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Current symptomatic cholelithiasis in a combined hormonal contraceptive patch user — DFSRH MCQ

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HardGallbladder DiseaseCurrent symptomatic cholelithiasis in a combined hormonal contraceptive patch userDFSRH

A 35-year-old woman uses a combined hormonal contraceptive patch in a standard 3-weeks-on, 1-week-off regimen. She is 4 days into her second patch of the current cycle. Every patch has been applied on schedule, with no detachment, interacting medication, vomiting or diarrhoea. She had condomless intercourse yesterday. She has experienced four episodes of postprandial right upper-quadrant pain over the past 2 months. Each resolved within 4 hours without fever or jaundice. Ultrasonography confirms multiple gallstones without bile-duct dilatation; liver biochemistry and pancreatic enzymes are normal. She is pain-free today and has been referred for elective cholecystectomy but has not yet undergone definitive treatment. She wishes to retain an oral or transdermal method and would accept a desogestrel progestogen-only pill. She has no other medical contraindication to hormonal contraception. Which contraceptive plan is most appropriate?

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

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Correct answer: C — Remove the patch and commence desogestrel immediately, without emergency contraception or additional precautions

Her recurrent biliary colic with ultrasonographically confirmed stones constitutes current symptomatic gallbladder disease, notwithstanding the absence of pain at consultation. Combined hormonal contraception is UKMEC 3 in this setting, whereas progestogen-only pills are UKMEC 2. Because she accepts a suitable non-oestrogen alternative, continued combined hormonal exposure is not the preferred plan. She is in week 2 of correctly used combined hormonal contraception and has completed more than 7 consecutive days of active use after the patch-free interval. FSRH switching guidance therefore supports immediate initiation of a desogestrel pill without additional contraceptive precautions. Intercourse yesterday occurred while the patch remained effective, so emergency contraception is not indicated. A delays modification of a UKMEC 3 method despite an acceptable alternative. B also prolongs oestrogen exposure; there is no requirement to wait for the next patch change. C incorrectly reclassifies protected intercourse as requiring emergency contraception and would unnecessarily interrupt immediate progestogen initiation. D applies the usual 2-day precaution for starting desogestrel without accounting for uninterrupted protection during a correctly timed week-2 switch. After successful cholecystectomy, combined hormonal contraception becomes UKMEC 2 and could be reconsidered following individual assessment.

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 UK Medical Eligibility Criteria for Contraceptive Use (2016, amended September 2019) — https://www.fsrh.org/Common/Uploaded%20files/Standards-and-Guidance/fsrh-ukmec-full-book-2019.pdf 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