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Family history of early-onset venous thromboembolism with negative targeted thrombophilia testing — DFSRH MCQ

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EasyThrombophiliaFamily history of early-onset venous thromboembolism with negative targeted thrombophilia testingDFSRH

A 29-year-old woman requests the combined vaginal ring. Her brother had an unprovoked pulmonary embolism at 38 years and was found to be heterozygous for factor V Leiden. She has never had venous thromboembolism and previously underwent targeted testing for the familial factor V Leiden variant, which was negative. She has a BMI of 22 kg/m², does not smoke and has no other cardiovascular risk factors. She dislikes daily tablets but would accept a contraceptive implant. Which is the most appropriate contraceptive management?

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

Reveal the answer and explanation

Correct answer: A — Offer an etonogestrel implant because the early first-degree VTE history makes CHC UKMEC 3

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

Her brother is a first-degree relative who experienced VTE before 45 years of age. Under UKMEC, this makes combined hormonal contraception—including combined pills, patches and vaginal rings—UKMEC 3: its risks usually outweigh its benefits, and it is not usually recommended when an acceptable alternative exists. Her negative targeted factor V Leiden result excludes that identified familial variant but does not remove the independent risk signal from her family history or exclude other inherited and familial contributors to VTE. The implant is UKMEC 1 for family history of VTE and matches her preference for a non-daily method. A is incorrect because a lower-risk combined pill formulation does not override the UKMEC 3 classification. C is incorrect because vaginal delivery does not make a combined oestrogen-containing method exempt from CHC eligibility criteria. D is incorrect because routine thrombophilia testing of asymptomatic first-degree relatives is not recommended, and contraception need not be delayed when an appropriate non-oestrogen method is acceptable. E is incorrect because the LNG-IUD is suitable, but the premise is false: the implant and other progestogen-only methods are not UKMEC 3 solely because of this family history.

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: UKMEC 2016 (2016; amended September 2019) — https://www.fsrh.org/Common/Uploaded%20files/Standards-and-Guidance/fsrh-ukmec-full-book-2019.pdf Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (Published 26 March 2020; last updated 2 August 2023) — https://www.nice.org.uk/guidance/ng158/chapter/Recommendations