Gynecologic and Reproductive Health Care
Core concepts
Contraceptive counseling requires distinguishing perfect-use from typical-use failure and matching method to medical eligibility. Long-acting reversible methods are most effective; combined hormonal contraception is contraindicated with migraine with aura, uncontrolled hypertension, smoking at age ≥35 (≥15 cigarettes/day), prior VTE, and known thrombophilia. Emergency contraception options differ in efficacy and window-copper IUD is most effective and can be placed up to 5 days, ulipristal up to 120 hours, levonorgestrel up to 72 hours (with reduced efficacy at higher body weight).
Evaluate abnormal uterine bleeding structurally and nonstructurally (polyp, adenomyosis, leiomyoma, malignancy/hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Know PCOS diagnostic criteria, endometriosis presentation, menopause physiology and hormone therapy indications, and vulvovaginitis and PID management. Pelvic inflammatory disease is treated empirically with ceftriaxone plus doxycycline and metronidazole; remove an IUD only if it does not improve.
Traps
Do not withhold an IUD for a history of PID or nulliparity. A positive pregnancy test with abdominal pain and bleeding is an ectopic until proven otherwise. Postcoital bleeding and postmenopausal bleeding both require evaluation.
Worked example
A 26-year-old with migraine with aura requests combined pills: not eligible-offer progestin-only pill, implant, or IUD.
Rule of thumb
When efficacy matters most, recommend LARC; when bleeding is abnormal, evaluate rather than prescribe a pill to "regulate" it.