Contraception: Clinical

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Contraception: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 20-year-old female presents to the clinic with the complaints of irregular menstrual bleeding and breast tenderness. History reveals two months ago she was placed on medroxyprogesterone acetate injections for contraception. A urine pregnancy test at that time was negative. She is sexually active with one partner and does not use condoms during intercourse. The patient's symptoms are most likely due to which of the following?


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Contraception refers to various methods that can be used to prevent pregnancy, and they can be categorized by their efficacy.

Think of efficacy as the number of pregnancies that occur in 100 females using that method over the course of a year. Ideally that number to be as low as possible.

Tier 1 methods are the most effective, with less than 1 pregnancy in 100 females in a year. These include types of long active reversible contraception, or LARC, which includes intrauterine devices and contraceptive implants, and irreversible methods, like a vasectomy and bilateral tubal ligation. Of course, these can sometimes be reversed, but the reversal success rates vary.

Tier 2 methods are a little less effective, with 4 to 7 pregnancies in 100 females in a year. These include hormonal contraception, like contraceptive pills, patches, vaginal rings, and hormonal injections.

Finally, tier 3 methods are the least effective, with over 13 pregnancies in 100 females in a year. These include the male and female condoms, diaphragms and cervical caps, spermicides and sponges, and “natural” contraceptive methods like withdrawal of periodic abstinence during the fertile period.

Now, keep in mind that condoms are the only contraceptive method that also protect against sexually transmitted infections - so they should always be used when that’s a concern.

So, let’s start with tier 1 methods - specifically, LARC.

First, there’s intrauterine devices, which can be hormonal, meaning they contain a progestin called levonorgestrel, or non-hormonal, meaning they’re made out of copper.

Both hormonal and copper IUDs are good choices in adolescent and adult females who want a long term, highly effective contraceptive method, and in females who want to avoid estrogen exposure because they may have other risk factors for deep vein thrombosis and pulmonary embolism, like smoking and being over age 35.


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