Obstetrics and gynaecology · Moderate
This case is fictional and exists for study. It describes no real patient.
28 years · female
A 28-year-old woman attends a primary care clinic requesting advice on initiating hormonal contraception after starting a new relationship. During the medical history, she reports a 6-month history of monthly episodic headaches. These headaches are unilateral and throbbing, and they are typically preceded by 20 minutes of shimmering lights and jagged lines in her visual field. She has no other past medical history and takes no regular medications. On physical examination, her vital signs are normal, and a complete neurological examination shows no focal deficits.
Vital signs
- HR
- 72 bpm
- BP
- 118/76 mmHg
- RR
- 14/min
- Temp
- 36.6 °C
- SpO₂
- 98%
Examination findings
- Unremarkable neurological examination
- Normal cardiovascular examination
- Normal abdominal examination
Investigations
| Haemoglobin | 13.2 g/dL | reference: 12.0-15.5 |
| Urine hCG | Negative | reference: Negative |
Question 1 of 3
Which of the following contraceptive methods is the single most appropriate initial recommendation for this patient?
The patient has a history of migraine with visual aura (focal neurological symptoms). Oestrogen-containing contraceptives (combined oral contraceptive pill, combined transdermal patch, and combined vaginal ring) are contraindicated in women who experience migraine with aura due to a significantly increased risk of ischaemic stroke. Progestogen-only methods, such as the subdermal implant, progestogen-only pill, or progestogen-releasing intrauterine system, do not carry this risk and are safe to use.
Teaching point: Combined oestrogen-containing contraceptives are strictly contraindicated in patients with migraine with aura due to an elevated risk of ischaemic stroke.
Question 2 of 3
According to the UK Medical Eligibility Criteria (UKMEC) for contraceptive use, how is the patient's neurological history categorized regarding combined hormonal contraception?
Migraine with aura at any age falls under UKMEC Category 4 for combined hormonal contraceptives, which represents an unacceptable health risk. Category 1 indicates no restriction; Category 2 means advantages outweigh theoretical/proven risks; Category 3 indicates theoretical/proven risks usually outweigh advantages; Category 4 indicates an unacceptable health risk.
Teaching point: Migraine with aura is classified as UKMEC Category 4 for combined hormonal contraception.
Question 3 of 3
The patient chooses to start a desogestrel 75 microgram progestogen-only pill (POP). Which of the following statements represents accurate counselling regarding this specific medication?
Desogestrel POP has a missed-pill window of 12 hours (unlike traditional POPs which have a 3-hour window). If a desogestrel pill is missed by more than 12 hours, the user should take the missed pill as soon as remembered, continue daily pills, and use additional barrier protection (such as condoms) for 48 hours. Option D describes traditional POPs (e.g., levonorgestrel/norethisterone). Option C is incorrect because emergency contraception is only considered if unprotected intercourse occurred during the window of reduced protection and risk of ovulation. Option A describes the missed-pill rule for combined oral contraceptives (7 days), whereas POPs require only 48 hours.
Teaching point: Desogestrel progestogen-only pills have a 12-hour missed-pill window and require 48 hours of additional barrier precautions if missed.
Key learning points
- Migraine with visual or focal neurological aura is a UKMEC 4 contraindication to combined oestrogen-containing contraception due to stroke risk.
- Progestogen-only methods (POP, implant, depot injection, IUS) are safe options for patients with migraine with aura.
- Desogestrel progestogen-only pills have a 12-hour window before being considered missed, requiring 48 hours of extra precautions if late.
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