Long-acting reversible contraception — structured SAQ (15 marks)

(a) Contraceptive counselling framework — why LARC is first-line (4 marks)

One mark per point, with reasoning. ^[6][1][5]

• Apply the WHO MEC framework — categories 1 to 4 — to her characteristics: BMI 31 obesity (Category 1 for ENG implant, 52 mg LNG-IUS and Cu-IUD), age under 35 (she is below the smoker 15+ cigarettes/day, age 35+ CHC threshold), no migraine, regular periods and prior treated chlamydia. All three LARC methods are Category 1 to 2 for her; combined hormonal contraception is Category 1 with no other risk factors, but LARC outperforms CHC on typical-use failure rate.^[5][6]
• Lead with the most effective methods first — tiered counselling: ENG implant, 52 mg LNG-IUS, Cu-IUD as first-line; combined oral contraceptive, progestin-only pill, ring, patch as second-tier; barrier and fertility awareness as third-tier. The CHOICE Project demonstrated that when LARC is presented first and barriers removed, the majority of women choose LARC and unintended pregnancy rates fall.^[1]
• Address her lived concerns explicitly — bleeding profile: amenorrhoea common with the 52 mg LNG-IUS by 12 months; irregular spotting common with the ENG implant; menses heavier with the Cu-IUD. Insertion pain: anticipatory counselling, NSAIDs 30 to 60 minutes before insertion, paracervical block for nulliparous women.^[6][11]
• Document capacity, consent and confidentiality — competent adult (Gillick-style for adolescents in Australia; mature minor in some settings); consent in writing; document the counselling, the chosen method, and the alternative declined.^[6]

(b) The three LARC methods and their current approved durations for contraception (3 marks)

One mark per method, with duration named. ^[3][6]

• ENG implant (Nexplanon — 68 mg etonogestrel in a 4-cm rod) — up to 5 years for contraception per the January 2026 FDA label extension, building on a Pearl Index of 0.0 in years 4 and 5.^[6]
• 52 mg LNG-IUS (Mirena) — up to 8 years for contraception per the Mirena Extension Trial (Jensen 2022): 3-year Pearl Index 0.28 (95% CI 0.03 to 1.00) across years 6 to 8, cumulative failure 0.68%. HMB label remains 5 years in many jurisdictions.^[3]
• Copper IUD (Cu-IUD, typically 380 mm² copper) — typically 10 years in UK/Australian labelling; some jurisdictions allow longer durations. Also used as emergency contraception if inserted within 5 days of unprotected intercourse.^[6]

(c) 52 mg LNG-IUS insertion technique and consent essentials (4 marks)

One mark per technical step, with consent essentials summarised separately. ^[6]

• Bimanual examination to confirm uterine size, position and version; speculum visualisation of the cervix; tenaculum to the anterior lip of the cervix for traction and to straighten the utero-cervical angle.^[6]
• Sound the cavity (typical depth 6 to 9 cm); load the device under sterile no-touch technique; advance to the fundus; deploy the arms by retracting the slider once the tip is at the fundus; trim the strings to approximately 3 cm outside the external os.^[6]
• Procedural analgesia — NSAID (ibuprofen 800 mg or naproxen) 30 to 60 minutes before insertion; consider paracervical block with 1% lidocaine or topical anaesthetic cream in nulliparous women.^[6]
• Informed consent essentials — counsel on bleeding pattern (spotting is common in the first 3 to 6 months, with amenorrhoea by 12 months in many users); explain perforation risk (~1 to 2 per 1 000), expulsion risk (1 to 5 per 100), failed insertion rate (1 to 5 per 100); explain the lost-strings algorithm; sign written consent and document the alternative declined; arrange the 4 to 6-week string check and explain the user's role in thread self-check.^[6]

(d) Lost strings at 6 weeks — next steps (4 marks)

One mark per imaging/risk step, with the management plan. ^[6][16]

• Confirm the threads are not visible at speculum examination; gently sweep the endocervical canal with a cytobrush or thread retriever — strings occasionally retract into the cavity and become visible again.^[6]
• Order a transvaginal pelvic ultrasound to localise the device within the uterine cavity. If the device is in the correct cavity position, do not attempt to retrieve it; document the position; continue the method.^[6]
• If the device is not seen in the cavity on transvaginal ultrasound, perform a pelvic X-ray to confirm perforation and migration; CT abdomen and pelvis if X-ray is negative but perforation is still suspected.^[6]
• Bridging contraception and consent — advise that the device may not be providing contraception and use a barrier method or short-acting contraceptive in the interval; do not attempt office retrieval without imaging confirmation because forcible attempts risk uterine perforation and trauma. If the device is confirmed outside the cavity, refer for laparoscopic removal.^[6][16]