Which of the following are key components of contraceptive counseling? Select all that apply.

Depot medroxyprogesterone acetate (DMPA)is a progestin-only injectable contraceptiveadministered every 12 weeks. It suppresses ovulation, thickens cervical mucus, and thins the endometrium. Common side effects include weight gain, irregular bleeding, and bone mineral density lossdue to hypoestrogenic effects. DMPA delays return to fertility by 9 to 10 monthson average. It is safe during lactation, but does not increase milk supply. Normal bone mineral density (BMD) T-score is ≥−1.0; prolonged DMPA use may reduce BMD, especially in adolescents.

Rationale for correct answers

1.Weight gain is a documented side effect of DMPA, with average increases of 2–4 kg in the first year. It is attributed to increased appetite and fluid retention.

3.DMPA can reduce bone mineral density due to suppression of estrogen. This effect is reversible upon discontinuation but is significant in long-term use, especially in adolescents.

5.Irregular bleeding is common, especially in the first 6–12 months. It results from endometrial thinning and unpredictable shedding. Amenorrhea may develop with continued use.

Rationale for incorrect answers

2.DMPA does not result in immediate return to fertility. Ovulation may be delayed for 9–10 months after the last injection. This is due to prolonged suppression of the hypothalamic-pituitary-ovarian axis.

4.DMPA is compatible with breastfeeding but does not increase milk supply. It does not contain estrogen, which can suppress lactation, but its progestin component does not stimulate milk production.

Take home points

• DMPA causes weight gain, irregular bleeding, and potential bone density loss.
• Fertility return is delayed after discontinuation.
• Safe during lactation but does not enhance milk supply.
• Long-term use requires monitoring of bone health.

Emergency contraception works by interfering with ovulation, fertilization, or implantationdepending on the type and timing of administration. The most common forms include levonorgestrel and ulipristal acetate. Levonorgestrel inhibits LH surge, preventing ovulation, while ulipristal delays follicular rupture. Normal serum LH levels range from 5–25 IU/L during the mid-cycle surge. These agents do not affect an already implanted embryo and are ineffective once pregnancy is established. Side effects include nausea, headache, and menstrual irregularities. Contraindications include known pregnancy and hypersensitivity to components.

Rationale for correct answers

2.Emergency contraception prevents ovulation or fertilization. Levonorgestrel inhibits the luteinizing hormone surge, blocking ovulation if taken before the peak. Ulipristal acetate delays follicular rupture. These mechanisms act before fertilization, making this the correct explanation.

Rationale for incorrect answers

1.Emergency contraception does not terminate an established pregnancy. It is ineffective once implantation has occurred. Agents like mifepristone are used for termination, not levonorgestrel or ulipristal. Emergency contraception is not abortifacient.

3.Endometrial shedding is not the primary mechanism. While some thinning of the endometrium may occur, it is not reliable or consistent enough to prevent implantation. The dominant action is inhibition of ovulation.

4.Emergency contraception does not immobilize sperm permanently. Sperm motility is unaffected by these agents. Barrier methods or spermicides are used to impair sperm movement, not hormonal emergency contraception.

Take home points

• Emergency contraception prevents ovulation or fertilization, not implantation.
• It is ineffective once pregnancy is established.
• It does not cause permanent sperm immobilization.
• It must be differentiated from abortifacients like mifepristone.