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Symptomatic endometriosis requiring relugolix combination therapy — DFSRH MCQ

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HardEndometriosisSymptomatic endometriosis requiring relugolix combination therapyDFSRH

A 35-year-old woman with laparoscopically confirmed endometriosis has persistent dysmenorrhoea and non-menstrual pelvic pain despite previous laparoscopic excision and continuous desogestrel. Following specialist review, she elects to start relugolix–estradiol–norethisterone (Ryeqo). Pregnancy has been excluded and initiation will be timed appropriately. She has no history of thromboembolism, migraine with aura, osteoporosis, severe liver disease or other contraindication. She does not wish to conceive, declines intrauterine contraception and asks about contraceptive cover, including what to do if tablets are missed or treatment is stopped. Which advice is most appropriate?

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Correct answer: E — Stop desogestrel before Ryeqo and use non-hormonal contraception for at least 1 month; after two or more consecutive missed tablets use non-hormonal contraception for 7 days; start alternative contraception immediately on cessation.

Ryeqo is a NICE-recommended option for symptomatic endometriosis in adults of reproductive age who have already received medical or surgical treatment, as in this case. Its contraceptive sequence differs from that of conventional combined hormonal contraception. Hormonal contraception must be stopped before Ryeqo because concomitant use is contraindicated. A non-hormonal method is required for at least the first month. Thereafter, relugolix suppresses follicular development and the LH surge, and Ryeqo provides adequate contraception when taken at the recommended dose. If two or more tablets are missed on consecutive days, contraceptive protection may be reduced and non-hormonal contraception is required for the next 7 days. Ovulation returns rapidly after discontinuation, so alternative contraception must start immediately rather than waiting for bleeding. A and E incorrectly overlap Ryeqo with desogestrel; A also delays contraception after cessation. B applies a 7-day rather than 1-month initiation interval. C resembles the advice for linzagolix, which has not been demonstrated to provide contraception, but unnecessarily requires non-hormonal contraception throughout Ryeqo treatment and gives incorrect missed-dose and cessation advice.

Reference: Relugolix–estradiol–norethisterone for treating symptoms of endometriosis: Recommendation (16 April 2025) — https://www.nice.org.uk/guidance/ta1057/chapter/1-Recommendation Ryeqo 40 mg/1 mg/0.5 mg film-coated tablets: Summary of Product Characteristics (Text revised 27 August 2024) — https://www.medicines.org.uk/emc/product/12934/smpc