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Summary Table

Domain	Key Points
Target Population	Women of reproductive age (15-49 years), couples (Pasangan Usia Subur / PUS). Special populations: postpartum, breastfeeding, post-abortion, adolescents, women with chronic disease
Core Exam Concepts	WHO Medical Eligibility Criteria (MEC) Categories 1-4; mechanism of action per method; effectiveness ranking; timing of initiation; contraindications by method; side effects vs. complications; return to fertility; method-appropriate counseling
Classification	By duration: Long-Acting Reversible Contraception (LARC) vs. Non-LARC. By content: Hormonal vs. Non-Hormonal. By type: Modern vs. Traditional
Most Effective Methods	Implant > Vasectomy > Tubectomy > IUD-LNG > IUD-Cu (all <1 pregnancy per 100 women/year with typical use)
Least Effective Methods	Withdrawal (coitus interruptus), fertility awareness-based methods, female condom
Keywords	"MEC Category," "LARC," "DMPA," "Copper T," "LNG-IUS," "progestin-only," "combined hormonal," "emergency contraception," "lactational amenorrhea," "postpartum contraception," "back-up method for 7 days"

1. Foundational Concepts and Mechanisms

WHO Medical Eligibility Criteria (MEC)

MEC Category	Meaning	Clinical Implication
1	No restriction for use	Use freely
2	Advantages generally outweigh theoretical or proven risks	Generally use; may need closer follow-up
3	Theoretical or proven risks usually outweigh advantages	Not usually recommended unless no other suitable method
4	Unacceptable health risk	Absolutely contraindicated

The exam tests your ability to match a clinical scenario (patient condition) to a MEC category for a given method. For example, a 37-year-old heavy smoker wanting combined oral contraceptives is MEC Category 4 (absolute contraindication due to thromboembolic risk), whereas the same patient requesting progestin-only pills is MEC Category 1 (smoking is not a contraindication for progestin-only methods).

Mechanisms of Action

Understanding how each contraceptive works is critical because the exam links mechanism to both expected side effects and contraindications.

Combined hormonal methods (combined oral contraceptives / COCs, combined injectable contraceptives / CIC) contain both estrogen and progestin. The estrogen component is responsible for the key contraindications: venous thromboembolism (VTE), stroke, and cardiovascular risk. These methods suppress ovulation as their primary mechanism, and secondarily thicken cervical mucus and thin the endometrium.

Progestin-only methods (progestin-only pills / POPs, DMPA injectable, implant, LNG-IUS) lack estrogen and therefore avoid the estrogen-related thromboembolic risks. Their primary mechanisms vary by method:

Implant and DMPA: reliably suppress ovulation as the dominant mechanism, plus thicken cervical mucus
Progestin-only pills (POPs): ovulation suppression is inconsistent; the dominant mechanism is cervical mucus thickening. This is why POPs must be taken at the same time every day with a very narrow missed-pill window
LNG-IUS: local progestin release causes endometrial atrophy and cervical mucus thickening; ovulation suppression is variable

Copper IUD: entirely non-hormonal. The copper ions create a sterile inflammatory reaction in the uterine cavity that is toxic to sperm and ova. This is why copper IUD can serve as emergency contraception (up to 5 days post-unprotected intercourse), and it is the single most effective emergency contraceptive method.

2. Classification and Effectiveness

Classification of Contraceptive Methods

Method	Hormonal?	LARC / Non-LARC
Copper IUD (AKDR-Cu)	Non-Hormonal	LARC
LNG-IUS (AKDR-LNG)	Hormonal	LARC
Implant	Hormonal	LARC
Combined Injectable (CIC/KSK)	Hormonal	Non-LARC
Progestin-only Injectable (DMPA/KSP)	Hormonal	Non-LARC
Combined Oral Contraceptive (COC/KPK)	Hormonal	Non-LARC
Progestin-only Pill (POP/KPP)	Hormonal	Non-LARC
Male Condom	Non-Hormonal	Non-LARC
Female Condom	Non-Hormonal	Non-LARC
Tubectomy (MOW)	Non-Hormonal	Permanent
Vasectomy (MOP)	Non-Hormonal	Permanent
Lactational Amenorrhea (LAM/MAL)	Non-Hormonal	Non-LARC
Fertility Awareness-Based	Non-Hormonal	Non-LARC
Withdrawal (Coitus Interruptus)	Non-Hormonal	Non-LARC

Effectiveness Ranking

The exam frequently asks you to rank methods or identify the most/least effective option.

Tier	Method	Typical Use Failure Rate
Very Effective (<1%)	Implant	0.1%
	Vasectomy	0.15%
	Tubectomy	0.5%
	LNG-IUS	0.7%
	Copper IUD	0.8%
Effective (1-9%)	LAM (6 months only)	2%
	Combined Injectable	3%
	DMPA Injectable	4%
	COC / POP	7%
Moderately Effective (10-19%)	Male Condom	13%
	Standard Days Method	12%
	Two-Day Method	14%
Less Effective (20%+)	Ovulation Method	23%
	Withdrawal	20%
	Female Condom	21%
	No Method	85%

High-yield point: There is a stark difference between perfect use and typical use failure rates for user-dependent methods (pills, condoms, injectables). For LARC methods (IUD, implant), perfect and typical use rates are nearly identical because they do not depend on user compliance. This is why LARC methods are promoted as the preferred choice, especially for populations with adherence challenges.

3. Method-by-Method Clinical Details

Copper IUD (AKDR Copper T 380A)

Feature	Detail
Mechanism	Sterile inflammatory reaction; copper ions toxic to sperm
Duration	Up to 10 years (studies show effectiveness up to 12 years)
Effectiveness	0.6-0.8 per 100 women/year
Return to Fertility	Immediate upon removal
Unique Role	Most effective form of emergency contraception (within 5 days post-unprotected intercourse or up to 5 days post-ovulation)
Insertion Timing	Within 12 days of menses onset: no backup needed. After 12 days: can insert if pregnancy excluded, no backup needed. Within 48 hours postpartum (including cesarean). After 48 hours: delay until at least 4 weeks postpartum
Key Contraindications	48 hours to 4 weeks postpartum; active pelvic infection; very high individual STI risk at time of insertion; severe clinical HIV/AIDS; uterine anomaly distorting cavity; unexplained vaginal bleeding (before evaluation)
Side Effects	Heavier and longer menstrual periods; increased dysmenorrhea; spotting between periods

When a vignette describes a woman wanting long-term, non-hormonal contraception or a breastfeeding mother needing immediate postpartum contraception, the Copper IUD is the answer. When a vignette describes a woman presenting within 5 days of unprotected intercourse and asking for the most effective emergency contraception, the answer is also the Copper IUD (not levonorgestrel pills).

Levonorgestrel Intrauterine System (LNG-IUS / AKDR-LNG)

Feature	Detail
Mechanism	Local release of levonorgestrel causing endometrial atrophy, cervical mucus thickening, and variable ovulation suppression
Duration	Up to 5 years (studies show effectiveness up to 7 years)
Effectiveness	0.5-0.7 per 100 women/year
Return to Fertility	Immediate upon removal
Added Benefits	Reduces menstrual bleeding and dysmenorrhea; therapeutic alternative for dysfunctional uterine bleeding and adenomyosis; prevents iron-deficiency anemia
Insertion Timing	Within 7 days of menses onset: no backup needed. After 7 days: backup method for 7 days. Within 48 hours postpartum. After 48 hours: delay until 4 weeks
Key Contraindications	Same as Copper IUD plus: acute DVT/PE, breast cancer (>5 years ago, not recurred), severe liver cirrhosis/tumor, SLE with positive antiphospholipid antibodies

The LNG-IUS is the answer when a woman has menorrhagia or dysmenorrhea and also needs contraception. It serves dual purpose. However, note the critical difference from Copper IUD: the LNG-IUS is NOT used as emergency contraception. Additionally, after emergency contraceptive pills with ulipristal acetate (UPA), the LNG-IUS should NOT be inserted for at least 6 days due to drug interaction.

Subdermal Implant

Feature	Detail
Types	Two-rod (Levonorgestrel 75 mg/rod, effective 4-5 years) and Single-rod / Implanon (Etonogestrel 68 mg, effective 3-5 years)
Mechanism	Ovulation suppression + cervical mucus thickening
Effectiveness	0.1% typical use failure rate (the most effective reversible method)
Return to Fertility	Immediate upon removal
Insertion Timing	Within 7 days of menses: no backup. After 7 days: backup for 7 days. Breastfeeding <6 months without menses: anytime, no backup needed
Key Contraindications	Acute DVT/PE, unexplained vaginal bleeding (before evaluation), breast cancer (>5 years, not recurred), severe liver cirrhosis/tumor, SLE with positive antiphospholipid antibodies
Unique advantage	Safe in smokers of any age (unlike combined methods). No cardiovascular risk increase from estrogen since it is progestin-only

The implant is the best choice when the vignette describes a woman who wants the most effective reversible method and has difficulty with daily adherence. It is also the correct answer for a smoker over 35 who cannot use combined hormonal methods.

DMPA Injectable (Progestin-Only, KSP)

Feature	Detail
Type	DMPA 150 mg IM every 3 months (or Depo-subQ provera 104 SC); NET-EN IM every 2 months
Mechanism	Ovulation suppression + cervical mucus thickening + endometrial atrophy
Effectiveness	4% typical use (0.2% perfect use)
Return to Fertility	Delayed, average 4 months after last injection (can be up to 10 months)
Breastfeeding	Can start at 6 weeks postpartum
Key Contraindications	Systolic BP >=160 or diastolic >=100 mmHg; acute DVT/PE; ischemic heart disease or stroke history; multiple cardiovascular risk factors; breast cancer; diabetes >20 years with vascular damage; severe liver disease; SLE with positive antiphospholipid antibodies or severe thrombocytopenia
Side Effects	Amenorrhea (most common long-term); irregular bleeding initially; weight gain; decrease in bone mineral density with long-term use (partially reversible after discontinuation)
Therapeutic Benefits	Helps prevent endometrial cancer, uterine fibroids, symptomatic PID; reduces endometriosis symptoms and sickle cell crises

DMPA is testable for two reasons. First, the delayed return to fertility is a classic trap: if a vignette describes a woman wanting to conceive in the next 6 months, DMPA is a poor choice. Second, the bone mineral density concern makes the exam ask about long-term use in adolescents or perimenopausal women. Note that DMPA is safe in smokers and in women with hypertension (up to a threshold), unlike combined methods.

Combined Injectable Contraceptive (CIC / KSK)

Feature	Detail
Composition	Medroxyprogesterone Acetate + Estradiol Cypionate in various dose combinations
Schedule	Monthly, bimonthly, or quarterly depending on formulation
Key Contraindications	Nearly identical to COC: age >=35 and smoking >15 cig/day; BP >=140/90; breastfeeding <6 months; migraine with or without aura (age-dependent); DVT/PE; multiple cardiovascular risk factors; lamotrigine use
Breastfeeding	Delay until 6 months postpartum or until breastmilk is no longer the primary nutrition source
Timing	Within 7 days of menses onset: no backup. After 7 days: backup for 7 days. Non-breastfeeding: can start day 21-28 postpartum (delay to 6 weeks if additional DVT risk)

Because CIC contains estrogen, it shares the same contraindication profile as COC. The exam tests whether you recognize that the estrogen component is the driver of cardiovascular and thromboembolic risk. If a patient has any estrogen-related contraindication, neither COC nor CIC is appropriate.

Combined Oral Contraceptives (COC / KPK)

Feature	Detail
Types	Monophasic, Biphasic, Triphasic, Quadriphasic (government-supplied: Monophasic 30 mcg EE / 150 mcg LNG, 21+7)
Mechanism	Ovulation suppression + cervical mucus thickening + tubal motility alteration
Effectiveness	7% typical use (0.3% perfect use)
Return to Fertility	Immediate after discontinuation
Timing	Within 5 days of menses: no backup needed. After 5 days: backup for 7 days
Key Contraindications	The classic exam list: Age >=35 + any smoking; BP >=140/90; history or current DVT/PE; ischemic heart disease/stroke; migraine with aura (any age); migraine without aura (age >=35); breast cancer; breastfeeding <6 months; <3 weeks postpartum without breastfeeding (DVT risk); diabetes >20 years with vascular damage; severe liver disease; jaundice on prior COC use; lamotrigine therapy
Drug Interactions	Rifampicin, phenytoin, carbamazepine, oxcarbazepine, barbiturates, primidone, topiramate reduce COC effectiveness. COC reduces lamotrigine effectiveness
Non-Contraceptive Benefits	Reduces: dysmenorrhea, menorrhagia, ovulation pain, acne. Prevents: endometrial cancer, ovarian cancer, ovarian cysts, PID, iron-deficiency anemia

COC is the most commonly tested hormonal contraceptive. The exam tests three things primarily: (1) absolute contraindications (especially migraine with aura, age >=35 + smoking, and hypertension), (2) drug interactions (especially rifampicin and anti-epileptic drugs), and (3) the distinction between estrogen-containing vs. progestin-only methods in patients with cardiovascular risk factors.

Progestin-Only Pills (POP / KPP)

Feature	Detail
Type	Lynestrenol 0.5 mg (government-supplied, 28-pill pack); also Norgestrel 75 mcg or Levonorgestrel 300 mcg / Norethindrone 350 mcg
Mechanism	Cervical mucus thickening (primary); variable ovulation suppression; endometrial atrophy
Effectiveness	7% typical use (same as COC)
Return to Fertility	Rapid
Timing	Within 5 days of menses: no backup. After 5 days: backup for 2 days (not 7 days like other hormonal methods)
Key Advantage	Safe during breastfeeding (can start immediately at 6 weeks postpartum). Safe in smokers of any age. Safe with hypertension and migraine
Key Contraindications	Acute DVT/PE; breast cancer >5 years ago; severe liver disease; SLE with positive antiphospholipid antibodies; concurrent CYP3A4 inducers (rifampicin, carbamazepine, phenytoin, barbiturates, etc.)
Critical Rule	Must be taken at the same time every day. Missing even one pill raises failure risk more than with COC

The backup period for POP is 2 days (compared to 7 days for most other hormonal methods). This is a common exam trick. POP is the answer when a breastfeeding mother needs an oral contraceptive, or when a woman has estrogen contraindications but prefers pills.

Male and Female Condoms

Feature	Male Condom	Female Condom
Material	Latex, polyurethane, polyisoprene, lambskin, nitrile	Latex, polyurethane, nitrile
Effectiveness	13% typical use	21% typical use
Unique Benefit	Dual protection: prevents pregnancy AND STIs including HIV	Same dual protection; woman-initiated
Contraindications	Severe latex allergy only	Severe latex allergy (for latex types)

Condoms are the only method that prevents STIs. When a vignette involves STI risk, condoms should always be recommended alongside any other contraceptive method. This is the concept of dual method use.

Tubectomy (Female Sterilization / MOW)

Feature	Detail
Technique	Minilaparotomy (suprapubic for interval; subumbilical for postpartum) or Laparoscopy
Mechanism	Tubal occlusion (cut and tie, or ring application) preventing sperm-ovum meeting
Effectiveness	0.5% failure rate
Timing	Within 48 hours postpartum; or any time >=6 weeks postpartum; within 48 hours post-abortion (no complications); or interval (any time if not pregnant)
Criteria	Parity >2; understanding of permanent nature; voluntary written informed consent
Contraindications	Unexplained vaginal bleeding; acute systemic or pelvic infection; uncertain about future fertility; no written consent
Reversal	Reanastomosis surgery is possible but not reliably successful

Vasectomy (Male Sterilization / MOP)

Feature	Detail
Technique	No-scalpel vasectomy (preferred): cutting and ligating the vas deferens
Mechanism	Prevents sperm from mixing with semen
Effectiveness	0.15% failure rate
Key Point	Not immediately effective. Requires backup contraception for 3 months (approximately 20 ejaculations). Semen analysis should confirm azoospermia after 3 months
Performed by	Trained GP, general surgeon, or urologist

The 3-month waiting period for vasectomy effectiveness is a classic exam point. A vignette may describe unprotected intercourse 2 weeks post-vasectomy resulting in pregnancy, and the explanation is that residual sperm remain in the distal vas deferens.

Lactational Amenorrhea Method (LAM / MAL)

LAM is effective only when ALL THREE criteria are simultaneously met:

Amenorrhea: menses have not returned
Exclusive or near-exclusive breastfeeding: no supplemental feeding; breastfeeding >8 times/day, day and night
Baby is less than 6 months old

If any one criterion is no longer met, the method is no longer reliable and the woman must switch to another method.

Feature	Detail
Mechanism	Frequent suckling suppresses GnRH pulsatility, preventing ovulation
Effectiveness	2% failure rate (when all 3 criteria met)
Duration	Maximum 6 months
Contraindications	HIV-positive women (consider alternative); medications that pass into breast milk (ergotamine, anti-metabolites, cyclosporine, high-dose corticosteroids, lithium, radioactive drugs, certain anticoagulants); infant unable to breastfeed effectively

LAM questions always test whether you remember all three criteria. A common distractor is a woman who is breastfeeding and amenorrheic but whose baby is 7 months old. Since the age criterion is no longer met, LAM is unreliable.

Fertility Awareness-Based Methods

Sub-Method	Basis	Key Requirement
Standard Days Method	Calendar-based; abstain days 8-19	Regular cycles 26-32 days
Rhythm / Calendar Method	Calculate fertile window from cycle history	Requires at least 4 recorded cycles
Two-Day Method	Cervical secretion observation	Check secretions daily
Ovulation (Billings) Method	Cervical mucus quality	Identify peak mucus day
Basal Body Temperature	Temperature rise post-ovulation	Daily temperature measurement before rising
Symptothermal	Combines mucus + temperature + calendar	Most accurate of the group

These methods require no drugs or devices but demand consistent compliance and training. They are not recommended during breastfeeding (delay until regular cycles return) or when cycle-altering medications are used (certain antidepressants, thyroid medications, long-term NSAIDs, antibiotics).

Emergency Contraception

Method	Regimen	Time Window	Notes
Levonorgestrel (LNG) pill	1.5 mg as single dose (or 0.75 mg x 2)	Within 5 days (120 hours), more effective the earlier taken	May be less effective in women with BMI >=30
Ulipristal Acetate (UPA)	30 mg single dose	Within 5 days	Progesterone receptor modulator. Interacts with hormonal contraception: do not start hormonal method for 6 days after UPA
Yuzpe Regimen (combined pills)	EE 100 mcg + LNG 0.5 mg, repeated in 12 hours	Within 5 days	Higher nausea rate; less effective than LNG or UPA
Copper IUD	Insertion	Within 5 days post-intercourse (or up to 5 days post-estimated ovulation)	Most effective emergency contraceptive method; can then remain as long-term contraception

The exam loves to test the UPA-hormonal contraception interaction. After taking UPA, a woman must wait at least 6 days before starting (or restarting) any hormonal contraceptive (pills, implant, injectable). If she starts hormonal contraception earlier, both UPA and the hormonal method may be less effective. The LNG-IUS specifically should NOT be placed within 6 days of UPA.

4. Postpartum Contraception: Timing Summary

This table synthesizes one of the most tested areas. The exam presents a postpartum woman and asks which methods are appropriate based on breastfeeding status and time since delivery.

Time Postpartum	Breastfeeding Status	Appropriate Methods	Methods to Avoid
0-48 hours	Any	Copper IUD, LNG-IUS, Tubectomy	COC, CIC
48 hours - 4 weeks	Any	Implant (if not BF: can start anytime), POP (non-BF <4 wks: anytime)	IUD insertion (delay until 4 weeks), COC, CIC
4-6 weeks	Breastfeeding	Implant, POP, Copper IUD, LNG-IUS	COC, CIC, DMPA (delay DMPA to 6 weeks)
4-6 weeks	Not Breastfeeding	All progestin-only methods, Copper IUD, LNG-IUS, COC/CIC starting day 21-28 (if no additional DVT risk)	COC/CIC if additional DVT risk factors (delay to 6 weeks)
6 weeks - 6 months	Exclusively Breastfeeding	All progestin-only, IUDs, LAM, Implant	COC, CIC (delay until 6 months or until breastmilk is no longer primary nutrition)
>6 months	Any	All methods available	None (standard MEC criteria apply)

Combined hormonal contraception (COC, CIC) is delayed the longest in breastfeeding women because estrogen reduces milk production. Progestin-only methods do not affect breastmilk quality or volume.

5. Side Effects Management

Side Effect	Applicable Methods	Management
Irregular bleeding	Implant, LNG-IUS, DMPA, POP	Reassurance (usually self-limiting within 3-6 months). Short-term: mefenamic acid 500 mg BID for 5 days, or valdecoxib 40 mg daily for 5 days
Amenorrhea	DMPA (most common), LNG-IUS, Implant	Reassurance. Rule out pregnancy if concerned. This is a normal and expected effect, not a complication
Heavy/prolonged menses	Copper IUD	Mefenamic acid 500 mg TID for 5 days, or EE 50 mcg daily for 21 days. Iron supplementation. If refractory: consider switching method
Weight change	DMPA, Implant, POP	Dietary counseling
Headache (non-migraine)	Any hormonal method	Aspirin 500 mg, ibuprofen 400 mg, or paracetamol 500-1000 mg
Decreased bone density	DMPA (long-term use)	Partially reversible after discontinuation. Consider alternative methods for adolescents and perimenopausal women when possible

Key distinction: Side effects (expected, manageable) vs. Complications (require method discontinuation or urgent intervention). The development of new-onset migraine with aura in a COC user is a complication requiring immediate discontinuation, not a side effect to manage.

6. Exam Scenarios

This section focuses on exam scenarios where methods can be confused or where the wrong answer looks appealing.

Scenario	Tempting Wrong Answer	Why It's Wrong	Correct Answer
37-year-old woman, smokes 20 cig/day, wants oral contraceptive	COC (combined pill)	Age >=35 + smoking = MEC Category 4 for combined hormonal. Estrogen increases thromboembolic risk	POP (progestin-only pill) or Implant
Breastfeeding mother, 3 months postpartum, wants contraception	COC	Estrogen reduces milk supply; COC is avoided until 6 months in exclusively breastfeeding women	POP, Implant, DMPA (if >=6 weeks postpartum), Copper IUD, or LNG-IUS
Woman wants most effective emergency contraception	Levonorgestrel 1.5 mg pill	LNG pill is effective but NOT the most effective	Copper IUD (most effective emergency contraceptive)
Woman took UPA emergency pill yesterday, wants to start COC	Start COC today	UPA and hormonal contraception interact; starting too early reduces effectiveness of both	Wait 6 days before starting COC; use backup method in the interim
2 weeks post-vasectomy, wife becomes pregnant	Vasectomy failed permanently	Vasectomy is not immediately effective; residual sperm remain for approximately 3 months	Normal occurrence during the 3-month waiting period; not a surgical failure
Breastfeeding, amenorrheic, baby is 8 months old	LAM is still effective	Baby exceeds 6-month age criterion	LAM no longer reliable; must switch to another method
Woman with SLE and positive antiphospholipid antibodies	Any IUD is fine	LNG-IUS is contraindicated in SLE with antiphospholipid antibodies (MEC 3). Copper IUD with severe thrombocytopenia is also problematic	Copper IUD is acceptable if platelets are adequate; otherwise, non-IUD progestin-only method
Woman on rifampicin for TB treatment	COC at standard dose	Rifampicin is a potent CYP3A4 inducer that reduces COC and POP effectiveness	Copper IUD, DMPA (injectable not significantly affected by enzyme inducers), or LNG-IUS
Woman with menorrhagia wanting contraception	Copper IUD	Copper IUD actually increases menstrual flow and dysmenorrhea	LNG-IUS (reduces menstrual bleeding; therapeutic for menorrhagia)

7. Traps and High-Yield Pearls

Trap 1: The backup method duration varies by method. Most hormonal methods require a 7-day backup if not started within the recommended window. However, the progestin-only pill is a notable exception: it requires only a 2-day backup. The Copper IUD requires no backup at all regardless of when it is inserted (as long as pregnancy is excluded). Mixing up these durations is one of the most common errors.

Trap 2: "Immediately postpartum" is not the same as "any time postpartum." IUDs can be inserted within 48 hours of delivery OR after 4 weeks. The window between 48 hours and 4 weeks is a contraindicated period for IUD insertion because the risk of uterine perforation and expulsion is highest during uterine involution.

Trap 3: DMPA and return to fertility. Unlike every other reversible method, DMPA has a delayed return to fertility (average 4 months, sometimes up to 10 months). The exam may present a couple planning pregnancy in 6 months and ask which method to avoid. The answer is DMPA.

Trap 4: Vasectomy is not immediately effective. The exam often presents a scenario where a couple relies solely on vasectomy within the first 3 months and then a pregnancy occurs. The explanation is persistent sperm in the vas deferens. The man should use backup contraception for 3 months and confirm azoospermia by semen analysis before relying on vasectomy alone.

Trap 5: Emergency contraception interaction with UPA. If a patient took ulipristal acetate (UPA) as emergency contraception, she must wait 6 days before starting or resuming any hormonal contraception. Starting hormonal methods too early renders both the UPA and the hormonal method less effective. The Copper IUD, however, can be placed on the same day as LNG-based emergency pills (but NOT on the same day as UPA for the LNG-IUS).

Trap 6: COC and anti-epileptic drugs. The interaction is bidirectional for lamotrigine: COC reduces lamotrigine serum levels (risking seizure breakthrough), while lamotrigine does not reduce COC effectiveness. This is different from other enzyme-inducing anti-epileptics (phenytoin, carbamazepine, barbiturates) which reduce COC effectiveness. The exam may ask about which direction the interaction goes.

Trap 7: Copper IUD is the only IUD that works as emergency contraception. The LNG-IUS does NOT function as emergency contraception. This is one of the most commonly tested distinctions.

Pearl: When in doubt on an exam, LARC wins. If a vignette describes a woman who has difficulty adhering to daily or periodic methods, or who has completed her family but does not want permanent sterilization, the answer is almost always a LARC method (IUD or implant). LARC methods have the highest continuation rates and lowest failure rates among reversible methods.

Pearl: Progestin-only methods are the universal "safe harbor." When combined hormonal methods are contraindicated (hypertension, smoking >=35, migraine with aura, breastfeeding, DVT/PE history), the correct pivot is always to a progestin-only method. The exam tests whether you can identify the estrogen component as the source of cardiovascular risk and correctly switch to a progestin-only alternative.

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