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Persistent undiagnosed breast lump in a current combined hormonal contraceptive user — DFSRH MCQ

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HardBenign Breast DiseasePersistent undiagnosed breast lump in a current combined hormonal contraceptive userDFSRH

A 36-year-old woman attends a sexual and reproductive health clinic for repeat combined oral contraception. She has used a 30 microgram ethinylestradiol/levonorgestrel pill for 3 years and values its control of dysmenorrhoea. She has no contraindication to combined hormonal contraception. Ten days ago, she noticed a new lump in her left breast. Examination identifies a 22 mm discrete, smooth, mobile, mildly tender mass in the upper outer quadrant. There is no skin tethering, nipple abnormality or axillary lymphadenopathy. The mass has persisted unchanged through her subsequent hormone-free interval and withdrawal bleed. She has no previous breast disease or relevant family history. Pregnancy testing is negative. She asks whether she may continue her current pill while the lump is investigated. Which is the most appropriate management plan?

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Correct answer: D — Make a suspected cancer pathway referral and continue the combined oral contraceptive pending assessment

The smooth, mobile and tender character makes a benign lesion such as a cyst or fibroadenoma plausible, but clinical phenotype cannot establish the diagnosis. Because she is aged 30 or older and has a persistent unexplained discrete breast lump, NICE recommends referral through a suspected cancer pathway; pain does not reduce the required referral priority. Further observation or routine referral is therefore inappropriate. ([nice.org.uk](https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer?utm_source=openai)) The contraceptive decision depends on distinguishing initiation from continuation. FSRH classifies combined hormonal contraception as UKMEC 3 for initiation in someone with undiagnosed breast symptoms, but UKMEC 2 for continuation. As she is an established user with no independent contraindication, the advantages of continuing generally outweigh the theoretical risk while prompt breast assessment proceeds. ([fsrh.org](https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf)) A is wrong because persistence across the hormone-free interval does not justify delaying assessment of a discrete lump. B applies insufficient urgency at her age. C incorrectly treats undiagnosed symptoms as confirmed breast cancer; current breast cancer would make combined hormonal contraception UKMEC 4. D offers a medically suitable non-hormonal method, but an invasive method change is not required solely because investigation is pending and disregards her preference for the pill's non-contraceptive benefit.

Reference: Suspected cancer: recognition and referral (NG12) — Recommendations organised by site of cancer (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer 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