition. - It is classified as **UKMEC 4** because the absolute medical risk to the patient outweighs any contraceptive benefit until the infection is fully resolved. *History of ectopic pregnancy* - This scenario is classified as **UKMEC 1**, meaning there is no restriction on the use of the copper intrauterine device. - While an IUD does not protect against ectopic pregnancy as effectively as it protects against intrauterine pregnancy, a **prior history** is not a contraindication. *Endometrial cancer awaiting treatment* - This is typically classified as **UKMEC 4 for initiation**, but the management usually focuses on oncology protocols rather than standard family planning. - While it represents a contraindication, **active infection** like PID is often considered a more immediate and classic clinical risk for IUD insertion in primary care exams. *Unexplained vaginal bleeding* - **Unexplained vaginal bleeding** (suspicious for serious pathology) is categorized as **UKMEC 4** for initiation of a copper IUD. - However, in many clinical frameworks, **current PID** is considered the more definitive and immediate physiological contraindication compared to symptoms awaiting investigation. *Severe thrombocytopenia with platelet count of 30 × 10⁹/L* - Severe **thrombocytopenia** is classified as **UKMEC 3** for the copper IUD, meaning the risks generally outweigh the benefits. - This is due to the potential for increased **menstrual blood loss** and heavy bleeding, but it does not reach the absolute contraindication level of UKMEC 4.

Q: A 47-year-old woman presents with a 9-month history of hot flushes, night sweats, and mood changes. Her periods have become irregular, with the last one occurring 8 weeks ago. She requests HRT but is concerned about side effects. Her mother had a deep vein thrombosis at age 72 following hip replacement surgery. The patient's BMI is 27 kg/m² and blood pressure is 118/76 mmHg. What is the most appropriate initial HRT regimen?

Sequential combined transdermal HRT. ***Sequential combined transdermal HRT*** - This patient is **perimenopausal** (irregular periods with the last one 8 weeks ago); therefore, she requires a **sequential (cyclical)** regimen to provide endometrial protection and regular withdrawal bleeds. - **Transdermal HRT** is the preferred route as it avoids first-pass hepatic metabolism and does not increase the risk of **venous thromboembolism (VTE)**, which is ideal given her concern and family history. *Sequential combined oral HRT* - While the sequential component is correct for a perimenopausal woman, the **oral route** is associated with a higher risk of **VTE** compared to the transdermal route. - Oral oestrogen increases the production of clotting factors in the liver, making it less suitable for patients concerned about thrombosis. *Continuous combined oral HRT* - **Continuous combined HRT** is only indicated for **postmenopausal** women (at least 12 months after the last menstrual period). - Using this in a perimenopausal woman often lead to heavy, **unscheduled breakthrough bleeding** due to the patient's own endogenous oestrogen production. *Oestrogen-only transdermal HRT* - Oestrogen-only HRT is strictly contraindicated in women with an **intact uterus**. - Without a progestogen to oppose the oestrogen, there is a significant risk of **endometrial hyperplasia** and **endometrial cancer**. *Tibolone* - Tibolone is a synthetic compound with oestrogenic, progestogenic, and androgenic properties but is intended for **postmenopausal** use only. - If used in the perimenopausal period, it causes poor cycle control and a high incidence of **irregular vaginal bleeding**.

Q: A 35-year-old woman attends for review 3 years after copper IUD insertion for long-term contraception. She has no complaints and examination reveals the threads are visible. Her last menstrual period was 2 weeks ago. She plans to start trying for pregnancy in 6 months. What is the most appropriate management?

Reassure and arrange review when she wishes to conceive. ***Reassure and arrange review when she wishes to conceive*** - Modern **Copper IUDs** are licensed for **5 to 10 years**; since this device was inserted 3 years ago and the patient is asymptomatic, it remains effective and safe to use.- Removing the IUD 6 months prior to the desired conception date is unnecessary and would leave the patient at risk of **unplanned pregnancy**, as fertility returns to baseline **immediately upon removal**.*Replace the IUD with a new copper IUD*- Replacing a functioning IUD after only 3 years is incorrect because the device has not reached the end of its **licensed lifespan**.- Routine replacement is not indicated unless the device is expired, displaced, or causing **refractory clinical issues**.*Remove the IUD now as she wishes to conceive soon*- Early removal is contraindicated because she explicitly stated she wants to start trying in **6 months**, not immediately.- Removing it now would necessitate the use of an alternative **short-acting contraceptive** method, which is less efficient than keeping the current IUD in situ.*Arrange hysteroscopy to check IUD position*- **Hysteroscopy** is an invasive procedure and is not indicated when **IUD threads are visible** during a speculum examination.- IUD position is generally confirmed via **ultrasound** only if the threads are missing or clinical symptoms like pelvic pain suggest displacement.*Advise changing to the levonorgestrel intrauterine system*- There is no clinical indication to switch to the **LNG-IUS** as the patient is happy with her current method and has no complaints like **heavy menstrual bleeding**.- Switching methods 6 months before planned conception is impractical and may cause side effects during the **hormonal adjustment** period.

Q: A 31-year-old woman with polycystic ovary syndrome presents requesting contraception. She has a BMI of 34 kg/m² and oligomenorrhoea. Her blood pressure is 132/84 mmHg on two separate occasions. She is a non-smoker with no personal or family history of venous thromboembolism. She prefers not to have a coil fitted. What is the most appropriate contraceptive option for this patient?

Etonogestrel contraceptive implant. ***Etonogestrel contraceptive implant*** - This is a **Long-Acting Reversible Contraceptive (LARC)** and is categorized as **UKMEC 1** for this patient, meaning there are no restrictions on its use despite her BMI and blood pressure. - It provides highly effective contraception for 3 years without the **user-dependence** associated with oral pills, which is beneficial for managing her PCOS symptoms. *Combined oral contraceptive pill* - Although often used in PCOS to regulate cycles, her **BMI of 34 kg/m²** and **borderline hypertension** (132/84 mmHg) increase the risks associated with estrogen-containing methods. - The **Combined Hormonal Contraceptive (CHC)** is generally avoided or used with caution (UKMEC 2/3) when multiple cardiovascular risk factors like obesity and elevated BP are present. *Progestogen-only pill* - This is a safe option (**UKMEC 1**), but it is considered less ideal than a LARC because its efficacy depends on **consistent daily administration**. - It does not offer the same high level of long-term contraceptive security as the **subdermal implant** for a patient seeking reliable protection. *Depot medroxyprogesterone acetate injection* - While effective, the **Depot injection** is frequently associated with **weight gain**, which is undesirable in a patient who is already obese (**BMI 34 kg/m²**). - There are also concerns regarding a reduction in **bone mineral density** with long-term use, making it a second-line choice compared to the implant. *Progesterone-only emergency contraception until blood pressure controlled* - Emergency contraception is only indicated after **unprotected sexual intercourse**, which is not the primary presentation here. - Her blood pressure (132/84 mmHg) is not high enough to contraindicate the immediate initiation of a **progestogen-only** maintenance contraceptive.

Question 1

A 33-year-old woman attends for insertion of a levonorgestrel intrauterine system for contraception and management of heavy menstrual bleeding. She has no history of pelvic infection and is in a stable relationship. During insertion, she experiences significant pain and the procedure is abandoned. What is the most appropriate next step in management?

Accepted Answer

Offer cervical priming with misoprostol and insertion under local anaesthetic in 2-4 hours

Answer

Prescribe mefenamic acid and attempt insertion again immediately

Answer

Arrange insertion under general anaesthesia

Answer

Prescribe misoprostol and reattempt insertion in one week

Answer

Refer for hysteroscopic insertion

Question 2

A 56-year-old woman with a BMI of 38 kg/m² presents with moderate vasomotor symptoms and requests HRT. She had her last menstrual period 3 years ago. She has a history of non-alcoholic fatty liver disease and impaired glucose tolerance. Her blood pressure is 128/82 mmHg. She has never had venous thromboembolism. What is the most appropriate form of HRT to prescribe?

Accepted Answer

Continuous combined transdermal HRT

Answer

Continuous combined oral HRT

Answer

Tibolone

Answer

Oestrogen-only transdermal patch

Answer

No HRT - recommend lifestyle measures and non-hormonal treatments only

Question 3

A 42-year-old woman with a history of migraine without aura has been using the combined oral contraceptive pill for 8 years. She now reports that over the past 6 months her migraines have changed character and she is experiencing visual disturbances with zigzag lines lasting about 20 minutes before the headache starts. She has had 3 such episodes. She smokes 5 cigarettes daily. What is the most appropriate management of her contraception?

Accepted Answer

Stop the combined oral contraceptive pill immediately and arrange alternative contraception

Answer

Continue the combined oral contraceptive pill as current migraine is still infrequent

Answer

Switch to a progestogen-only pill and review in 3 months

Answer

Reduce the dose of ethinylestradiol in her combined pill

Answer

Continue current pill but add prophylactic aspirin

Question 4

A 53-year-old woman who has been taking continuous combined HRT for 6 months presents with a 4-day episode of vaginal bleeding. Her last menstrual period was 18 months ago. She has no abdominal pain or other symptoms. On examination, her abdomen is soft and non-tender. She is otherwise well with no significant medical history. What is the most appropriate initial investigation?

Accepted Answer

Transvaginal ultrasound scan to measure endometrial thickness

Answer

Outpatient hysteroscopy and endometrial biopsy

Answer

Cervical smear test

Answer

Serum FSH and LH levels

Answer

Repeat examination in 4 weeks if bleeding has settled

Question 5

A 28-year-old woman presents 110 hours after unprotected sexual intercourse requesting emergency contraception. She is on day 18 of a regular 28-day menstrual cycle. She has no significant medical history and is not taking any regular medications. Her BMI is 24 kg/m². She had another episode of unprotected intercourse 8 days ago. What is the most appropriate management?

Accepted Answer

Insert a copper intrauterine device

Answer

Prescribe ulipristal acetate 30 mg as a single dose

Answer

Prescribe levonorgestrel 1.5 mg as a single dose

Answer

Prescribe double-dose ulipristal acetate due to the time elapsed

Answer

Advise that emergency contraception is no longer effective and arrange pregnancy test

Question 6

According to the UK Medical Eligibility Criteria (UKMEC), which of the following clinical scenarios represents a UKMEC 4 (unacceptable health risk) for the copper intrauterine device?

Accepted Answer

Current pelvic inflammatory disease

Answer

History of ectopic pregnancy

Answer

Endometrial cancer awaiting treatment

Answer

Unexplained vaginal bleeding

Answer

Severe thrombocytopenia with platelet count of 30 × 10⁹/L

Question 7

A 47-year-old woman presents with a 9-month history of hot flushes, night sweats, and mood changes. Her periods have become irregular, with the last one occurring 8 weeks ago. She requests HRT but is concerned about side effects. Her mother had a deep vein thrombosis at age 72 following hip replacement surgery. The patient's BMI is 27 kg/m² and blood pressure is 118/76 mmHg. What is the most appropriate initial HRT regimen?

Accepted Answer

Sequential combined transdermal HRT

Answer

Sequential combined oral HRT

Answer

Continuous combined oral HRT

Answer

Oestrogen-only transdermal HRT

Answer

Tibolone

Question 8

A 35-year-old woman attends for review 3 years after copper IUD insertion for long-term contraception. She has no complaints and examination reveals the threads are visible. Her last menstrual period was 2 weeks ago. She plans to start trying for pregnancy in 6 months. What is the most appropriate management?

Accepted Answer

Reassure and arrange review when she wishes to conceive

Answer

Replace the IUD with a new copper IUD

Answer

Remove the IUD now as she wishes to conceive soon

Answer

Arrange hysteroscopy to check IUD position

Answer

Advise changing to the levonorgestrel intrauterine system

Question 9

A 50-year-old woman presents with vasomotor symptoms and requests HRT. She has a history of stage 1 endometrial cancer treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy 18 months ago. Histology showed grade 1 endometrioid adenocarcinoma confined to the endometrium with no myometrial invasion. She has been discharged from oncology follow-up. What is the most appropriate management regarding HRT?

Accepted Answer

Prescribe oestrogen-only HRT as the risk of recurrence is very low

Answer

Prescribe continuous combined HRT as she has had a hysterectomy

Answer

Prescribe vaginal oestrogen only for symptom management

Answer

Prescribe tibolone as an alternative to conventional HRT

Answer

Advise that HRT is absolutely contraindicated due to her cancer history

Question 10

A 31-year-old woman with polycystic ovary syndrome presents requesting contraception. She has a BMI of 34 kg/m² and oligomenorrhoea. Her blood pressure is 132/84 mmHg on two separate occasions. She is a non-smoker with no personal or family history of venous thromboembolism. She prefers not to have a coil fitted. What is the most appropriate contraceptive option for this patient?

Accepted Answer

Etonogestrel contraceptive implant

Answer

Combined oral contraceptive pill

Answer

Progestogen-only pill

Answer

Depot medroxyprogesterone acetate injection

Answer

Progesterone-only emergency contraception until blood pressure controlled

Reproductive Health — MCQs

Reproductive Health — MCQs

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