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Incorrect drospirenone progestogen-only pill use during severe diarrhoea — DFSRH MCQ

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HardDiarrhoeaIncorrect drospirenone progestogen-only pill use during severe diarrhoeaDFSRH

A 29-year-old woman has used a drospirenone 4 mg progestogen-only pill in a 24-active/4-placebo regimen for 8 months. Pills up to day 21 of her previous pack were taken correctly. During days 22–24, she developed severe watery diarrhoea within 2 hours of each active tablet and took no replacement tablets. She then took all four placebo tablets rather than omitting them. The diarrhoea resolved before she started her next pack, and she has correctly taken its first two active tablets. She had condomless intercourse 60 hours ago, during the placebo phase, and again 12 hours ago. A urine pregnancy test is negative. She takes no enzyme-inducing medication and declines a copper intrauterine device after counselling. Which is the most appropriate oral emergency contraception and ongoing contraceptive plan?

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

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Correct answer: D — Give levonorgestrel 1.5 mg now, continue drospirenone daily, and use condoms until 7 consecutive active tablets have been correctly absorbed

Severe diarrhoea within 3–4 hours of an active drospirenone pill may prevent absorption; without a timely replacement, missed-pill guidance applies. Thus, the final three active pills were effectively missed. Although missing up to four pills on days 18–24 may carry a low pregnancy risk when preceding pills were correct, protection depends on promptly restarting active pills and omitting the four-day hormone-free interval. She instead took every placebo, creating a prolonged interruption adjacent to condomless intercourse, so emergency contraception should be considered. After incorrect drospirenone POP use, FSRH advises levonorgestrel emergency contraception, with immediate continuation or restart of drospirenone. Condoms are required until seven consecutive active pills have been correctly taken; a pregnancy test should be advised 21 days after the last condomless intercourse. A is inferior because residual and subsequently withheld progestogen complicate ulipristal use, while delaying drospirenone for five further days increases the period without ovulation suppression. B incorrectly applies the five-day delay required after ulipristal to levonorgestrel. D overlooks her failure to omit the placebo interval. E risks reducing ulipristal's ovulation-delaying effect through immediate progestogen exposure.

Reference: FSRH Guideline: Progestogen-only Pills (August 2022, amended July 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-ceu-clinical-guideline-progestogen-only-pills-aug22-amended-11july-2023-.pdf Slynd 4 mg film-coated tablets: Summary of Product Characteristics (Revised 20 October 2023) — https://www.medicines.org.uk/emc/product/15275/smpc