Obstetrics and Gynaecology — Contraception and Family Planning, NMC MBBS licence examination syllabus (Nepal Medical Council).
Two ideas carry most of this subject: effectiveness depends on how little the user has to remember, and oestrogen is the part that carries the risk.
Contraception is asked about constantly — in obstetrics, in gynaecology, in general practice and in public health — and it is one of the few clinical topics where the counselling is the treatment. A method the woman abandons after two months has not worked, however effective it is on paper.
Methods are ranked not by how cleverly they work but by how much the user has to do.
Implants, intrauterine devices and sterilisation require nothing once in place, so there is almost no gap between perfect use and typical use. The pill, the patch and the injection must be remembered, so typical use falls well below perfect use. Condoms, withdrawal and fertility awareness demand an action at every act, and sit lowest.
The gap between perfect use and typical use is the whole point. Perfect use describes the method; typical use describes what happens to real people with jobs, children and imperfect memories — and typical use is the number that matters when advising a patient.Combined methods contain oestrogen, and oestrogen raises the risk of venous thromboembolism. So before prescribing one, ask about smoking over the age of 35, migraine with aura, previous thrombosis, high blood pressure, prolonged immobility, breast cancer and significant liver disease.
Migraine with aura is the one candidates miss. Migraine without aura is not the same, and the distinction changes the advice — so the question to ask is not "do you get headaches" but whether there are visual or other neurological symptoms beforehand.
Progestogen-only methods do not carry that clot risk. So a contraindication to oestrogen is not a contraindication to contraception — and the alternatives happen to be the more effective ones. "You cannot take the pill" should never end a consultation.Emergency contraception works mainly by delaying or preventing ovulation. It acts before fertilisation and does not end an established pregnancy — a point worth being able to state clearly, because it is widely misunderstood and the misunderstanding stops women from seeking it.
Because it works by delaying ovulation, its effectiveness falls the longer it is left. Sooner is better, and no woman should be sent away to come back tomorrow.
An intrauterine device is the most effective emergency option, and it can then remain in place as ongoing contraception — solving two problems in one visit.
Two risks pull in opposite directions here.
Fertility returns before the first period. A woman can conceive without any warning bleed, which is why "I haven't had a period yet" is not reassurance. Breastfeeding does delay the return of fertility, but it is not reliable on its own as a method.
But the risk of clotting is highest in the weeks immediately after delivery, which is precisely when oestrogen is least safe. The resolution is straightforward: progestogen-only methods are suitable early, and the conversation should happen before discharge rather than at a follow-up appointment the woman may not be able to attend.
Short intervals between births carry real risk for both mother and baby, so spacing is a clinical issue and not merely a preference.
Warn about bleeding changes before they happen. Irregular bleeding is the commonest reason methods are stopped, and a woman who was told to expect it usually continues, while a woman who was not usually does not. Ninety seconds of warning outperforms any amount of later reassurance.
Ask about her circumstances — her plans for future children, how far she must travel, what she can afford, and whether the method needs to be discreet. These change the answer more than the pharmacology does.
And the choice is hers. Consent is individual, confidentiality applies, and pressure toward a particular method — including from family — is something to notice and to counter rather than to work with.
A woman of 38 who smokes, requesting the combined pill. Smoking over 35 is a significant risk factor with oestrogen. Explain why, and offer progestogen-only or long-acting methods — which are more effective in any case.
A woman with migraine preceded by visual disturbance. That is migraine with aura, and combined methods are avoided. Progestogen-only and intrauterine options remain open.
Six weeks after delivery, breastfeeding, no period yet, wants to avoid another pregnancy soon. Fertility can return before menstruation, and breastfeeding is not reliable alone. A progestogen-only method is appropriate; oestrogen is avoided this early.
Requesting emergency contraception after one episode of unprotected sex. Provide it now rather than later, offer the intrauterine device as the most effective option, consider infection risk and testing, and arrange ongoing contraception.
Perfect use and typical use. The first describes the method, the second describes reality — and only the second predicts what happens to your patient.
Migraine with and without aura. Only the first contraindicates oestrogen, so the presence of aura must be asked about specifically.
Combined and progestogen-only. The clot risk belongs to the oestrogen, so ruling out one does not rule out the other.
Emergency contraception and termination. It prevents ovulation and acts before fertilisation; it does not end an established pregnancy.
Breastfeeding and contraception. Breastfeeding delays fertility but does not reliably prevent pregnancy on its own.
Effectiveness tracks how little the user must remember — implants and intrauterine devices highest, condoms and withdrawal lowest.
Condoms are the only method that also prevents infection, so they are often used alongside another.
Oestrogen carries the clot risk — ask about smoking over 35, migraine with aura, previous thrombosis, hypertension, immobility.
A contraindication to oestrogen is not a contraindication to contraception.
Emergency contraception delays ovulation, works better the sooner it is given, and the intrauterine device is the most effective option.
Fertility returns before the first period after childbirth, but oestrogen is avoided in the early weeks.
Warn about bleeding changes in advance — it is the commonest reason methods are abandoned.
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