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Perioperative management of combined hormonal contraception — DFSRH MCQ

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HardVenous ThromboembolismPerioperative management of combined hormonal contraceptionDFSRH

A 32-year-old woman is scheduled for elective tibial osteotomy in 4 weeks and 3 days, followed by 4 weeks of non-weight-bearing immobilisation. Postoperative low-molecular-weight heparin prophylaxis is planned. She has no personal or family history of venous thromboembolism and uses a combined contraceptive vaginal ring correctly. She is on day 10 of the current ring cycle, having used the preceding ring and hormone-free interval correctly. She wishes to switch to an etonogestrel implant today and wants uninterrupted highly effective contraception. Which management plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Remove the ring and insert the implant today; no additional contraceptive precautions

Explanation lettering: B = shown as A · E = shown as B · D = shown as C · A = shown as D · C = shown as E

The vaginal ring is combined hormonal contraception (CHC), so the same perioperative VTE recommendations apply as for combined oral contraception. Tibial osteotomy followed by four weeks of non-weight-bearing is major surgery with prolonged immobilisation, for which CHC is UKMEC 4. Planned LMWH prophylaxis does not remove the recommendation to stop CHC at least four weeks before surgery. As surgery is only 4 weeks and 3 days away, estrogen exposure should cease now. She is in week 2 of correctly used CHC. FSRH switching guidance permits immediate insertion of an etonogestrel implant during weeks 2–3, with no additional contraceptive precautions. Therefore, removing the ring and inserting the implant today provides both timely estrogen cessation and uninterrupted contraception. A is incorrect because thromboprophylaxis does not justify continuing CHC through prolonged postoperative immobilisation. C unnecessarily prolongs estrogen exposure and would leave less than four weeks between ring removal and surgery; overlap is not required in week 2. D similarly leaves fewer than four weeks after CHC cessation. E stops estrogen appropriately but creates an avoidable contraceptive gap and incorrectly delays a medically eligible implant. The perioperative recommendation is consensus-based (FSRH grade D), but it is reinforced by UKMEC classification and NICE VTE-prevention guidance.

Reference: FSRH Guideline: Combined Hormonal Contraception (January 2019, amended October 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf FSRH Guideline: Combined Hormonal Contraception, Table 7 (January 2019, amended October 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf UK Medical Eligibility Criteria for Contraceptive Use (April 2016, amended September 2019) — https://www.fsrh.org/Common/Uploaded%20files/Standards-and-Guidance/fsrh-ukmec-full-book-2019.pdf