Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

Contraception and Sterilization

5–1. Which of the following poses the highest risk of death in fertile women aged 35 to 44 years?

a. Pregnancy

b. Oral contraceptive use

c. Intrauterine device (IUD) use

d. Surgical tubal sterilization procedure

5–2. Which of the following is a second-tier contraceptive method with an expected failure rate of 3 to 9 percent per 100 users during the first year?

a. Spermicide

b. Withdrawal

c. Intrauterine device

d. Oral contraceptive pills

5–3. Your patient delivered a healthy infant 2 weeks ago and wishes to initiate use of a contraceptive method during the next few weeks. She is breastfeeding exclusively. For which of the following is there strong evidence that use decreases the quantity and quality of breast milk?

a. Progestin-only pills

b. Depot medroxyprogesterone acetate

c. Combination hormonal contraceptives

d. None of the above

5–4. A 16-year-old nulligravida is requesting a contraceptive method. She plans to become sexually active with her boyfriend soon. Which of the following is legally required in most states prior to prescribing hormonal contraception for adolescents below the age of consent?

a. Parental consent

b. Pelvic examination

c. Cervical cancer screening

d. None of the above

5–5. Which of the following conditions is NOT listed by the manufacturer as a contraindication of this contraceptive method?


a. Acute liver disease

b. Heavy menses due to coagulation disorder

c. Increased susceptibility to pelvic infection

d. Uterine anomaly with distortion of the uterine cavity

5–6. Your patient is a 26-year-old multipara who presents for a well-woman examination. She has no complaints. She is satisfied with her current method of contraception (shown here). It was inserted 2 years ago, and she wishes to continue with this contraceptive method. Her pelvic exam is normal. Cervical cytology (Pap test) is obtained and is negative for malignancy, but Actinomyces is identified on the smear. Which of the following is NOT a reasonable treatment option for managing this incidental finding according to current recommendations from the American College of Obstetricians and Gynecologists (2005)?


a. Hysterectomy

b. Expectant management (no intervention)

c. Extended course of antibiotics with intrauterine device (IUD) left in place

d. IUD removal and initiation of an alternative contraceptive method

5–7. For which of the following is the use of an intrauterine device associated with an increased complication rate?

a. Adolescence

b. Human immunodeficiency infection

c. Insertion immediately after spontaneous or induced abortion

d. None of the above

5–8. What is the spontaneous expulsion rate for the intrauterine device during the first year after placement?

a. 1 percent

b. 5 percent

c. 10 percent

d. 15 percent

5–9. What is the approximate risk of the complication shown here per intrauterine device insertion?


Photograph contributed by Dr. Kimberly Kho.

a. 1in100

b. 1 in 1000

c. 1 in 10,000

d. 1 in 100,000

5–10. A 34-year-old multipara with a copper-containing IUD in place presents for intrauterine device (IUD) removal because she plans to become pregnant soon. Her last menstrual period was 8 weeks ago. Her urine pregnancy test is positive, and sonography confirms an eight-week intrauterine gestation. She wishes to continue this pregnancy, if possible. She feels well, is afebrile, and has no cervical discharge or pelvic tenderness. You visualize the IUD tail strings protruding from the external cervical os. Which of the following management strategies is recommended to optimize the outcome for your patient?

a. Perform IUD removal and evacuation of uterine contents

b. Perform IUD removal and plan expectant pregnancy management

c. Leave the IUD in place and plan expectant pregnancy management

d. Leave the IUD in place and administer broad-spectrum antibiotics for the next 4 weeks

5–11. For which of the following contraceptive methods is a history of previous ectopic pregnancy considered by its manufacturer to be a contraindication to its use?

a. Copper-containing intrauterine device

b. Progestin-containing subdermal implant

c. Depot medroxyprogesterone acetate (DMPA)

d. Levonorgestrel-releasing intrauterine system (LNG-IUS)

5–12. Which of the following is thought to be a mechanism of action by which this device provides contraception?


Reproduced with permission of N.V. Organon, a subsidiary of Merck & Co, Inc. All rights reserved. Implanon is a registered trademark of N.V. Organon.

a. Ovulation suppression

b. Endometrial atrophic changes

c. Increased cervical mucus viscosity

d. All of the above

5–13. Which of the following statements is true regarding the effects of female tubal sterilization?


Reproduced, with permission, by Hoffman BL, Horsager R, Roberts SW, et al: Williams Obstetrics 23rd Edition Study Guide. New York, McGraw-Hill, 2011, Figure 33-6B.

a. Ovarian cancer risk is increased.

b. The incidence of menorrhagia and dysmenorrhea are increased.

c. At least 10 percent of pregnancies occurring after the procedure are ectopic.

d. By 5 years postprocedure, 50 percent of women aged 30 years or younger at the time of sterilization express regret.

5–14. Which of the following statements regarding vasectomy is true?

a. Semen analysis should be performed 3 months after vasectomy to confirm azoospermia.

b. The postoperative complication rate is 20 times less than that of female tubal sterilization.

c. The failure rate is 30 times less than that of female tubal sterilization.

d. All of the above

5–15. Which of the following is NOT a physiologic effect exerted by the progestin component of combination hormonal contraceptives?

a. Lowered serum free testosterone levels

b. Suppressed serum levels of luteinizing hormone

c. Elevated serum levels of follicle-stimulating hormone

d. All are physiologic effects

5–16. Which of the following is NOT an absolute contraindication to use of this contraceptive method?


Reproduced, with permission, from Stuart GS: Contraception and sterilization. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 5-10.

a. Thrombotic disorders

b. Cholestatic jaundice

c. Migraines with focal neurologic deficits

d. Uncomplicated systemic lupus erythematosus (including negative testing for antiphospholipid antibodies)

5–17. Which of the following statements regarding this method of contraception compared with combination oral contraceptive pills (COCs) is true?


Reproduced, with permission, by Hoffman BL, Horsager R, Roberts SW, et al: Williams Obstetrics 23rd Edition Study Guide. New York, McGraw-Hill, 2011, Figure 32-12.

a. Total estrogen exposure is greater with this method.

b. This method is less likely to cause breast tenderness.

c. This method controls dysmenorrhea in a greater percentage of women.

d. The pregnancy rate with this method is slightly higher than with COCs.

5–18. Rates of which of the following are increased with use of extended cycle hormonal contraception compared with traditional cyclic hormonal contraception use?

a. Headaches

b. Escape ovulation

c. Endometrial cancer

d. Unpredictable bleeding

5–19. Use of which of the following drugs most clearly decreases combined hormonal contraceptive efficacy?

a. Rifampin

b. Penicillin

c. Doxycycline

d. Ciprofloxacin

5–20. Low-dose combination hormonal contraceptives most clearly increase the risk of developing which of the following?

a. Obesity

b. Clinically significant hypertension

c. Overt diabetes in women with prior gestational diabetes

d. None of the above

5–21. With combination hormonal contraceptive use, stroke risk is elevated by which of the following being coexistent?

a. Tobacco use

b. Hypertension

c. Migraine headaches with aura

d. All of the above

5–22. Your patient is concerned after reading that the risk of deep-vein thrombosis and pulmonary embolism is tripled or quadrupled in current users of combination hormonal contraceptives (CHCs) compared with that of the general population. You explain that this is true, but that the risk is still lower than the risk of venous thrombosis related to pregnancy. What is the approximate rate of thromboembolic events per 10,000 woman years with CHC use?

a. 4 events

b. 24 events

c. 44 events

d. 64 events

5–23. Your patient is an 18-year-old nulligravida who is not sexually active, but takes combination oral contraceptive pills (COCs) to achieve good control of her irregular menses and dysmenorrhea. She has grand mal epilepsy. Her seizures are well controlled on medication. Serum levels of which anticonvulsant medication are decreased significantly by concurrent COC use?

a. Phenytoin

b. Lamotrigine

c. Carbamazepine

d. Phenobarbital

5–24. Contemporary low-dose combination oral contraceptives are most strongly implicated as a risk factor for the development of which of the following neoplasms?

a. Breast cancer

b. Cervical cancer

c. Benign hepatic adenomas

d. Lymphoma, if human immunodeficiency virus (HIV) infection is coexistent

5–25. Your patient has diabetes and hypertension but prefers to use “pills” for contraception. She declines an intrauterine device and barrier methods. She is considering a progestin-only contraceptive and favors progestin-only pills. You counsel her regarding the advantages as well as which of the following disadvantages of progestin-only pills compared with combination oral contraceptives?

a. Higher failure rate

b. High rate of irregular bleeding

c. Higher relative ectopic pregnancy rate

d. All of the above

5–26. Which of the following is generally increased by the use of depot medroxyprogesterone acetate compared with other contraceptive methods?

a. Acne

b. Bone fractures

c. Hepatic neoplasms

d. Interval to resumption of ovulation after method cessation

5–27. Which of the following is an advantage of lambskin condoms compared with latex rubber condoms?

a. Fewer allergic reactions

b. Lower breakage and slippage rates

c. Better protection against sexually transmitted infections

d. All of the above

5–28. Which of the following is an advantage of progestin-only emergency contraception (EC) regimens compared with estrogen-progestin combinations for this purpose?

a. More effective in preventing pregnancy

b. Effective if taken beyond 5 days after exposure

c. Provides better protection against sexually transmitted infections

d. None of the above


American College of Obstetricians and Gynecologists: Clinical management guidelines for obstetrician-gynecologists. Practice Bulletin No. 59, January 2005

Chapter 5 ANSWER KEY