Assessment of suitability of CHC (combined hormonal contraception) for an individual woman
Assessment of medical eligibility for CHC should include medical conditions, lifestyle factors and family medical history.
A drug history should identify:-
any prescribed or non-prescribed drug that could affect the effectiveness of the contraceptive
any prescribed or non-prescribed drug that could itself be affected by the contraceptive
a recent, accurate blood pressure recording should be documented for all women prior to first CHC prescription
BMI should be documented for all women prior to CHC prescription
Pelvic examination is not required prior to initiation of CHC
Breast examination, cervical screening, testing for thrombophilia, hyperlipidaemia or diabetes mellitus and liver function tests are not routinely required prior to initiation of CHC
women for whom CHC is unsuitable should be offered alternative effective contraception
The HCP should obtain a history that includes the woman’s age, past and current medical conditions, smoking, drug history (prescription, non-prescription and herbal preparations) and family history of significant medical conditions. BMI and blood pressure should be recorded.
Assessment of medical eligibility for CHC
Medical history and lifestyle factors
Definition of categories for the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC)
Specific attention should be given to enquiring about:
additional risk factors for venous or arterial thromboembolism (e.g. smoking, obesity, recent childbirth, immobility, hypertension, migraine, diabetes, hyperlipidaemia, antiphospholipid antibodies, arrhythmia, complicated congenital/valvular heart disease or cardiomyopathy)
personal history of breast cancer/known breast cancer-related gene mutation
hepatobiliary disease
recent childbirth, current breastfeeding
Measurements and tests
blood pressure and body mass index (BMI) should be documented for all women before prescription of CHC. The prescriber must be confident that measurements are recent and accurate
Blood pressure:
women with severe hypertension (systolic pressure ≥160 mmHg or diastolic pressure ≥100 mmHg) should not use CHC (UKMEC 4)
women with less severe hypertension (systolic pressure 140–159 mmHg or diastolic pressure 90–99 mmHg), or with adequately controlled hypertension should not use CHC (UKMEC 3)
blood pressure should therefore be evaluated before initiating CHC
Weight (BMI):
women with BMI <35 kg/m2 generally can use CHC (UKMEC 2)
women with BMI >= 35 kg/m2 generally should not use CHC (UKMEC 3), although CHC may be prescribed by a specialist provider
BMI should be documented before starting CHC. Baseline weight could additionally be helpful for monitoring any changes and counselling women who might be concerned about later weight change perceived to be associated with their contraceptive method
Pelvic examination:
a consultation regarding contraception may be used as an opportunity for health screening but screening should not be a condition for prescribing. Pelvic examination is not necessary before initiation of CHC because it does not affect the decision to prescribe or withhold hormonal contraception
Clinical breast examination:
although women with current breast cancer should not use CHC (UKMEC 4), screening asymptomatic women with a clinical breast examination before initiating CHC is not necessary because of the low prevalence of breast cancer among women of reproductive age
Assessment of factors that could affect contraceptive effectiveness
Drug interactions
some medications could reduce the contraceptive effectiveness of CHC by induction of hepatic enzymes. Contraceptive hormones can affect the action of certain medications.
Malabsorption
the effectiveness of COC (but not the CTP or CVR) could be reduced by malabsorption resulting from, for example, vomiting and severe diarrhoea
Key messages for women considering use of tailored combined hormonal contraception regimens
the evidence from studies is that combined hormonal contraception (CHC) is as safe and at least as effective for contraception if it is taken as an extended or continuous regimen as it is when it is taken in a traditional 21/7 cycle
a woman who is using CHC does not need to have a monthly withdrawal bleed to be healthy.
there is no build-up of menstrual blood inside a woman who uses CHC for an extended time without a break; extended CHC use keeps the lining of the womb thin
withdrawal bleeds during cyclical use of CHC have been reported by women who are pregnant; women should not consider monthly bleeds on CHC to be reassurance that they are not pregnant
by using extended or continuous CHC the frequency of withdrawal bleeds and associated symptoms (e.g. headache, mood change) is reduced; this could be useful for women who have heavy or painful bleeding or problematic symptoms associated with the hormone-free interval (HFI)
the ovaries start to become active during the traditional 7-day HFI. Fewer and/or shorter breaks in CHC use could mean that the risk of pregnancy could theoretically be lower with extended or continuous regimens than if a 7-day break is taken every month
there can be irregular bleeding or spotting in the first few months of CHC use, particularly with extended or continuous regimens; this does not usually mean that there is any medical problem and it generally improves with time
the evidence from studies is that using extended or continuous regimens of CHC does not affect the return of a woman’s fertility when she stops CHC.
Women using combined hormonal contraception: key indications for medical review Key symptoms that should prompt women to seek urgent medical review
calf pain, swelling and/or redness
chest pain and/or breathlessness and/or coughing up blood
loss of motor or sensory function
Key symptoms that should prompt women to seek medical review
breast lump, unilateral nipple discharge, new nipple inversion, change in breast skin
new onset migraine
new onset sensory or motor symptoms in the hour preceding onset of migraine
persistent unscheduled vaginal bleeding
New medical diagnoses that should prompt women to seek advice from their contraceptive provider (and review of the suitability of CHC)
high blood pressure
high body mass index (>35 kg/m2)
migraine or migraine with aura
deep vein thrombosis or pulmonary embolism
blood clotting abnormality
antiphospholipid antibodies
angina, heart attack, stroke or peripheral vascular disease
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