Kontrasepsi
Published on May 16, 2026
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" |
01Foundational Concepts and Mechanisms
WHO Medical Eligibility Criteria (MEC)
1
Meaning
No restriction for use
Clinical Implication
Use freely
2
Meaning
Advantages generally outweigh theoretical or proven risks
Clinical Implication
Generally use; may need closer follow-up
3
Meaning
Theoretical or proven risks usually outweigh advantages
Clinical Implication
Not usually recommended unless no other suitable method
4
Meaning
Unacceptable health risk
Clinical Implication
Absolutely contraindicated
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.
02Classification and Effectiveness
Classification of Contraceptive Methods
Copper IUD (AKDR-Cu)
Hormonal?
Non-Hormonal
LARC / Non-LARC
LARC
LNG-IUS (AKDR-LNG)
Hormonal?
Hormonal
LARC / Non-LARC
LARC
Implant
Hormonal?
Hormonal
LARC / Non-LARC
LARC
Combined Injectable (CIC/KSK)
Hormonal?
Hormonal
LARC / Non-LARC
Non-LARC
Progestin-only Injectable (DMPA/KSP)
Hormonal?
Hormonal
LARC / Non-LARC
Non-LARC
Combined Oral Contraceptive (COC/KPK)
Hormonal?
Hormonal
LARC / Non-LARC
Non-LARC
Progestin-only Pill (POP/KPP)
Hormonal?
Hormonal
LARC / Non-LARC
Non-LARC
Male Condom
Hormonal?
Non-Hormonal
LARC / Non-LARC
Non-LARC
Female Condom
Hormonal?
Non-Hormonal
LARC / Non-LARC
Non-LARC
Tubectomy (MOW)
Hormonal?
Non-Hormonal
LARC / Non-LARC
Permanent
Vasectomy (MOP)
Hormonal?
Non-Hormonal
LARC / Non-LARC
Permanent
Lactational Amenorrhea (LAM/MAL)
Hormonal?
Non-Hormonal
LARC / Non-LARC
Non-LARC
Fertility Awareness-Based
Hormonal?
Non-Hormonal
LARC / Non-LARC
Non-LARC
Withdrawal (Coitus Interruptus)
Hormonal?
Non-Hormonal
LARC / Non-LARC
Non-LARC
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.
Very Effective (<1%)
Method
Implant
Typical Use Failure Rate
0.1%
Very Effective (<1%)
Method
Vasectomy
Typical Use Failure Rate
0.15%
Very Effective (<1%)
Method
Tubectomy
Typical Use Failure Rate
0.5%
Very Effective (<1%)
Method
LNG-IUS
Typical Use Failure Rate
0.7%
Very Effective (<1%)
Method
Copper IUD
Typical Use Failure Rate
0.8%
Effective (1-9%)
Method
LAM (6 months only)
Typical Use Failure Rate
2%
Effective (1-9%)
Method
Combined Injectable
Typical Use Failure Rate
3%
Effective (1-9%)
Method
DMPA Injectable
Typical Use Failure Rate
4%
Effective (1-9%)
Method
COC / POP
Typical Use Failure Rate
7%
Moderately Effective (10-19%)
Method
Male Condom
Typical Use Failure Rate
13%
Moderately Effective (10-19%)
Method
Standard Days Method
Typical Use Failure Rate
12%
Moderately Effective (10-19%)
Method
Two-Day Method
Typical Use Failure Rate
14%
Less Effective (20%+)
Method
Ovulation Method
Typical Use Failure Rate
23%
Less Effective (20%+)
Method
Withdrawal
Typical Use Failure Rate
20%
Less Effective (20%+)
Method
Female Condom
Typical Use Failure Rate
21%
Less Effective (20%+)
Method
No Method
Typical Use Failure Rate
85%
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.
03Method-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
Material
Male Condom
Latex, polyurethane, polyisoprene, lambskin, nitrile
Female Condom
Latex, polyurethane, nitrile
Effectiveness
Male Condom
13% typical use
Female Condom
21% typical use
Unique Benefit
Male Condom
Dual protection: prevents pregnancy AND STIs including HIV
Female Condom
Same dual protection; woman-initiated
Contraindications
Male Condom
Severe latex allergy only
Female Condom
Severe latex allergy (for latex types)
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
Standard Days Method
Basis
Calendar-based; abstain days 8-19
Key Requirement
Regular cycles 26-32 days
Rhythm / Calendar Method
Basis
Calculate fertile window from cycle history
Key Requirement
Requires at least 4 recorded cycles
Two-Day Method
Basis
Cervical secretion observation
Key Requirement
Check secretions daily
Ovulation (Billings) Method
Basis
Cervical mucus quality
Key Requirement
Identify peak mucus day
Basal Body Temperature
Basis
Temperature rise post-ovulation
Key Requirement
Daily temperature measurement before rising
Symptothermal
Basis
Combines mucus + temperature + calendar
Key Requirement
Most accurate of the group
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
Levonorgestrel (LNG) pill
Regimen
1.5 mg as single dose (or 0.75 mg x 2)
Time Window
Within 5 days (120 hours), more effective the earlier taken
Notes
May be less effective in women with BMI >=30
Ulipristal Acetate (UPA)
Regimen
30 mg single dose
Time Window
Within 5 days
Notes
Progesterone receptor modulator. Interacts with hormonal contraception: do not start hormonal method for 6 days after UPA
Yuzpe Regimen (combined pills)
Regimen
EE 100 mcg + LNG 0.5 mg, repeated in 12 hours
Time Window
Within 5 days
Notes
Higher nausea rate; less effective than LNG or UPA
Copper IUD
Regimen
Insertion
Time Window
Within 5 days post-intercourse (or up to 5 days post-estimated ovulation)
Notes
Most effective emergency contraceptive method; can then remain as long-term 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.
04Postpartum 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.
0-48 hours
Breastfeeding Status
Any
Appropriate Methods
Copper IUD, LNG-IUS, Tubectomy
Methods to Avoid
COC, CIC
48 hours - 4 weeks
Breastfeeding Status
Any
Appropriate Methods
Implant (if not BF: can start anytime), POP (non-BF <4 wks: anytime)
Methods to Avoid
IUD insertion (delay until 4 weeks), COC, CIC
4-6 weeks
Breastfeeding Status
Breastfeeding
Appropriate Methods
Implant, POP, Copper IUD, LNG-IUS
Methods to Avoid
COC, CIC, DMPA (delay DMPA to 6 weeks)
4-6 weeks
Breastfeeding Status
Not Breastfeeding
Appropriate Methods
All progestin-only methods, Copper IUD, LNG-IUS, COC/CIC starting day 21-28 (if no additional DVT risk)
Methods to Avoid
COC/CIC if additional DVT risk factors (delay to 6 weeks)
6 weeks - 6 months
Breastfeeding Status
Exclusively Breastfeeding
Appropriate Methods
All progestin-only, IUDs, LAM, Implant
Methods to Avoid
COC, CIC (delay until 6 months or until breastmilk is no longer primary nutrition)
>6 months
Breastfeeding Status
Any
Appropriate Methods
All methods available
Methods to Avoid
None (standard MEC criteria apply)
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.
05Side Effects Management
Irregular bleeding
Applicable Methods
Implant, LNG-IUS, DMPA, POP
Management
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
Applicable Methods
DMPA (most common), LNG-IUS, Implant
Management
Reassurance. Rule out pregnancy if concerned. This is a normal and expected effect, not a complication
Heavy/prolonged menses
Applicable Methods
Copper IUD
Management
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
Applicable Methods
DMPA, Implant, POP
Management
Dietary counseling
Headache (non-migraine)
Applicable Methods
Any hormonal method
Management
Aspirin 500 mg, ibuprofen 400 mg, or paracetamol 500-1000 mg
Decreased bone density
Applicable Methods
DMPA (long-term use)
Management
Partially reversible after discontinuation. Consider alternative methods for adolescents and perimenopausal women when possible
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.
06Exam Scenarios
This section focuses on exam scenarios where methods can be confused or where the wrong answer looks appealing.
37-year-old woman, smokes 20 cig/day, wants oral contraceptive
Tempting Wrong Answer
COC (combined pill)
Why It's Wrong
Age >=35 + smoking = MEC Category 4 for combined hormonal. Estrogen increases thromboembolic risk
Correct Answer
POP (progestin-only pill) or Implant
Breastfeeding mother, 3 months postpartum, wants contraception
Tempting Wrong Answer
COC
Why It's Wrong
Estrogen reduces milk supply; COC is avoided until 6 months in exclusively breastfeeding women
Correct Answer
POP, Implant, DMPA (if >=6 weeks postpartum), Copper IUD, or LNG-IUS
Woman wants most effective emergency contraception
Tempting Wrong Answer
Levonorgestrel 1.5 mg pill
Why It's Wrong
LNG pill is effective but NOT the most effective
Correct Answer
Copper IUD (most effective emergency contraceptive)
Woman took UPA emergency pill yesterday, wants to start COC
Tempting Wrong Answer
Start COC today
Why It's Wrong
UPA and hormonal contraception interact; starting too early reduces effectiveness of both
Correct Answer
Wait 6 days before starting COC; use backup method in the interim
2 weeks post-vasectomy, wife becomes pregnant
Tempting Wrong Answer
Vasectomy failed permanently
Why It's Wrong
Vasectomy is not immediately effective; residual sperm remain for approximately 3 months
Correct Answer
Normal occurrence during the 3-month waiting period; not a surgical failure
Breastfeeding, amenorrheic, baby is 8 months old
Tempting Wrong Answer
LAM is still effective
Why It's Wrong
Baby exceeds 6-month age criterion
Correct Answer
LAM no longer reliable; must switch to another method
Woman with SLE and positive antiphospholipid antibodies
Tempting Wrong Answer
Any IUD is fine
Why It's Wrong
LNG-IUS is contraindicated in SLE with antiphospholipid antibodies (MEC 3). Copper IUD with severe thrombocytopenia is also problematic
Correct Answer
Copper IUD is acceptable if platelets are adequate; otherwise, non-IUD progestin-only method
Woman on rifampicin for TB treatment
Tempting Wrong Answer
COC at standard dose
Why It's Wrong
Rifampicin is a potent CYP3A4 inducer that reduces COC and POP effectiveness
Correct Answer
Copper IUD, DMPA (injectable not significantly affected by enzyme inducers), or LNG-IUS
Woman with menorrhagia wanting contraception
Tempting Wrong Answer
Copper IUD
Why It's Wrong
Copper IUD actually increases menstrual flow and dysmenorrhea
Correct Answer
LNG-IUS (reduces menstrual bleeding; therapeutic for menorrhagia)
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) |
07Traps 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.