Selection of combined oral contraception in a medically eligible woman aged over 40 — DFSRH MCQ

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EasyRiskSelection of combined oral contraception in a medically eligible woman aged over 40DFSRH

A 42-year-old woman requests combined oral contraception for pregnancy prevention and control of predictable cyclical bleeding. She does not smoke, has a BMI of 26 kg/m² and a blood pressure of 118/72 mmHg. She has no migraine, cardiovascular disease, personal or family history of venous thromboembolism, or relevant medication use. Following discussion of alternative methods, she prefers a combined oral contraceptive but wishes to minimise her cardiovascular and thrombotic risk. Which is the most appropriate initial oral formulation?

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Correct answer: D — Ethinylestradiol 30 micrograms with levonorgestrel

Explanation lettering: C = shown as A · D = shown as B · A = shown as C · B = shown as D

Age over 40 does not by itself preclude combined hormonal contraception. This woman is under 50 and has no identified contraindication, so a combined oral contraceptive can be offered after counselling. The formulation should then be selected by considering both estrogen dose and progestogen type. FSRH advises that a preparation containing no more than 30 micrograms of ethinylestradiol with levonorgestrel or norethisterone is a reasonable first-line choice to minimise cardiovascular risk. Option B satisfies both components. Drospirenone, desogestrel and gestodene preparations are effective contraceptives but are associated with a less favourable venous thromboembolism risk profile than levonorgestrel-containing pills, making A, C and E less appropriate when risk minimisation is the stated priority. Option D contains norethisterone, a suitable progestogen from a thrombotic-risk perspective, but its 35-microgram ethinylestradiol dose is higher than the recommended first-line dose for a woman over 40. An estradiol-containing preparation should not be assumed to be safer solely on theoretical grounds, because comparative clinical safety evidence remains insufficient. Individual preference or non-contraceptive effects may justify another formulation after counselling, but they do not displace option B in this case.

Reference: FSRH Guideline: Combined Hormonal Contraception (October 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf FSRH Guideline: Combined Hormonal Contraception (October 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf