• 1.
  

  a) F b) F c) T d) F e) F

A dose of 200mcg has similar efficacy compared with 400 or 600mcg. Surgical vacuum aspirations carried out at less than 7 weeks gestation are three times more likely to fail to remove the gestation sac than those carried out between 7 and 12 weeks. Side-effects are more frequent in women receiving misoprostol by the oral route compared with the vaginal route. Misoprostol is more effective if administered vaginally than orally. Products of conception removed in a confirmed viable intrauterine pregnancy need not necessarily be sent for histological examination.

• 2.
  

  a) F b) F c) F d) T e) F

The risk of uterine perforation is 1–4 in 1000, and is lower for early abortions and those carried out by experienced clinicians. There is no proven association with breast cancer nor with ectopic pregnancies. Post-abortion infections occur in up to 10% of cases, and the risk is higher in the presence of Chlamydia trachomatis , Neisseria gonorrhoea and bacterial vaginosis. There is no proven association with subsequent infertility.

• 3.
  

  a) T b) T c) F d) T e) T

Pre-abortion ascertainment of the woman’s ABO and Rhesus blood group should be carried out so that Anti-D can be instituted to Rhesus-negative women undergoing induced abortion.

All women undergoing an abortion should have a risk assessment for venous thrombo-embolism. Ultrasound scanning is not considered to be an essential prerequisite of abortion in all cases; however, there should be access to appropriate ultrasound facilities when surgical abortion is being considered at less than 7 weeks gestation, where gestation is in doubt and where extra-uterine pregnancy is suspected. Universal antibiotic prophylaxis at the time of abortion is associated with a reduction in the risk of subsequent infective morbidity by around 50%. An alternative strategy would be to screen for lower genital organisms with treatment of positive cases. All women should undergo a risk assessment for other sexually transmitted infections, and screened for them as appropriate. A system for partner notification and follow up or referral to a sexual health service should be in place as well.

• 4.
  

  a) T b) T c) F d) T e) T

Recommended regimens for universal antibiotics prophylaxis are as follows:

Azithromycin 1 g orally on the day of abortion, plus metronidazole 1 g rectally or 800 mg orally before or at the time of abortion, or:

Doxycycline 100 mg orally twice daily for 7 days starting on the day of abortion, plus metronidazole 1g rectally or 800 mg orally before or at the time of abortion.

• 5.
  

  a) F b) F c) F d) T e) T

Several large acceptability studies have been published, often extending across several countries, which address these issues relating to male contraception. Although the responses are theoretical in terms of which preparations may be most acceptable, they provide an estimate of potential use. Perhaps more importantly, they show a high level of acceptance of the concept of developing better, reversible male contraceptive methods among both men and women.

• 6.
  

  a) F b) T c) F d) T e) F

The degree of risk that is acceptable will ultimately be determined by the user, but severe oligospermia is associated with a low risk of contraceptive failure, better than condoms. As with vasectomy, already made sperm needs to be washed out and that takes some weeks, but recovery is complete.

• 7.
  

  a) F b) T c) T d) F e) F

The physiological role of progesterone receptors in men is unknown, but they are effective in mediation suppression of luteinising hormone and FSH, as are gonadotropin-releasing hormone antagonists. This allows a lower dose of testosterone, essentially for add-back hormone replacement therapy, with consequentially fewer side-effects compared with higher dose, testosterone-only regimens. The basis for non-suppression is unclear, but is increasingly thought to reflect a low rate of steroidogenesis by Leydig cells even in the absence of detectable luteinising hormone stimulation.

• 8.
  

  a) F b) T c) F d) T e) T

Non-hormonal approaches generally do not affect testosterone production. The epididymis has a range of specific biochemical pathways that have been targeted, as does the generation of sperm motility, but not all animal model effects translate into man. Meiosis is also a promising target theoretically, as it only occurs in spermatogenesis, although clearly any off-target effects on mitosis would be a major concern.

• 9.
  

  a) T b) F c) T d) F e) F

There is no absolute medical contraindication, apart from known pregnancy, for the use of any hormonal emergency contraception. Existing evidence suggested no adverse effect on the fetal or pregnancy outcome upon inadvertent exposure to levonorgestrel in early pregnancy. The copper intrauterine device has the best efficacy among all existing options of emergency contraception; low dose mifepristone (10 or 25 mg) has the best efficacy among the hormonal methods reported in the literature. There is good evidence suggesting that providing EC over-the-counter or in advance would not promote its abuse nor encourage risky sexual behaviours, but would facilitate its timely use when indicated.

• 10.
  

  a) F b) F c) T d) F e) T

IUDs can be inserted at anytime, as long as all reasonable steps are taken to exclude pregnancy. IUDs can be inserted with care after C-section. Option c is true as it is frameless. The increased infection risk after IUD insertion lasts only 21 days.

• 11.
  

  a) T b) T c) F d) F e) T

Both methods have around <1:100 failure rate. PV spotting is a common side-effect. It primarily works by thickening cervical mucous and thinning the endometrium. Approximately 20% of cycles are anovulatory. The amenorrhea rate with IUS is around 20% and if inserted in the 1st 5 days of the cycle, it is effective before any risk of pregnancy.

• 12.
  

  a) F b) T c) F d) F e) F

Post coital bleeding should be investigated for infection or gynaecological pathology considered. Pregnancy is one cause of missing threads, and if present, could be ectopic. The absolute rate of ectopics is reduced in IUC users. Only oestrogen containing and injectable contraception is contra-indicated in diabetes with complications. IUC is a reliable and usually very acceptable method in nulliparous women.

• 13.
  

  a) T b) T c) T d) F e) F

Cu IUDs will prevent pregnancy up to 5 days after ovulation. Follow-up checks that the woman is happy to continue the method, allows for an infection screen and checks that the woman is not pregnant. The woman can choose to keep the method long-term or have it removed when pregnancy has been excluded. The LNG-IUS cannot be used as a method of emergency contraception only the Cu IUD. LNG oral emergency contraception cannot be prescribed as it is more than 120 hours since unprotected sex.

• 14.
  

  a) F b) F c) T d) T e) F

IUC provides effective contraception following an ectopic but an IUS would be preferable to an IUD. When all signs of pelvic inflammation have settled, IUC can be used. Modern Cu IUDs are more effective as they have > 350 sq mm of Cu. A Cu-IUD inserted when the woman is over 40 years of age should indeed give her effective contraception until she is post-menopausal. The IUS has a 5 year licence for contraception and a 4 year licence for the progestogen component of HRT.

• 15.
  

  a) T b) F c) T d) T e) F

Because implants and injectables do not contain oestrogen, they cause more menstrual irregularity than combined hormonal methods. Most women do experience irregular bleeding patterns with injectable or implant use, i.e., such changes are typical, but unfortunately the specific bleeding pattern cannot be predicted for any individual woman. Most implant users report a reduction in frequency and volume of bleeding. An analysis of 11 clinical trials of etonogestrel implants found that 34% had infrequent bleeding and 22% had amenorrhea; however, 24% had frequent or prolonged bleeding. With injectable use, irregular bleeding and spotting decrease over time and amenorrhea increases. Menstrual irregularities are the main reason that women discontinue use of their method. Counselling, anticipatory guidance and thoughtful management of side effects are therefore all very important to ensure user satisfaction and continuation.

• 16.
  

  a) F b) F c) F d) F e) F

According to evidence-based medical eligibility criteria for contraceptive use promulgated by normative bodies at the international level (WHO) and national level (e.g., RCOG; US CDC; ACOG), nulligravid women, adolescents, postpartum women, and women who wish to limit further childbearing are all eligible to use injectables and implants. Guidance currently differs on suitability of progestin-only contraceptive use by breastfeeding women in the first several weeks postpartum. WHO revisited this issue in March 2014 and may issue revised guidance later in 2014.

• 17.
  

  a) T b) T c) F d) T e) F

Several studies have examined whether an association exists between specific methods of hormonal contraception and HIV acquisition in HIV-negative women. Similarly, among women living with HIV, studies have examined whether an association exists between specific methods of hormonal contraception and (1) female-to-male transmission, (2) HIV disease progression, or (3) drug–drug interactions with certain antiretroviral medications.

A recent systematic review clarified that the preponderance of higher-quality epidemiological data suggest no association between oral contraceptive pills and HIV acquisition, but that the body of higher quality epidemiological data on progestin-only injectable contraceptives is mixed and difficult to interpret. Some investigators have reported a 1.5–2.2 times increased risk of HIV acquisition with contraceptive injectables, whereas other investigators have reported no statistically significant association. Limited or no data were available for contraceptive implants (or patches, rings, and hormonal intrauterine devices). Another systematic review assessed whether various hormonal contraceptive methods are associated with accelerated HIV disease progression. Here, the preponderance of evidence suggests that women living with HIV can use oral or injectable contraception without concerns related to HIV disease progression. Data were not available on contraceptive implants and HIV disease progression. In addition, some antiretroviral medications (such as protease inhibitors, the non-nucleoside reverse transcriptase inhibitors efavirenz and nevirapine, and cobicistat-boosted elvitegravir) may reduce the effectiveness of contraceptive implants (and combined oral contraceptive pills); however, DMPA (as well as the hormonal IUD) is unlikely to lose contraceptive effectiveness when taken with any antiretroviral medication.

• 18.
  

  a) F b) F c) F d) T e) F

Most women ovulate in the month after medical abortion, so contraception should be started immediately. The COCP does not affect the duration of bleeding after medical abortion. Guidelines from WHO advise that hormonal contraception can be started as soon as the first pill (mifepristone) has been taken. Mifepristone does not interact with hormonal contraceptives.

• 19.
  

  a) F b) T c) F d) F e) F

A Cochrane review and randomised-controlled trial have shown similar low rates of complication (e.g. perforation, expulsion, infection) with insertion at the time of surgical abortion, compared with delayed insertion several weeks later. Uptake rates are higher and pregnancies lower when intrauterine device is inserted at surgical abortion, as an extra visit is a barrier to uptake. There is no increase in the amount of bleeding if inserted at the time of the procedure.

• 20.
  

  a) F b) F c) F d) T e) T

Insertion of an implant immediately postpartum (days 1–3) is associated with similar times to lactation, milk composition and bleeding pattern, as insertion 1–2 months after delivery. Continuation rates of 86% at 12 months have been reported in observational studies of young mothers (< 25 years of age). These studies also showed an association between early postpartum uptake and a reduction in rapid repeat pregnancy among young mothers.

• 21.
  

  a) F b) F c) T d) F e) F

Women who are living with HIV who are not clinically well should not initiate use of IUDs. However, if they have an IUD and become clinically unwell, the IUD need not be removed. Additionally, a woman who is unwell may have an IUD inserted when her clinical condition improves, for instance if she initiates ARVs. Combined oral contraceptives, DMPA, and the contraceptive patch may all be used by women living with HIV regardless of their clinical status, although attention to drug interactions may be required if she is also initiating ARVs or is already using ARVs

• 22.
  

  a) F b) T c) F d) F e) T

Because the copper IUD and condoms do not rely on any systemic effects, but rather act locally, no interactions would be expected with systemic ARVs. Although DMPA is less likely than the other hormonal contraceptives listed to interact with ARVs, some interactions may still occur. Combined oral contraceptives and the levonorgestrel progestin-only contraceptive implant have theoretical or known interactions with ARVs.

• 23.
  

  a) F b) T c) F d) F e) F

The only contraceptive method that also prevents onward transmission of HIV is condoms, male or female. Use of nonoxynol-9 is not recommended for women living with HIV due to theoretical concerns that it may increase risk of HIV transmission. Neither DMPA nor sterilization prevent onward transmission of HIV, and limited evidence suggests that DMPA may itself be a risk factor for increased HIV transmission from women to men.

• 24.
  

  a) T b) F c) T d) F e) T

In a review of the clinical trial data at WHO, it was found that after adjustment for confounding factors, PID risk was more than six times higher during the 20 days after insertion than during later times. This risk was low and constant for up to eight years of follow-up. Rates varied according to geographical area (highest in Africa and lowest in China) and were inversely associated with age.

• 25.
  

  a) F b) T c) T d) T e) F

The Yuzpe-method is the least effective emergency contraceptive available. A Copper IUD can indeed be inserted up to 5 days after the expected date of ovulation. ellaOne acts as a selective progesterone receptor modulator (SPRM). Levonorgestrel 1.5mg can be taken in one go or in two divided doses 12 hours apart. If taken prior to ovulation (day 14 in the cycle provided) it may delay ovulation.

• 26.
  

  a) F b) T c) F d) T e) T

A LARC is a method that requires administration less than once per cycle or month. LARC methods combine reversibility with high effectiveness as they do not depend a great deal on compliance or correct use.

• 27.
  

  a) T b) F c) F d) T e) F

Depo-Provera can reduce heavy menstrual bleeding, but less effectively than the intrauterine system (IUS). Across all ages, 60% of women are amenorrhoeic after 1 year with Depo-Provera, and 70% by 2 years. Progestogen only contraception does not suppress the menopausal rise in FSH level (combined hormonal contraception and hormone replacement therapy [HRT] do). FSH levels can be measured during use of Depo-Provera to assess whether a woman is peri-menopausal. Current international guidelines do not contraindicate use of any progestogen only method by a woman with a history of venous thromboembolism.

• 28.
  

  a) F b) F c) F d) T e) T

Combined oral contraception (COC) protects against loss of bone mineral density in peri-menopausal women who are hypoestrogenic, but it is not clear whether this translates into a lower fracture risk. It does not seem to affect bone mineral density in women who are not hypoestrogenic. Use of COC for over 5 years increases cervical cancer risk. Breast cancer incidence is probably increased in all combined hormonal contraceptive users, including BRCA carriers. This risk must be weighed against the benefit of significant reduction in ovarian cancers amongst COC users. Ovarian cancer risk reduction persists (but reduces) over 20–30 years after stopping the COC. Combined hormonal contraception (CHC) significantly reduces heavy menstrual bleeding (although less than with the IUS), and for many women, offers regular bleeding patterns.

• 29.
  

  a) F b) F c) F d) F e) T

In the absence of contraindications, CHC can be continued to the age of 50 years, but should then be stopped. Withdrawal bleeds continue with CHC in many menopausal women. Follicle-stimulating hormone levels are not a useful guide to menopausal status in CHC or HRT users. If inserted in women under the age of 40 years, the IUD is effective for the duration of its licence. Any copper intrauterine device inserted over the age of 40 years will be effective for contraception until the menopause because of the rapid decline in fertility. An IUS inserted under the age of 45 years is effective for contraception for 5 years: if inserted after age 45 years, it will give 7 years of contraception (or until age 55 years if amenorrhoeic). However, an IUS used for endometrial protection with oestrogen replacement must be changed after 5 years. Current advice supports use of the SDI over the age of 50. Progestogen only pill (both traditional and desogestrel) can be continued until age 55 years.

• 30.
  

  a) F b) T c) F d) F e) F

The combined transdermal contraceptive patch seems to confer a higher VTE risk than combined oral contraception. This contrasts with combined transdermal HRT where studies demonstrate a lower VTE risk with transdermal HRT than with oral HRT. Evidence suggests that stroke risk may be higher in users of the combined contraceptive patch and ring than in COC users. There is no evidence that preparations containing natural oestradiol esters have a different effect on breast cancer risk than other COCs. Their effect on arterial and venous disease is not yet established. Progestogen-only contraception has not been shown to increase the risk of arterial disease: combined contraception would, however be contraindicated by the presence of arterial risk factors. After breast cancer, it is at present recommended that women avoid all hormonal methods of contraception. The role of the IUS for endometrial protection during tamoxifen treatment is not yet known.