The DFSRH tests contraceptive knowledge in clinical depth — not just "what methods exist" but "which method is most appropriate for this specific patient with this specific medical history and these specific preferences." This masterclass covers every method at the level the OTA and AHD demand.
Combined Hormonal Contraception (CHC)
Methods: Combined oral contraceptive pill (COC), combined transdermal patch, combined vaginal ring. All contain oestrogen + progestogen.
Mechanism: Primarily ovulation suppression. Also thickens cervical mucus and thins endometrium.
Efficacy: >99% with perfect use; approximately 91% with typical use.
Key UKMEC restrictions: Category 4 in migraine with aura, current breast cancer, active VTE, ischaemic heart disease/stroke, severe hepatic disease, smoking ≥15/day if ≥35. Category 3 in BMI ≥35, controlled hypertension, smoking <15/day if ≥35, <21 days postpartum (non-breastfeeding), current gallbladder disease.
Missed pill rules: Missing one pill (24-48 hours late) — take missed pill, continue, no additional contraception needed. Missing two or more pills (>48 hours late) — depends on week of cycle. Week 1: risk of ovulation, emergency contraception may be needed if UPSI in pill-free interval or week 1. Week 2: usually safe if previous 7 pills taken correctly. Week 3: omit pill-free interval, start new pack immediately.
Progestogen-Only Pill (POP)
Traditional POP (norethisterone): 3-hour window for late pill. Primarily thickens cervical mucus. Ovulation still occurs in many cycles.
Desogestrel POP (Cerazette/generic): 12-hour window. Inhibits ovulation in 97% of cycles. Preferred POP for most patients due to wider missed-pill window and more reliable ovulation suppression.
UKMEC: Very few Category 3/4 restrictions. Category 4 only for current breast cancer. Category 1-2 for most conditions that are Category 3/4 for CHC.
Progestogen-Only Injectable (Depo-Provera)
IM injection every 12 weeks (13 weeks window). Highly effective (>99%). Ovulation suppression. Common side effects: irregular bleeding (often amenorrhoea after 12 months), weight gain, delayed return to fertility (up to 12 months after last injection), BMD reduction with prolonged use.
UKMEC: Category 3 for under-18s and over-45s (BMD concerns). Category 2 for most other conditions.
Subdermal Implant (Nexplanon)
Single rod inserted subdermally in upper arm. Lasts 3 years. Most effective reversible method (>99.9%). Ovulation suppression. Common side effect: unpredictable bleeding pattern.
UKMEC: Very few restrictions. Category 4 for current breast cancer only.
Intrauterine System (IUS — Mirena, Levosert, Benilexa, Kyleena)
Progestogen-releasing intrauterine device. Mirena lasts up to 8 years (for contraception; 5 years for endometrial protection in HRT). Highly effective (>99%). Local progestogen effect thins endometrium — often reduces menstrual bleeding significantly.
UKMEC for initiation: Category 4 for current PID, current STI, current purulent cervicitis, post-septic abortion. Category 3 for 48 hours to 4 weeks postpartum. Category 2 for nulliparity, previous ectopic.
Intrauterine Device (IUD — Copper Coil)
Non-hormonal. Copper creates a toxic environment for sperm. Lasts 5-10 years depending on type. Most effective emergency contraception (up to 5 days after UPSI or up to 5 days after estimated ovulation). May increase menstrual bleeding and cramping.
UKMEC for initiation: Same as IUS. No hormonal side effects — suitable for patients who want hormone-free contraception.
Emergency Contraception
Levonorgestrel (Levonelle): Up to 72 hours after UPSI. Efficacy decreases with time. Reduced efficacy if BMI >26 or weight >70kg (consider double dose or alternative). Not affected by current progestogen-only contraception. Affected by enzyme-inducing drugs.
Ulipristal acetate (ellaOne): Up to 120 hours (5 days) after UPSI. More effective than levonorgestrel especially at 72-120 hours. Interacts with progestogen (do not start hormonal contraception for 5 days — use barrier in interim). Affected by enzyme-inducing drugs.
Copper IUD: Most effective emergency method. Up to 5 days after UPSI or up to 5 days after estimated ovulation. Can be retained as ongoing contraception. Initiation contraindications apply (UKMEC Category 4 conditions).
Clinical Decision-Making Framework
For every patient consultation, the DFSRH expects this reasoning process: identify the patient's preferences and priorities (efficacy, hormone-free, reversibility, convenience, bleeding pattern). Take a focused medical history for UKMEC assessment. Apply UKMEC categories to determine which methods are safe. Present appropriate options — tailored to the patient's preferences from the UKMEC-eligible methods. Discuss efficacy, advantages, side effects, and practical considerations for each option. Agree a plan through shared decision-making. Safety-net for side effects, method failure, and when to return.
The iatroX DFSRH Q-Bank tests this complete decision-making process through clinical scenarios — not just isolated factual recall. 850+ questions with adaptive spaced repetition ensure mastery across all methods and UKMEC scenarios.