Long-acting reversible contraception — structured oral station (12 minutes)

Opening prompt — "How are you going to approach this consultation?"

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

• "I would start with the WHO Medical Eligibility Criteria framework — categories 1 to 4 — applied to her. She is 22, BMI 31, smoker five a day, no migraine, prior chlamydia. All three LARC methods are Category 1 or 2 for her; combined hormonal contraception is Category 3 in obesity beyond BMI 35, but at 31 she can still use it — though typical-use failure is higher."^[5]
• "I would lead with the three LARC methods and present them as the first-line options. The Contraceptive CHOICE Project showed that when LARC is presented first and barriers removed, the majority of women choose it, and adolescent pregnancy, birth and abortion rates fall by roughly four fifths compared to national averages."^[1]
• "I would then ask her three questions — what she has heard about each, what concerns her, what she would prefer if cost and access were not in the way. Then I would examine for contraindications to IUD insertion, take a pregnancy test on the day, and offer insertion on the day if she chooses the IUS or implant."^[6]

Examiner is listening for: the WHO MEC framework, the LARC-first tiered counselling, and the offer of same-day insertion. ^[6]

Probe 1 — "She chooses the 52 mg LNG-IUS. Walk me through your consent."

• "Drug, dose, route, duration. I would counsel on the active substance (levonorgestrel 52 mg), the device form (T-frame, intrauterine), the duration of action (up to 8 years for contraception per the 2022 Mirena Extension Trial, Pearl Index 0.28 in years 6 to 8), the success rate (typical-use failure under 1 per 100 at 1 year), side effects (irregular spotting for the first 3 to 6 months, then amenorrhoea in many users), risks (perforation about 1 to 2 per 1 000, expulsion 1 to 5 per 100), STI risk (no protection — offer chlamydia/gonorrhoea NAAT today, condoms for partners), the alternative if she changes her mind (removal is a quick office procedure, fertility returns within a month), and the alternative if insertion fails (Nexplanon that day)."^[3][6]

Probe 2 — "She comes back at six weeks. She cannot feel the strings and you cannot see them at the os. What now?"

• "I would not panic and I would not try to fish for the strings. The Curtis SPR 2024 algorithm: confirm at speculum, gently sweep the endocervical canal with a cytobrush, then transvaginal ultrasound to confirm the device is in the cavity. If ultrasound shows the device in the cavity, document it, do not attempt retrieval, continue the method with counselling. If the device is not seen in the cavity on ultrasound, proceed to abdominal X-ray and CT to look for perforation, and refer for laparoscopic removal."^[6]
• "While imaging is arranged, she is at potential risk of unintended pregnancy if the device is expelled, so I would advise abstinence or barrier methods in the interim. I would also document the finding and report it as an incident if it turns out to be a perforation."^[6]

Probe 3 — "Walk me through your insertion technique."

• "Bimanual to confirm uterine size, shape and version; speculum visualisation of the cervix; tenaculum on the anterior lip of the cervix for gentle traction to straighten the utero-cervical angle; sound the cavity (typical 6 to 9 cm); load the LNG-IUS under sterile no-touch technique; advance the loaded inserter through the cervical os to the fundus; deploy the T-arms by retracting the slider once the tip is at the fundus; trim the strings to about 3 cm outside the os; document the string length and the patient's instructions for self-check. Pre-procedure NSAID (ibuprofen 800 mg or naproxen 30 to 60 minutes before) for pain; consider paracervical block for nulliparous women."^[6]
• "The Dermish 2013 study showed community IUD insertion failure rates of around 1 to 5 per 100 in nulliparous women. My plan B is a Nexplanon that day if insertion fails — I would have already obtained consent and the device available so we do not lose the opportunity."^[16]

Probe 4 — "At four months she calls saying she is bleeding constantly. She is not pregnant. She wants the device out. What is your approach?"

• "First, do not remove the device yet. Pre-insertion counselling predicted this — the bleeding may settle in the next 1 to 3 months. The Curtis 2024 SPR evidence summary supports non-steroidal anti-inflammatory drugs (mefenamic acid 500 mg two or three times daily for 5 to 7 days, ibuprofen 800 mg twice daily for 5 to 7 days), antifibrinolytics (tranexamic acid 500 mg twice daily for 5 days), or a short 14 to 42 day course of combined oral contraceptive. Remove the device only if she remains distressed after a trial of medical management, and arrange a replacement plan at the same time (switch to ENG implant, or Cu-IUD if she wants non-hormonal)."^[6]
• "Document the counselling and the offer of medical management; respect her autonomy if she chooses removal even after you recommend an interim trial."^[6]

Probe 5 — "Compare the implant with the LNG-IUS in one sentence for the patient."

• "The implant is a small rod in the arm, lasts up to 5 years, often produces irregular spotting but is extremely private and easy to use, and fertility returns immediately; the 52 mg LNG-IUS lasts up to 8 years for contraception, often produces amenorrhoea, requires an internal examination for insertion but is fully reversible, and your periods may stop."^[6]

Probe 6 — "She is a smoker but only 5 per day. Does that change anything?"

• "CHC in smokers is restricted over 35 years of age regardless of cigarettes per day; under 35 she can technically use CHC. But obesity is the bigger structural issue here — at BMI 31 she is Category 1 for CHC, but at higher BMI the category moves towards 3. Either way, LARC is the better choice because of typical-use efficacy and not depending on daily adherence, and LARC is Category 1 across her smoking and BMI profile."^[6]