Contraception and special groups

See also the separate Contraception from 40 to the Menopause and Postpartum Contraception articles.

UK Medical Eligibility Criteria¹

The UK Medical Eligibility Criteria (UKMEC) for contraceptive use (latest version 2009) are based on that published by the World Health Organization (WHO). They set out cautions and contra-indications for contraceptive use. Categories are as follows:

• Category 1: a condition for which there is no restriction for the use of the contraceptive method.

• Category 2: a condition for which the advantages of using the method generally outweigh the theoretical or proven risks.

• Category 3: a condition for which the theoretical or proven risks of using the method generally outweigh the advantages. The method is not usually recommended.

• Category 4: a condition which represents an unacceptable risk to health if the method is used.

Contraception for women who are obese²

• Intrauterine contraception (IUC): highly effective and evidence suggests safety and effectiveness not affected by body weight or body mass index (BMI).

• Progestogen-only implants: the etonogestrel (ENG) implant is highly effective and evidence suggests safety and effectiveness not affected by body weight or BMI.

• Progestogen-only injectable:

  • Evidence suggests effectiveness of depot medroxyprogesterone acetate (DMPA) is not affected by body weight or BMI.

  • From the limited evidence available it is not possible to confirm or exclude a causal association between DMPA use and venous thromboembolism (VTE).

  • Whilst obesity alone does not restrict the use of DMPA (UKMEC 1), DMPA use becomes a UKMEC 3 when obesity is one of multiple risk factors for cardiovascular disease (eg, smoking, diabetes and hypertension).

  • DMPA use appears to be associated with some weight gain, particularly in women under 18 years of age with a BMI ≥30 kg/m².

  • If using intramuscular DMPA or norethisterone enanthate injectable, consider use of a longer-length needle or deltoid administration to ensure the muscle layer is reached.

• Progestogen-only pill (POP):

  • Evidence suggests safe and effectiveness of the progestogen-only pill (POP) is not affected by body weight or BMI.

  • Double-dose POP for contraception is not recommended for women with overweight or obesity.

• Combined hormonal contraception (CHC):

  • Most evidence suggests effectiveness of combined oral contraception (COC) is not affected by body weight or BMI.

  • Limited evidence suggests possible reduction in patch effectiveness in women weighing ≥90 kg.

  • Limited evidence suggests effectiveness of the vaginal ring is not affected by body weight or BMI.

  • Combined hormonal contraception (CHC) use is UKMEC 2 for use by women with BMI ≥30–34 kg/m² and UKMEC 3 for women with BMI ≥35 kg/m².

  • Women with obesity should be informed that:

    • Risk of thrombosis increases with increasing BMI.

    • Current CHC use is associated with increased risk of VTE.

    • Current CHC use is associated with a small increased risk of myocardial infarction and ischaemic stroke.

    • If BMI is ≥35 kg/m² the risks associated with use of CHC generally outweigh the benefits.

• Emergency contraception (EC):

  • Evidence suggests effectiveness of the copper intrauterine device (Cu-IUD) is not affected by body weight or BMI.

  • 1.5 mg levonorgestrel emergency contraception (LNG-EC) appears to be less effective in women with BMI >26 kg/m² or weight >70 kg.

  • Ulipristal acetate EC (UPA-EC) may be less effective in women with BMI >30 kg/m² or weight >85 kg.

  • Women should be informed that the Cu-IUD is the most effective method of EC.

  • Women should be informed that BMI >26 kg/m2 or weight >70 kg may reduce the effectiveness of oral EC, particularly of LNG-EC.

  • Consider UPA-EC and, if this is not suitable, double-dose (3 mg) LNG-EC if BMI >26 kg/m² or weight >70 kg. The effectiveness of double-dose LNG-EC is unknown.

  • Double-dose UPA-EC is not recommended for women of any body weight or BMI.

• Weight-loss medication and contraception: it is possible that medications that induce diarrhoea and/or vomiting (e.g. orlistat, laxatives) could reduce the effectiveness of POP, COC and oral EC.

• Weight-loss surgery and contraception:

  • Non-oral contraceptives appear to be safe and effective.

  • For women with BMI ≥35 kg/m², risks associated with CHC use generally outweigh the benefits.

  • Effectiveness of oral contraception (OC), including oral EC, could be reduced by bariatric surgery and OC should be avoided in favour of non-oral methods of contraception.

  • Women should be advised to stop CHC and to switch to an alternative effective contraceptive method at least 4 weeks prior to planned major surgery (eg bariatric surgery) or an expected period of limited mobility.

Contraception for those also taking enzyme-inducing medication³

Liver enzyme-inducing drugs include:

• Antibiotics: rifampicin (potent inducer); rifabutin.

• Antiepileptics: carbamazepine; eslicarbazepine; oxcarbazepine; phenytoin; phenobarbital; primidone; rufinamide; topiramate (weak inducer).

• Antiretrovirals:

  • Protease inhibitors: ritonavir, atazanavir, darunavir, fosamprenavir, lopinavir, nelfinavir, saquinavir, and tipranavir.

  • Non-nucleoside reverse transcriptase inhibitors: efavirenz, nevirapine.

• Others: bosentan; modafinil; aprepitant; St John's Wort.

Advise on the potential interaction with hormonal contraception.

Advise reliable methods of contraception that are unaffected by enzyme-inducers (Cu-IUD, LNG-IUS, and the progestogen-only injectable).

Emergency contraception

• Take a total dose of 3 mg levonorgestrel as a single dose as soon as possible and within 72 hours of unprotected sex.

• Use of ulipristal acetate (UPA) is not advised in women using enzyme-inducing drugs or in those who have taken them in the preceding 28 days.

• Consider the use of a Cu-IUCD, which is unaffected.

Lamotrigine:

• Although not thought to be an enzyme-inducing drug, may interact with CHC and the POP. Avoid CHC as risks may outweigh the benefits. CHC may lead to decreased seizure control in the active hormone phase and increased lamotrigine exposure with a risk of toxicity in the hormone-free week. Desogestrel might increase lamotrigine levels and adverse effects.

• POP may increase lamotrigine levels. Monitor for adverse effects of lamotrigine. No additional precautions are needed.

Griseofulvin:

• Although not thought to be an enzyme-inducing drug, the contraceptive efficacy of CHC, POP, and the progestogen-only implant may be reduced by concurrent use.

• Do not use the POP or the progestogen-only implant.

• Avoid CHC as the risks may outweigh the benefits.

• Theoretical risk of teratogenic effects with griseofulvin, so using condoms during treatment and for 28 days after is also recommended.

Migraine headaches³

• Non-migrainous headaches: all hormonal and intrauterine methods of contraception can be used without restriction (UKMEC 1).

• Migraine without aura:

  • Combined hormonal contraception (pill, patch, or vaginal ring) can be initiated (UKMEC 2). However, if a migraine without aura develops in a woman already using a CHC, an alternative form of contraception should be considered as the risks of using the CHC would outweigh the benefits (UKMEC 3).

  • All other hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

• Migraine with aura:

  • Do not use CHC due to unacceptable health risks (UKMEC 4).

  • All other hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

• In women with a past history (5 years or more) of migraine with aura:

  • CHC is not recommended as the risks outweigh the benefits (UKMEC 3).

  • All other hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

Diabetes mellitus³

• In women with diabetes mellitus and no vascular disease: all hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

• In women with diabetes mellitus and nephropathy, retinopathy, neuropathy, or other vascular disease:

  • Combined hormonal contraception (pill, transdermal patch, or vaginal ring) is not recommended as the risks of using outweigh the benefits (UKMEC 3).

  • All other hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

• In women with a history of gestational diabetes: all hormonal and intrauterine methods of contraception can be used without restriction (UKMEC 1).

Hypertension³

In women with hypertension without cardiovascular disease:

• Do not use combined hormonal contraception (pill, transdermal patch, or vaginal ring) in the following circumstance due to the unacceptable health risk (UKMEC 4):

  • Blood pressure consistently 160/100 mmHg or higher.

• CHC is not recommended in the following circumstances as the risks of using outweigh the benefits (UKMEC 3):

  • Adequately controlled hypertension.

  • Systolic blood pressure more than 140–159 mmHg or diastolic blood pressure more than 90–99 mmHg.

• All other hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

In women with hypertension and cardiovascular disease:

• Do not use CHC due to the unacceptable health risk (UKMEC 4).

• The progestogen-only injection is not recommended as the risks of using outweigh the benefits (UKMEC 3).

• All other hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

Smoking³

• Women of any age who smoke may use all methods of contraception other than combined hormonal contraception without restriction. Other than combined hormonal contraception, all are UKMEC category 1.

• Do not use combined hormonal contraception (pill, transdermal patch, or vaginal ring) in the following circumstance due to unacceptable health risks (UKMEC 4):

  • Age 35 years or older and smokes 15 cigarettes or more daily.

• CHC is not recommended in the following circumstances as the risks of using outweigh the benefits (UKMEC 3):

  • Age 35 years of age or older and smokes less than 15 cigarettes a day.

  • Age 35 years of age or older and stopped smoking less than 1 year ago.

• All other hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

Multiple risk factors for cardiovascular disease³

In women with multiple risk factors for cardiovascular disease (eg smoking, diabetes, hypertension, obesity, and dyslipidaemias), the following methods are not recommended as the risks of using outweigh the benefits (UKMEC 3):

• Combined hormonal contraception (pill, transdermal patch, or vaginal ring).

• The progestogen-only injectables.

All other hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

Venous thromboembolism or risk of thromboembolism³

In women with venous thromboembolism (VTE) or a history of VTE, do not use combined hormonal contraception (pill, transdermal patch, or vaginal ring) in the following circumstances due to the unacceptable health risk (UKMEC 4):

• History of VTE.

• Current VTE (on anticoagulants).

• Major surgery with prolonged immobilization.

CHC is not recommended in the following circumstances as the risks of using outweigh the benefits (UKMEC 3):

• Family history of VTE in first-degree relative younger than 45 years of age.

• Immobility unrelated to surgery (for example wheelchair use or debilitating illness).

All other hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

A causal relationship between the POP and VTE has not been demonstrated.⁴

Menorrhagia and fibroids³

Idiopathic menorrhagia:

• All hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

• To help with symptom control, consider recommending the levonorgestrel intrauterine system (LNG-IUS) first line, the combined oral contraceptive (COC) pill second line, and the progestogen-only pill (POP) or progestogen-only injectables third line, provided there are no contraindications.

Unexplained vaginal bleeding:

• Do not initiate the copper intrauterine device (Cu-IUD) or the LNG-IUS, due to unacceptable health risks (UKMEC 4). However, the device can be left in place if the woman already has one fitted, as the advantages generally outweigh the theoretical or proven risks (UKMEC 2).

• The progestogen-only implant and progestogen-only injectable are not recommended as the risks of using outweigh the benefits (UKMEC 3).

• All other hormonal methods of contraception can be used as the benefits generally outweigh the risks (UKMEC 2).

History of ectopic pregnancy: all hormonal and intrauterine methods of contraception can be used without restriction (UKMEC 1).

Uterine fibroids:

• If no distortion of the uterine cavity: all hormonal and intrauterine methods of contraception can be used without restriction (UKMEC 1).

• If distortion of the uterine cavity: the Cu-IUD and LNG-IUS are not recommended as the risks of using outweigh the benefits (UKMEC 3). All other hormonal methods of contraception can be used without restriction (UKMEC 1).

Sexually transmitted infection or pelvic inflammatory disease³

Pelvic inflammatory disease (PID):

• Past infection, assuming there are no current risk factors for sexually transmitted infections (STIs): all hormonal and intrauterine methods of contraception can be used without restriction (UKMEC 1).

• Current infection:

  • Do not initiate the copper intrauterine device (Cu-IUD) or levonorgestrel intrauterine system (LNG-IUS) due to unacceptable health risks (UKMEC 4). However, the device can be left in place if the woman already has one fitted, as the advantages generally outweigh the theoretical or proven risks (UKMEC 2).

  • All other hormonal methods of contraception can be used without restriction (UKMEC 1).

Chlamydial infection:

• Current symptomatic infection: do not initiate the Cu-IUD or LNG-IUS, due to unacceptable health risks (UKMEC 4). However, the device can be left in place if the woman already has one fitted, as the advantages generally outweigh the theoretical or proven risks (UKMEC 2). All other hormonal methods of contraception can be used without restriction (UKMEC 1).

• Current asymptomatic infection: the Cu-IUD and the LNG-IUS are not recommended as the risks of using outweigh the benefits (UKMEC 3). However, the device can be left in place if the woman already has one fitted, as the advantages generally outweigh the theoretical or proven risks (UKMEC 2). All other hormonal methods of contraception can be used without restriction (UKMEC 1).

Current purulent cervicitis or gonorrhoea: do not initiate the Cu-IUD or LNG-IUS, due to unacceptable health risks (UKMEC 4). However, the device can be left in place if the woman already has one fitted, as the advantages generally outweigh the theoretical or proven risks (UKMEC 2). All other hormonal methods of contraception can be used without restriction (UKMEC 1).

Vaginitis (including Trichomonas vaginalis and bacterial vaginosis), other current STIs (excluding HIV and hepatitis), or increased risks for STIs: all hormonal and intrauterine methods of contraception can be used (UKMEC 1 or 2).

Contraception for those with learning disabilities³

• For women with learning disabilities there is high use of injectable contraceptives and IUCDs. However, management of contraceptive needs of young women with an intellectual disability is similar in most cases to the management of non-disabled women.

• A person with learning disability or mental impairment may be competent to make an informed choice regarding method of contraception and be able to use any method reliably. An assessment of competence to consent to treatment should be made.

• It is therefore essential to consider the individual circumstances and wishes of women with learning disabilities and not necessarily opt for those methods that do not require the understanding and involvement of the user.

• A woman with an intellectual disability may need the assistance of an experienced worker to fully explain contraceptive options in order to make an informed choice. She should be supported in making her own decision.