Why Contraception Counselling Is High-Yield
Contraception stations appear in GP, sexual health, and general medicine OSCE circuits. They test your knowledge of methods, eligibility criteria, and your ability to involve the patient in a shared decision. Poor performers tend to list methods without asking what matters to the patient. That loses marks.
The key framework is: ask before you advise.
Step 1: Set Up the Consultation
Open with an open question and establish what the patient already knows:
- "What brought you in today?"
- "Have you used contraception before? What did you think of it?"
- "Is there anything particular you're looking for in a contraceptive method?"
Then gather the information you need to prescribe safely.
Step 2: History Before Prescribing
Before recommending any method, you must ask:
| Area | What to ask |
|---|---|
| LMP and pregnancy | "Is there any chance you could be pregnant?" |
| Current contraception | "Are you using anything at the moment?" |
| Smoking | "Do you smoke? How many a day?" (age + smoking matters for CHC) |
| Migraine | "Do you get migraines? Do you get visual symptoms before them?" |
| Blood pressure | "Have you ever been told your blood pressure is high?" |
| VTE / thrombosis history | "Have you ever had a clot in your legs or lungs?" |
| Liver disease | "Any liver problems?" |
| Cardiovascular disease | "Any heart problems or strokes?" |
| Breast cancer history | "Any personal or family history of breast cancer?" |
| Medications | "Are you on any medications, including things bought over the counter?" (enzyme inducers reduce efficacy) |
⚠️ Red Flag
Migraine with aura is a UKMEC 4 (absolute contraindication) for combined hormonal contraception. This is one of the most commonly tested contraindications in OSCEs. Always ask specifically about aura.
UKMEC Categories
The UK Medical Eligibility Criteria (UKMEC) classifies conditions by safety:
| Category | Meaning |
|---|---|
| UKMEC 1 | No restriction, method can be used |
| UKMEC 2 | Advantages outweigh risks |
| UKMEC 3 | Risks generally outweigh advantages |
| UKMEC 4 | Unacceptable health risk, do not use |
Combined Hormonal Contraception (CHC)
Includes: combined oral contraceptive pill (COCP), patch, vaginal ring.
Absolute contraindications (UKMEC 4):
- Migraine with aura (at any age)
- Current or history of VTE
- Ischaemic heart disease or stroke
- Breast cancer (current or within 5 years)
- Liver disease or liver tumour
- Age 35+ and smoking 15+ cigarettes/day
- Uncontrolled hypertension (systolic above 160 mmHg)
Key counselling points:
- 99%+ effective with perfect use
- Regulates periods and reduces dysmenorrhoea
- Small increased risk of VTE (3–4x relative risk, absolute risk remains very low)
- Start on day 1 of cycle for immediate protection
💡 Tip
If a patient asks about the pill, check whether they mean combined or progestogen-only. Many patients do not know the difference. Clarify before counselling.
Progestogen-Only Methods
Progestogen-Only Pill (POP / Mini-pill)
- Suitable for most women including those in whom CHC is contraindicated
- Must be taken at the same time each day (3-hour or 12-hour window depending on type)
- Can cause irregular bleeding, especially in first 3 months
Implant (Nexplanon)
- Small rod inserted into upper arm, lasts 3 years
- Over 99% effective
- Irregular bleeding is common, particularly in the first year
- Suitable during breastfeeding
Injectable (Depo-Provera)
- Given every 12–13 weeks as an intramuscular injection
- Fertility can take up to 12 months to return after stopping
- Suitable for patients who struggle with daily pill adherence
Long-Acting Reversible Contraception (LARC)
💎 Clinical Pearl
LARC methods are the most effective contraceptives and are cost-effective for the NHS. The FSRH recommends offering LARC as first-line in most consultations. Mentioning this in an OSCE demonstrates up-to-date knowledge.
| Method | Duration | Efficacy | Notes |
|---|---|---|---|
| Copper IUD | Up to 10 years | Over 99% | Non-hormonal, can worsen periods |
| Levonorgestrel IUS (Mirena) | Up to 5 years | Over 99% | Reduces periods, may cause amenorrhoea |
| Progestogen implant | 3 years | Over 99% | Subdermal arm implant |
| Depo injection | 12 weeks | Over 99% | Delayed fertility return |
Emergency Contraception
Two oral options and one device option:
Levonorgestrel (Levonelle):
- Within 72 hours of unprotected sex
- Efficacy decreases with time (95% at 24h, 58% at 49-72h)
- Safe in breastfeeding
Ulipristal acetate (ellaOne):
- Within 120 hours of unprotected sex
- More effective than levonorgestrel in the 72-120 hour window
- Avoid breastfeeding for 1 week after use
Copper IUD:
- Most effective emergency contraceptive (over 99%)
- Can be fitted up to 5 days after unprotected sex or up to 5 days after the earliest expected ovulation
- Also provides ongoing contraception
⚠️ Red Flag
Both oral emergency contraceptive pills are less effective in women with BMI above 26 (levonorgestrel) or above 35 (ulipristal acetate). The copper IUD is the recommended option for these patients.
Enzyme-Inducing Drugs and Contraception
Drugs that induce CYP450 reduce the efficacy of hormonal methods:
- Rifampicin, rifabutin
- Enzyme-inducing antiepileptics (carbamazepine, phenytoin, phenobarbital, topiramate)
- St John's Wort
If a patient takes these, recommend the copper IUD or injectable (Depo is not affected). The implant and POP are also unreliable with enzyme inducers.
Closing the Consultation
After presenting options:
- 1Check understanding: "Have I explained that clearly? Do you have any questions?"
- 2Confirm choice: "Which option sounds like the best fit for you?"
- 3Safety net: "If the method you choose causes problems or you change your mind, you can come back at any time."
- 4STI: "It's worth mentioning that contraception does not protect against sexually transmitted infections. Condoms do both."
Frequently Asked Questions
"What are the absolute contraindications to the combined oral contraceptive pill?"
The absolute contraindications (UKMEC 4) to the COCP are: migraine with aura at any age; personal history of venous thromboembolism (DVT or PE); current or past ischaemic heart disease or stroke; current breast cancer (UKMEC 4) or within the last 5 years; decompensated cirrhosis or hepatocellular carcinoma; age 35 or older and smoking 15 or more cigarettes per day; and uncontrolled hypertension with systolic BP above 160 mmHg or diastolic above 100 mmHg. UKMEC 3 conditions (where risks generally outweigh advantages) include: controlled hypertension, age 35+ and fewer than 15 cigarettes/day, BMI above 35, immobility, family history of VTE in a first-degree relative under 45, and migraine without aura in women 35 years and older.
"What is the difference between levonorgestrel and ulipristal acetate for emergency contraception?"
Levonorgestrel (Levonelle 1500) must be taken within 72 hours of unprotected sex. It works mainly by delaying or preventing ovulation. Its efficacy decreases significantly with time: approximately 95% effective within 24 hours, 85% within 25-48 hours, and 58% within 49-72 hours. Ulipristal acetate (ellaOne) is effective for up to 120 hours (5 days) after unprotected sex and is more effective than levonorgestrel in the 72-120 hour window. Ulipristal is a selective progesterone receptor modulator and can also inhibit ovulation even if the LH surge has already begun. Ulipristal should not be taken concurrently with progesterone-containing contraception, and breastfeeding should be avoided for one week after use. Both drugs are less effective at higher BMI, and the copper IUD is the preferred option for women with BMI above 26.
"What would you tell a patient about the hormonal implant?"
Nexplanon is a small (4 cm) flexible rod containing etonogestrel, inserted subdermally into the upper arm under local anaesthetic. It is effective for 3 years and is over 99% effective, making it one of the most reliable contraceptive methods available. It can be inserted at any time in the cycle if pregnancy is excluded, with immediate contraceptive protection if inserted on days 1-5 of the cycle. The most common side effect is irregular bleeding, which is unpredictable and may be heavier, lighter, or absent, this affects around 1 in 5 users significantly and is the most common reason for early removal. Fertility returns immediately after removal. It is safe during breastfeeding. Examiners want to hear you address the bleeding side effect proactively, as many patients are not prepared for irregular periods.
"A 40-year-old woman who smokes 20 cigarettes a day asks about the combined pill. What do you do?"
Age 35 or over combined with smoking 15 or more cigarettes per day is a UKMEC 4 absolute contraindication to combined hormonal contraception. You should not prescribe the COCP, patch, or vaginal ring for this patient. Acknowledge her request non-judgementally: "I want to help you find the best option, but the combined pill isn't safe for everyone, and in your situation the risks would be too high." Explain that you can offer excellent alternatives: the progestogen-only pill, implant, Depo-Provera, copper IUD, or hormonal IUS are all safe and effective options. Smoking cessation should also be raised sensitively, as it would expand her future contraceptive choices. Do not simply refuse and leave the patient without an alternative.
"How do enzyme-inducing medications affect contraception?"
Enzyme-inducing drugs increase the activity of cytochrome P450 enzymes in the liver, which accelerates the metabolism of oestrogen and progestogen, reducing plasma levels of hormonal contraceptives below their effective concentration. Affected drugs include rifampicin and rifabutin (highly potent inducers), enzyme-inducing antiepileptics (carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, topiramate at doses above 200 mg/day), and St John's Wort. The combined pill, POP, and implant are all affected. The injectable (Depo-Provera) and the copper IUD are NOT affected by enzyme inducers, making them the preferred hormonal and non-hormonal options respectively for patients on these drugs. If a patient must use a CHC with a short-term enzyme inducer like rifampicin, additional contraception is needed during treatment and for 28 days after stopping.