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Severe asthma requiring long-term systemic corticosteroids — DFSRH MCQ

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EasyAsthmaSevere asthma requiring long-term systemic corticosteroidsDFSRH

A 26-year-old woman with severe asthma requests long-acting reversible contraception. Her asthma treatment includes high-dose inhaled therapy and prednisolone 7.5 mg daily, which she has taken continuously for 18 months. Her BMI is 18.7 kg/m², and she sustained a distal radial fracture after falling from standing height last year. She does not smoke and takes no enzyme-inducing medication. She would prefer depot medroxyprogesterone acetate because she hopes to become amenorrhoeic. She declines intrauterine contraception but would accept a contraceptive implant. Pregnancy has been reasonably excluded. 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 in preference to depot medroxyprogesterone acetate

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

This woman has several clinically important risk factors for reduced bone mineral density and fragility fracture: prolonged systemic corticosteroid exposure, low BMI and a previous low-trauma fracture. Depot medroxyprogesterone acetate suppresses ovarian oestrogen production and is associated with a small loss of bone mineral density, usually recovering after discontinuation. FSRH advises considering other contraceptive methods when significant medical or lifestyle risk factors for osteoporosis are present. The etonogestrel implant provides highly effective, non-user-dependent contraception, meets her preference for a non-intrauterine LARC and avoids the established hypo-oestrogenic effect of DMPA. Its bleeding pattern must nevertheless be discussed; amenorrhoea cannot be guaranteed. A is incorrect because routine bone densitometry before DMPA is not recommended and a measurement would not remove her cumulative skeletal risk. B is incorrect because calcium and vitamin D support general bone health but do not negate DMPA-associated oestrogen suppression. C reflects the standard requirement to reassess prolonged DMPA use, but waiting 2 years is inappropriate when substantial baseline osteoporosis risk and an acceptable alternative already exist. D avoids DMPA-related skeletal concerns but is user-dependent and therefore does not meet her stated preference as well as the implant.

Reference: FSRH Guideline: Progestogen-only Injectable Contraception (December 2014, amended July 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/progestogen-only-injectable-december-2014-amended-11july2023.pdf SAYANA PRESS 104 mg/0.65 ml suspension for injection: Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/3148/smpc