Emergency contraception — structured oral station (12 minutes)

Opening prompt — "Take me through your consultation."

Model response — say it in this order: ^[6]

• "I would start with a focused contraceptive history: the time of unprotected intercourse (now 14 hours ago, well within 5 days for any EC), the cycle day (day 12 of 28 days, her fertile window), prior contraception, medical history (BMI 26, no migraine, non-smoker, no drug interactions), what she has tried, what she wants today, and her reproductive intentions."^[6]
• "I would offer the copper IUD as the most effective option, citing the Turok 2013 prospective cohort of 1 771 women with no pregnancies at one month, and the Cleland 2012 systematic review of 7 034 women with a 0.09% pregnancy rate. The Cu-IUD has the added benefit of becoming her ongoing contraception (10 years)."^[8]
• "If she declines the Cu-IUD, ulipristal acetate 30 mg orally within 120 hours, citing the Brache 2013 pooled analysis showing UPA delays follicular rupture by 5 days or more in 58.8% of cycles versus 14.6% for levonorgestrel; levonorgestrel 1.5 mg orally is the third option, with efficacy dropping on days 4 to 5 per the Cochrane 2019 review."^[1][2]

Probe 1 — "She does not want an IUD. Walk me through your UPA vs LNG choice."

• "UPA is the most effective oral EC across the full 5-day window because it acts further into the follicular phase than LNG — Brache's pooled pharmacodynamic data showed follicular rupture delayed by 5 days or more in 58.8% of UPA-treated cycles versus 14.6% of LNG-treated cycles, and UPA was effective even at the time of the LH surge (79% vs LNG 14%)."^[2]
• "LNG 1.5 mg is reasonable at 14 hours post-UPI but pregnancy rates rise on days 4 to 5. UPA is preferable when she presents later in the window or has a higher BMI; LNG is faster acting early on and remains the standard for rapid presentations."^[1][2]
• "Either way, I would also offer a same-day or 5-day-delayed bridge to a LARC method, including Nexplanon insertion the same day if LNG or Yuzpe is used (no waiting period) or after 5 days if UPA is used."^[6]

Probe 2 — "She asks about combined oral contraception today. What do you counsel?"

• "Combined oral contraception is Category 1 for her — no migraine, non-smoker, BMI 26, regular periods. Typical-use failure rate is roughly 7 per 100 in year 1, but she is missing the pill 3 to 4 times a month — this is exactly the cue to talk about LARC, where typical-use failure is under 1 per 100."^[6]
• "If she chooses the ENG implant today after LNG or Yuzpe, no waiting period. If she chooses the implant today after UPA, wait at least 5 days because UPA's antiprogestin effect may reduce implant efficacy. Backup barrier for 7 days from method start."^[6]

Probe 3 — "She vomits an hour after taking UPA. What now?"

• "Vomiting within 3 hours of the dose means absorption may be incomplete. I would offer an antiemetic (e.g. ondansetron) and repeat the full dose. If oral medication is not tolerated, the Cu-IUD is the definitive alternative that bypasses oral absorption."^[6]

Probe 4 — "How do you explain the WHO MEC categories to her?"

• "WHO MEC is a four-tier framework: Category 1 means no restriction for the method in her circumstance; Category 2 means advantages outweigh risks; Category 3 means risks usually outweigh advantages, so the method should not be used unless no alternative exists; Category 4 means the method carries unacceptable health risk and must not be used."^[5]
• "For this patient all three LARC methods are Category 1; CHC is Category 1; POP is Category 1; the Cu-IUD is Category 1 as ongoing contraception."^[5]

Probe 5 — "She wants to know why Cu-IUD EC is more effective than UPA."

• "The Cu-IUD works continuously and locally — copper ions make the uterine cavity spermicidal for 5 days post-coitally and beyond. UPA delays ovulation pharmacologically; its efficacy requires that ovulation has not yet occurred when the dose is taken. Cu-IUD efficacy is essentially independent of cycle timing once inserted."^[2][8]

Probe 6 — "She is on carbamazepine for epilepsy and now wants regular contraception. What is your advice?"

• "Enzyme-inducing drugs reduce oestrogen and progestogen levels and reduce the efficacy of CHC, POP, implant and possibly LNG-IUS. The Cu-IUD is unaffected by enzyme-inducing drugs and is the recommended LARC option for women on chronic enzyme-inducer therapy. The LNG-IUS is generally MEC Category 1 to 2 but with theoretical concern about reduced LNG levels. The ENG implant is generally not preferred."^[6]