Contraceptive choices: Using the UKMEC guidance

Contraceptive choices: Using the UKMEC guidance

INTRODUCTION

Many women using contraceptives are fit and healthy and the use of contraception therefore carries very low risk. However, some women have medical conditions or certain characteristics which increase the risks associated with some contraceptives. Knowing which methods are suitable for which women is essential knowledge for all clinicians prescribing contraception.¹

The Faculty of Sexual and Reproductive Health (FSRH) published the third edition of the UKMEC in May 2016,¹ following the latest WHO Medical Eligibility Criteria (MEC) guidelines. It is available to everyone on the FSRH website (www.fsrh.org). UKMEC 2016 includes some new conditions and removes others, removes guidance for certain contraceptives and clarifies certain risks in order to make it easier to use and more relevant to women living in the UK today.

HOW TO USE THE UKMEC

For each different contraceptive type (intrauterine contraceptives – IUD and IUS, progestogen only implants, progestogen only injections, combined hormonal contraceptives – pills, patches and rings, and progestogen only pills) each relevant medical condition is given a UKMEC category from category 1 to category 4.

In practice, this means:

• Category 1: no problem – the contraceptive method can definitely be used
• Category 2: the method can be used but consideration needs to be given to the risks
• Category 3: generally the method should not be used. An expert opinion should be obtained before prescribing the contraceptive method
• Category 4: the contraceptive method should not be used.

These categories relate to the safety of the method when used in women with a particular condition or characteristic. They do not reflect the efficacy of that method with that condition and/or treatment.

The categories are not additive. If a woman has 2 conditions or characteristics, which are UKMEC 2, this does not mean that the method is a UKMEC 4. However, if a woman has multiple UKMEC 2 conditions for one contraceptive method, the clinician should consider whether an alternative method would be more suitable.

Initiating and continuing methods

Sometimes the category an individual method is given will depend on whether the woman had the condition before that method was started (initiation) or whether the woman developed the condition whilst on the contraceptive method (continuation).

Clarification

For each medical condition or characteristic, clarification is given explaining the evidence.

Contraceptive methods

The only contraceptive methods considered in the new 2016 UKMEC are:

• Intrauterine contraceptive methods – both the copper IUD (Cu-IUD) and levonorgestrel IUS (LNG-IUS)
• The progestogen only implant
• The progestogen only injectable
• The progestogen only pill (POP)
• Combined hormonal contraception (CHC).

Emergency contraception (EC) is also considered and has been updated to include Ulipristal Acetate (UPA). The order in which the EC methods are presented reflects their decreasing efficacy i.e. from Copper IUD to UPA to levonorgestrel (LNG).

Medical conditions

As more women in the UK are living with more complex medical conditions, the UKMEC has included some new conditions, including:

• History of bariatric surgery
• Organ transplant
• Cardiomyopathy
• Cardiac arrhythmias
• Rheumatoid arthritis
• Positive antiphospholipid (aPL) antibodies.

Newer evidence and experience in clinical practice has led to revision of some sub-conditions. These include:

• The post-partum period
• Gestational trophoblastic disease
• Cervical cancer
• Infection with human immunodeficiency virus (HIV)
• Systemic lupus erythematosus (SLE).

Drug interactions

Some medications interact with hormonal contraceptives. Some can decrease the efficacy of hormonal contraceptives and, conversely, some hormonal contraceptives can affect other medications causing adverse effects. Unfortunately, any documented evidence on drug interactions can quickly become out of date as new drugs are developed and new evidence is found.

Where medications are known to interact with contraceptives (e.g. HIV, infection and epilepsy) there are reminders to check online drug interaction checkers (websites are documented) and/or the FSRH guideline on Drug interactions with hormonal contraception (available in the clinical guidance section of the FSRH website).

SUMMARY OF THE IMPORTANT CHANGES

At the beginning of the UKMEC 2016 guidance there is a helpful summary of the changes that have occurred since the last edition. General practice nurses should refer to the UKMEC 2016 for full details.

Post-partum period

Breast feeding women can now use CHC from 6 weeks to 6 months after delivery (UKMEC 2) as there has been no evidence that its use affects the outcome of the breast-fed child.

Cardiovascular disease

In women who have multiple risk factors for cardiovascular disease CHC is a UKMEC 3.

Cardiomyopathy with impaired cardiac function is UKMEC 2 except CHC, which is UKMEC 4.

In atrial fibrillation CHC is contraindicated (UKMEC 4). Other contraceptive methods are UKMEC 2 except the Cu-IUD which is UKMEC 1.

Bariatric surgery

Women who have had previous bariatric surgery can use any type of contraceptive freely (UKMEC 1) except for CHC. The use of CHC in the presence of bariatric surgery depends on their current BMI. If their BMI is less than 30, CHC is UKMEC 1, but this rises to 2 with a BMI of between 30 and 34, and to 3 if their BMI is 35 or more.

Organ transplant

If a woman has had an uncomplicated organ transplant, all methods, including CHC, are UKMEC 2. However, if the transplant is complicated, e.g. by graft failure or rejection, CHC and the initiation of a Cu-IUD and LNG-IUS are UKMEC 3.

Gestational trophoblastic disease

All non-intrauterine methods of contraception can be used at any point after gestational trophoblastic disease. The only concern is the use of intrauterine contraceptives when levels of beta-human chorionic gonadotropin (bHCG) hormone are still detectable. If there are persistently elevated levels of bHCG or malignant disease, intrauterine contraception is contraindicated (UKMEC 4), but if the levels of bHCG are decreasing, intrauterine contraception (Cu-IUD and LNG-IUS) are UKMEC 3.

Breast disease

If a woman develops a breast mass or breast symptoms while using CHC, she may continue with it (UKMEC 2), but if she had the symptoms before starting, CHC should be avoided (UKMEC 3).

Cervical cancer – radical trachelectomy

As the anatomy of the uterus will have altered due to the surgery, it is recommended that any intrauterine contraception is inserted in a specialist setting (UKMEC 3).

Asymptomatic chlamydia

If an asymptomatic woman is found to have chlamydia, the insertion of a Cu-IUD or LNG-IUS would be best delayed until she has been treated (UKMEC 3), unless it is needed for emergency contraception, when it can be inserted at the same time as treatment for chlamydia is initiated.

HIV infection

Generally, HIV infection does not prevent any contraceptive being used. However many antiretroviral medications can induce liver enzymes and therefore reduce the efficacy of most hormonal contraceptives. In view of the risk of infection, in women who have HIV infection and low CD4 counts (<200 cells/mm³), the initiation of an intrauterine method is UKMEC 3. If, however, they have a low viral load it may be appropriate.

Rheumatic diseases

This is a new addition to the UKMEC. Women who have rheumatoid arthritis can generally use all contraceptive methods (UKMEC 2) although the Cu-IUD is the only one that has unrestricted use (UKMEC 1).

In systemic lupus erythematosus (SLE), it is the presence or absence of antiphospholipid (aPL) antibodies that determines the suitability of most contraceptive methods. The Cu-IUD has unrestricted use (UKMEC 1) whether or not the woman has aPL antibodies. Other contraceptive methods are UKMEC 2 in women with SLE who do not have aPL antibodies. Any woman who has positive aPL antibodies (even if they do not have SLE) cannot use CHC (UKMEC 4) but all other contraceptives can generally be used (UKMEC 2).

SUMMARY

The UKMEC 2016 guidance provides up-to-date recommendations on the suitability of different contraceptive types for women with different medical conditions. The additional resources in the document to aid the correct diagnosis of migraine headaches, with or without aura, make the guidance an indispensable resource for all clinicians dealing with contraception. All clinicians should ensure they have easy access to this document during their clinics so that they can refer to it when needed.

REFERENCE

1. The Faculty of Sexual and Reproductive Healthcare FSRH 2016; UK Medical Eligibility Criteria for contraceptive use. UKMEC 2016. Available from http://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/

PRACTICE NURSE FEATURED ARTICLE 

Read this article in full: Best practice: the updated UKMEC contraception guidance Dr Caroline Taylor

ACTIVITY

Reflect on your consultations with the last 5 patients you saw for a repeat of their contraception:

Do you always remember to ask about any change to medical history, drug history and family history since their last review, as well as doing their blood pressure and BMI? Use every consultation to double check whether they have any condition that may affect their eligibility for a specific contraceptive method?

What, if any, changes could you make to your practice templates to ensure that this information is sought?