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Coeliac disease with reduced bone mineral density — DFSRH MCQ

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EasyCoeliac DiseaseCoeliac disease with reduced bone mineral densityDFSRH

A 29-year-old woman requests non-oral contraception. She was recently diagnosed with coeliac disease following prolonged diarrhoea and weight loss. Her BMI is 17.8 kg/m², serum 25-hydroxyvitamin D remains low despite initial replacement, and DXA shows a lumbar-spine Z-score of −2.4. She is now following a gluten-free diet and is undergoing specialist management of her metabolic bone health. She declines intrauterine contraception and is deciding between depot medroxyprogesterone acetate and the etonogestrel implant. She accepts unpredictable bleeding and has no other medical contraindication to either method. Pregnancy is reasonably excluded. Which is the most appropriate contraceptive plan?

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

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Correct answer: D — Initiate the etonogestrel implant and continue coeliac-related bone management

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

The etonogestrel implant is the most appropriate option. This patient has several clinically significant risk factors for osteoporosis: coeliac disease, low BMI, persistent vitamin D deficiency and already documented low bone mineral density. FSRH advises considering contraceptive methods other than depot medroxyprogesterone acetate (DMPA) in women with significant medical or lifestyle risk factors for osteoporosis. DMPA suppresses ovarian oestrogen production and is associated with a small, usually reversible reduction in bone mineral density. A is therefore less appropriate: vitamin D replacement does not remove her existing skeletal risk or negate DMPA-associated bone loss. B is attractive because it proposes surveillance, but FSRH states that evidence is insufficient to recommend routine DXA monitoring specifically for DMPA users; monitoring does not prevent additional bone loss. C meets her request for effective, non-oral, non-intrauterine contraception without the established DMPA-associated skeletal effect. Evidence concerning implant-related bone loss is limited, but there is insufficient evidence of harm to warrant routine BMD monitoring. D is incorrect because low BMD is not a contraindication to the implant. E is inappropriate because combined hormonal contraception should not be prescribed as treatment for reduced BMD; her coeliac disease and nutritional bone disease require continued specialist management.

Reference: FSRH Progestogen-only Injectable Contraception (December 2014; amended 11 July 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/progestogen-only-injectable-december-2014-amended-11july2023.pdf FSRH Guideline: Progestogen-only Implant (February 2021; amended 10 July 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-progestogen-only-implants.pdf NICE NG20: Coeliac disease—recognition, assessment and management (2 September 2015) — https://www.nice.org.uk/guidance/ng20/chapter/Recommendations