Contraception for MCCQE1 Preparation

Introduction to Contraception in Canadian Healthcare

Contraception is a crucial aspect of reproductive health and family planning in Canada. As a medical student preparing for the MCCQE1 exam, understanding the various contraceptive methods, their efficacy, and their relevance to the Canadian healthcare system is essential. This comprehensive guide will cover key concepts, Canadian guidelines, and provide practice questions to help you excel in your MCCQE1 preparation.

Types of Contraceptive Methods

Efficacy of Contraceptive Methods

Understanding the efficacy of different contraceptive methods is crucial for counseling patients and for MCCQE1 preparation. The following table compares the effectiveness of various methods:

Canadian Guidelines for Contraception

The Society of Obstetricians and Gynaecologists of Canada (SOGC) provides comprehensive guidelines for contraception. Here are key points to remember for your MCCQE1 preparation:

1. Informed Choice: Healthcare providers must ensure patients have access to accurate, unbiased information about all contraceptive options.

2. Accessibility: Emphasis on improving access to contraception, especially for underserved populations.

3. LARC Methods: Long-Acting Reversible Contraception (LARC) methods, such as IUDs and implants, are recommended as first-line options due to their high efficacy and low user-dependence.

4. Emergency Contraception: Guidelines emphasize the importance of easy access to emergency contraception, including over-the-counter availability of levonorgestrel emergency contraceptive pills.

5. Adolescent Contraception: Special considerations for adolescents, including confidentiality and age-appropriate counseling.

Combined Hormonal Contraceptives (CHCs)

Combined hormonal contraceptives include combined oral contraceptives (COCs), the contraceptive patch, and the vaginal ring. These methods contain both estrogen and progestin.

Key Points for MCCQE1

1. Mechanism of Action:

   • Primary: Suppression of ovulation
   • Secondary: Thickening of cervical mucus, thinning of endometrium

2. Benefits:

   • High efficacy when used correctly
   • Regulation of menstrual cycles
   • Reduction in menstrual blood loss and dysmenorrhea
   • Improvement in acne
   • Reduction in risk of ovarian and endometrial cancers

3. Risks and Side Effects:

   • Increased risk of venous thromboembolism (VTE)
   • Slight increase in breast cancer risk
   • Nausea, breast tenderness, headaches

4. Contraindications:

   • History of VTE
   • Smokers over 35 years old
   • Uncontrolled hypertension
   • Migraine with aura

Progestin-Only Methods

Progestin-only methods include progestin-only pills (POPs), injectable contraceptives (e.g., Depo-Provera), and hormonal IUDs.

Key Points for MCCQE1

1. Mechanism of Action:

   • Primary: Thickening of cervical mucus
   • Secondary: Suppression of ovulation (not consistent for all methods)

2. Benefits:

   • Safe for use in women with contraindications to estrogen
   • Can be used while breastfeeding
   • May reduce menstrual blood loss (especially with hormonal IUDs)

3. Risks and Side Effects:

   • Irregular bleeding patterns
   • Potential for weight gain (with injectable methods)
   • Delayed return to fertility (with injectable methods)

4. Special Considerations:

   • POPs require strict adherence to timing
   • Injectable methods may cause bone mineral density loss
   • Hormonal IUDs provide long-acting, highly effective contraception

Intrauterine Devices (IUDs)

IUDs are long-acting reversible contraceptives (LARCs) that are highly effective and increasingly recommended as first-line contraception in Canada.

Types of IUDs

1. Copper IUDs:

   • Non-hormonal
   • Effective for up to 10 years
   • May increase menstrual bleeding and cramping

2. Hormonal IUDs:

   • Release levonorgestrel
   • Effective for 3-7 years depending on the model
   • Often reduce menstrual bleeding and cramping

Key Points for MCCQE1

• Efficacy: >99% effective in both perfect and typical use
• Mechanism: Primarily prevents fertilization; may also prevent implantation
• Benefits: Long-acting, reversible, high satisfaction rates
• Insertion: Can be inserted at any time during the menstrual cycle if pregnancy is reasonably excluded
• Contraindications: Active pelvic inflammatory disease, unexplained vaginal bleeding, cervical cancer

Emergency Contraception

Emergency contraception (EC) is used to prevent pregnancy after unprotected intercourse or contraceptive failure.

Types of Emergency Contraception

1. Levonorgestrel EC (Plan B):

   • Available over-the-counter in Canada
   • Most effective when taken within 72 hours of unprotected intercourse
   • No medical contraindications

2. Ulipristal Acetate (Ella):

   • Prescription required in Canada
   • Can be taken up to 5 days after unprotected intercourse
   • More effective than levonorgestrel, especially after 72 hours

3. Copper IUD:

   • Most effective form of EC
   • Can be inserted up to 7 days after unprotected intercourse
   • Provides ongoing contraception

Key Points for MCCQE1

• EC does not terminate an existing pregnancy
• Efficacy decreases with time, so prompt use is crucial
• Regular contraception should be initiated or resumed immediately after EC use
• Counseling on ongoing contraception is essential when providing EC

Permanent Contraception

Permanent contraception methods include tubal ligation for women and vasectomy for men.

Tubal Ligation

• Procedure: Fallopian tubes are cut, tied, or blocked
• Efficacy: >99% effective
• Considerations:
  • Requires surgery under general anesthesia
  • Immediate effectiveness
  • Potential for regret, especially in younger women

Vasectomy

• Procedure: Vas deferens are cut and sealed
• Efficacy: >99% effective after confirmed azoospermia
• Considerations:
  • Can be performed under local anesthesia
  • Requires confirmation of azoospermia before relying on it for contraception
  • Lower risk of regret compared to tubal ligation

Contraception in Special Populations

Adolescents

• Emphasize dual protection (contraception + condoms) for STI prevention
• Long-acting reversible contraceptives (LARCs) are safe and highly effective
• Confidentiality is crucial, but encourage parental involvement when appropriate

Postpartum Women

• Can start progestin-only methods immediately postpartum
• IUD insertion can be performed immediately after delivery or at the postpartum visit
• Combined hormonal contraceptives typically started 3-6 weeks postpartum, depending on breastfeeding status and risk factors

Perimenopausal Women

• Contraception needed until 1 year after last menstrual period if >50 years old, or 2 years if <50 years old
• Consider non-hormonal methods or progestin-only options if there are contraindications to estrogen

Key Points to Remember for MCCQE1

1. Understand the efficacy, mechanisms, benefits, and risks of all contraceptive methods
2. Be familiar with Canadian guidelines and accessibility of contraception
3. Know the criteria for initiating various contraceptive methods
4. Understand emergency contraception options and their appropriate use
5. Be prepared to counsel patients on contraceptive choices, considering individual factors and preferences
6. Recognize the importance of LARC methods in Canadian contraceptive guidelines
7. Understand contraceptive considerations for special populations (adolescents, postpartum, perimenopausal)

Sample Question

A 28-year-old woman presents to your family practice clinic requesting contraception. She has no significant medical history but reports that her mother had a deep vein thrombosis at age 45. The patient is a non-smoker with a BMI of 22 kg/m². She is in a monogamous relationship and desires a highly effective method of contraception. Which of the following would be the most appropriate first-line contraceptive option for this patient?

• A. Combined oral contraceptive pill
• B. Progestin-only pill
• C. Copper intrauterine device
• D. Levonorgestrel intrauterine device
• E. Contraceptive patch

Explanation

The correct answer is:

• D. Levonorgestrel intrauterine device

Explanation: For this patient, a levonorgestrel intrauterine device (LNG-IUD) would be the most appropriate first-line contraceptive option. Here's why:

1. High Efficacy: The patient desires a highly effective method of contraception. LNG-IUDs are among the most effective reversible contraceptives, with a failure rate of less than 1%.

2. Safety: The patient has a family history of deep vein thrombosis (DVT). While this alone doesn't necessarily contraindicate estrogen-containing methods, it's prudent to consider non-estrogen options as first-line choices to minimize any potential increased risk of thrombosis.

3. Long-acting: As a long-acting reversible contraceptive (LARC), the LNG-IUD provides effective contraception for 3-7 years (depending on the specific device), which can be ideal for a woman in her reproductive years who isn't seeking pregnancy in the near future.

4. Canadian Guidelines: The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends LARC methods, including IUDs, as first-line contraceptive options due to their high efficacy and low user-dependence.

5. Additional Benefits: LNG-IUDs often reduce menstrual bleeding and cramping, which can be an added benefit for many women.

Let's review why the other options are less suitable:

A. Combined oral contraceptive pill: While effective, it contains estrogen, which may increase the risk of thrombosis, especially with a family history of DVT.

B. Progestin-only pill: While safe, it requires daily adherence and is less effective than LARCs in typical use.

C. Copper intrauterine device: While highly effective and non-hormonal, it may increase menstrual bleeding and cramping, making it less desirable as a first-line option when a hormonal IUD is available.

E. Contraceptive patch: Like combined oral contraceptives, it contains estrogen and may increase thrombosis risk.

Remember, for the MCCQE1 exam, it's crucial to consider the patient's medical history, desires, and the most current Canadian guidelines when selecting contraceptive options.

References

1. Black, A., Guilbert, E., Costescu, D., Dunn, S., Fisher, W., Kives, S., ... & Waddington, A. (2015). Canadian Contraception Consensus (Part 1 of 4). Journal of Obstetrics and Gynaecology Canada, 37(10), 936-942.

2. Society of Obstetricians and Gynaecologists of Canada. (2015). Canadian Contraception Consensus. Retrieved from https://www.sogc.org/guidelines (opens in a new tab)

3. World Health Organization. (2018). Family planning/Contraception. Retrieved from https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception (opens in a new tab)

4. Trussell, J. (2011). Contraceptive failure in the United States. Contraception, 83(5), 397-404.

5. Curtis, K. M., Tepper, N. K., Jatlaoui, T. C., Berry-Bibee, E., Horton, L. G., Zapata, L. B., ... & Whiteman, M. K. (2016). U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recommendations and Reports, 65(3), 1-103.