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Migraine with aura and inadvertent combined hormonal contraceptive exposure — DFSRH MCQ

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HardDispensing ErrorMigraine with aura and inadvertent combined hormonal contraceptive exposureDFSRH

A 33-year-old woman with established migraine with visual aura was prescribed drospirenone 4 mg progestogen-only pills because she wishes to continue oral contraception. A dispensing error occurred and she was supplied with Yasmin, containing drospirenone 3 mg with ethinylestradiol 30 micrograms. She started the dispensed tablets on day 1 of a normal menstrual period and has taken 16 consecutive active tablets correctly. She had condomless intercourse on days 13 and 16. Today is day 17, and she has not yet taken a tablet. She recognised the error after reading the packaging. She is asymptomatic, takes no interacting medication and has no contraindication to drospirenone-only contraception. Which is the most appropriate immediate contraceptive plan?

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Correct answer: B — Stop Yasmin and start drospirenone 4 mg today without emergency contraception or additional precautions

Yasmin must be stopped because migraine with aura makes combined hormonal contraception UKMEC 4: its use represents an unacceptable health risk, principally because of the increased risk of ischaemic stroke. Completing the pack would unnecessarily prolong exposure to ethinylestradiol. However, the dispensed tablets have provided effective contraception. She started on day 1 and has taken 16 active combined pills correctly, so intercourse on days 13 and 16 does not indicate emergency contraception. She is also in weeks 2–3 of correctly used combined hormonal contraception, when FSRH switching guidance permits immediate commencement of a progestogen-only pill without additional precautions. The drospirenone-only product should therefore replace the next combined pill today, avoiding any hormone-free interval. A is unsafe because it continues a contraindicated combined method. B and E incorrectly treat the recent intercourse as occurring without effective contraception; ulipristal would additionally require delayed hormonal contraception. D applies the 7-day precaution used when drospirenone POP is initiated without reliable preceding contraceptive cover, but continuous ovarian suppression has already been established here. The dispensing error should also be disclosed, documented and managed through the relevant medication-safety processes, but this does not alter the immediate contraceptive plan.

Reference: FSRH Guideline: Progestogen-only Pills (August 2022; amended 30 April 2026) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-ceu-clinical-guideline-progestogen-only-pills-aug22-amended-11july-2023-.pdf?UNLID=90977413202485122516 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 Slynd 4 mg film-coated tablets: Summary of Product Characteristics (20 October 2023) — https://www.medicines.org.uk/emc/product/15275/smpc