Preparatory Mindset
Family planning (contraception) is a counselling OSCE staple — examiners want to see you match a method to a woman's age, medical history, fertility wishes, and contraindications. The mindset: contraceptive efficacy (Pearl index / failure rate), reversibility, and side-effect profile are the three axes; the combined oral contraceptive (COC) is the workhorse for young healthy women, LARC (long-acting reversible contraception — IUCD/IUS, implant) is the most effective reversible option, and emergency contraception has a 72-hour (levonorgestrel) / 120-hour (ulipristal acetate) window. In China, family planning also includes the statutory post-abortion/contraception counselling and the historical one-child→two-child→three-child policy context. The exam pearl: always screen for pregnancy first and rule out contraindications (smoker >35 + COC = VTE risk; IUCD in active PID = avoid).
Core Concepts
1. Contraceptive methods — efficacy and characteristics
| Method | Typical failure (1 yr) | Reversible | Key points |
|---|---|---|---|
| No method | 85% | — | Baseline |
| Withdrawal / rhythm | 20-25% | Yes | High failure — not recommended as primary |
| Male condom | ~13-15% | Yes | STI protection — the only method that does both |
| Female condom / diaphragm | 20% | Yes | Diaphragm + spermicide |
| COC (combined oral contraceptive) | ~7% (typical) / <1% (perfect) | Yes | Most popular hormonal; oestrogen + progestogen; cycle control, acne benefit; VTE risk (smoker >35 — contraindicated) |
| POP (progestogen-only pill) | ~7% | Yes | Lactation-friendly (from 6 weeks), migraine-with-aura friendly; must take same time daily |
| DMPA (depot medroxyprogesterone, 3-monthly) | ~4% | Delayed return of fertility (up to 1 yr) | Bone density concern — avoid long-term in young women |
| IUCD (copper) | <1% | Yes | LARC; emergency contraception (5 days); non-hormonal; heavier periods |
| IUS (levonorgestrel, Mirena) | <1% | Yes | LARC; heavy bleeding treatment; lighter periods/amenorrhoea; good for fibroids/adenomyosis |
| Implant (etonogestrel) | <1% | Yes | LARC; most effective reversible; irregular bleeding; insertion/removal skill |
| Male/female sterilisation | <1% | No (surgical reversal difficult) | Definitive; for completed family |
| Lactational amenorrhoea (LAM) | ~2% (if fully breastfeeding <6 mo) | — | Requires exclusive breastfeeding + amenorrhoea + <6 months |
2. LARC — the under-used winners
- Copper IUCD: non-hormonal; also emergency contraception (up to 5 days post-coitus); good for women who want to avoid hormones; menorrhagia side effect.
- Mirena IUS: levonorgestrel; 5 years; treats heavy menstrual bleeding; reduces endometrial cancer risk; first-line for AUB (ch11); spotting in first 3-6 months then light/absent periods.
- Implant: etonogestrel; 3 years; most effective reversible method; irregular bleeding the main downside.
Advantages over pills: no daily adherence (typical-use efficacy ≈ perfect-use efficacy), rapid return of fertility (IUCD/implant) — except DMPA.
3. Combined oral contraceptive (COC) — indications and contraindications (WHO MEC)
Indications: contraception, cycle control, dysmenorrhoea, acne/hirsutism (PCOS), endometriosis symptom control, menorrhagia, PMDD.
Contraindications (WHO categories 3-4):
| Category | Condition |
|---|---|
| Category 4 (never use) | Current VTE/PE, history of VTE, thrombophilia (factor V Leiden), ischaemic heart disease, stroke, complicated migraine (with aura), breast cancer (current), severe liver disease, smoker ≥35 + COC |
| Category 3 (usually avoid) | Hypertension (uncontrolled), migraine without aura, active liver disease, past breast cancer (>5 yr), obesity BMI >35 (caution) |
| Category 1-2 (can use) | Most healthy women; mild HTN (2 — monitor) |
COC + smoking + >35 = VTE risk — the most tested contraindication.
4. Progestogen-only methods
| Method | Use |
|---|---|
| POP | Breastfeeding (from 6 weeks — progestogen-safe), migraine with aura, smoker >35 (no oestrogen), hypertension — the "oestrogen-avoiders" |
| DMPA | 3-monthly; bone density ↓ (avoid >2 years in <18 or near menopause); weight gain |
| IUS / implant | As above |
5. Emergency contraception (EC)
| Method | Window | Efficacy | Notes |
|---|---|---|---|
| Levonorgestrel 1.5 mg (single) or 0.75 mg × 2 | Up to 72 h (best <24 h) | ~85-95% | OTC in many regions; less effective with higher BMI |
| Ulipristal acetate (UPA) 30 mg | Up to 120 h (5 days) | Higher efficacy, effective throughout | Prescription; progestogen-sensitive — use same-day before COC |
| Copper IUCD | Up to 5 days (or 5 days after expected ovulation) | >99% — most effective EC | Also provides ongoing contraception — the gold standard EC |
Mechanism: delay ovulation (hormonal) vs prevent fertilisation/implantation (IUCD).
6. Contraception in special situations
| Situation | Preferred | Avoid |
|---|---|---|
| Lactation (<6 wk) | LAM, progestogen-only (POP/IUS/implant from 6 wk), IUCD, condoms | COC (oestrogen affects milk) until 6 weeks (3 weeks in some guidelines) |
| Smoker ≥35 | IUCD/IUS/implant, POP, condoms | COC (VTE) |
| Migraine with aura | POP, IUCD/IUS, implant | COC |
| Obesity BMI ≥30 | IUCD/IUS, implant, POP (all fine); COC caution | — |
| Active liver disease / breast cancer | Copper IUCD, condoms, barrier | Hormonal methods |
| Completed family | Sterilisation (male vasectomy — simpler, safer than female) | — |
| Post-abortion/postpartum | IUCD immediately post-abortion; IUS/implant postpartum; COC from 3 weeks (VTE risk first 3 weeks) | — |
7. Counselling principles (the OSCE format)
- Explore the woman's goals, lifestyle, medical history, fertility wishes, partner involvement.
- Pregnancy test first (any reproductive-age woman).
- Present options matched to her (LARC vs pill vs barrier), with efficacy, side effects, reversibility honestly.
- Check contraindications (WHO MEC) — smoker/age/HTN/migraine/breast disease.
- STI risk discussion — condoms as dual protection.
- Follow-up plan — return for problems, IUS review at 3-6 weeks, COC review at 3 months.
High-Yield Points
| Topic | Must-remember |
|---|---|
| Most effective reversible | LARC (IUCD/IUS/implant — <1% failure) |
| Only dual protection | Male condom (contraception + STI) |
| COC contraindication #1 | Smoker ≥35 — VTE risk (category 4) |
| COC + migraine with aura | Contraindicated (stroke risk) |
| POP indications | Lactation, migraine with aura, smoker >35, hypertension |
| DMPA | Bone density ↓; delayed return of fertility |
| Mirena IUS | 5 years; treats menorrhagia; spotting → light periods |
| Copper IUCD | Non-hormonal; emergency contraception up to 5 days |
| Levonorgestrel EC | 72 h window (best <24 h) |
| Ulipristal EC | 120 h (5 days) — prescription |
| Best EC | Copper IUCD (>99%) |
| Sterilisation | Male vasectomy — simpler + safer than female |
| WHO MEC categories | 4 = never use; 3 = usually avoid; 1-2 = can use |
Topic Summary
Family planning matches contraceptive method to the woman: LARC (IUS/IUCD/implant) is the most effective reversible choice (<1% failure); COC is the hormonal workhorse (but contraindicated in smokers ≥35, migraine with aura, VTE history); POP suits oestrogen-avoiders (lactation, migraine); condoms add STI protection; copper IUCD doubles as emergency contraception (5 days, >99%); and sterilisation (male vasectomy preferred) is the definitive option. Counselling is patient-centred: pregnancy test first, WHO MEC check, options matched to history, honest efficacy/risk discussion, follow-up.
LMCHK OSCE Practice — Contraception Counselling
Station setup: A 38-year-old woman, 6 weeks postpartum, exclusively breastfeeding, smokes 15 cigarettes/day. She wants reliable contraception. Her mother had a DVT. She asks what she can use.
Candidate tasks (8 min):
- Take a history (delivery, breastfeeding, smoking, personal/family VTE history, medical conditions, STI risk).
- Recognise the constraints: breastfeeding <6 weeks → avoid COC; smoker ≥35 + family history of VTE → COC absolutely contraindicated; hormonal options with oestrogen → avoid.
- Recommend options: progestogen-only (POP from 6 weeks, IUS/implant), copper IUCD (non-hormonal — excellent here), condoms (dual protection); discuss LAM (if fully breastfeeding + amenorrhoea + <6 months — but not as reliable long-term).
- Explain the COC VTE risk clearly (smoking + age + family history).
- Offer emergency contraception plan and follow-up review.
Key marking cues:
- Avoids COC (smoker ≥35 + family VTE history) — the exam-critical decision.
- Offers progestogen-only / copper IUCD / condoms appropriately.
- Discusses LAM correctly (exclusive BF + amenorrhoea + <6 months).
- Counsels on dual protection (STI).
- Schedules follow-up (IUS review at 3-6 weeks, method satisfaction).