Combined oral contraceptive pill: comorbidities

Question 1

Combined oral contraceptive pill: comorbidities

Answer 1

Women who present for contraceptive advice are generally in good health. There are however a number of conditions which may affect the choice of contraceptive:

During this discussion reference will be made to the UKMEC recommendations on contraceptions made by the Faculty of Sexual and Reproductive Health (FSRH):

• UKMEC 2: advantages generally outweigh the disadvantages
• UKMEC 3: disadvantages generally outweigh the advantages
• UKMEC 4: represents an unacceptable health risk

Question 2

Combined oral contraceptive pill: comorbidities

Smoking

Answer 2

The FSRH make the following UKMEC recommendations with respect to the combined oral contraceptive pill (COCP) due to the increased risk of cardiovascular disease:

• UKMEC 2: age < 35 years
• UKMEC 3: age > 35 years and smoking < 15 cigarettes/day
• UKMEC 4: age > 35 years and smoking > 15 cigarettes/day

There is no increased risk of cardiovascular disease with progestogen-only contraceptives so they are classed as UKMEC 1, regardless of the patient’s age/cigarette intake.

Question 3

Combined oral contraceptive pill: comorbidities

Obesity

Answer 3

Obesity increases the risk of venous thromboembolism for women taking the COCP. For the COCP the following recommendations are made:

• UKMEC 2: BMI 30-34 kg/m²
• UKMEC 3: BMI >= 35 kg/m²

All other methods of contraception have a UKMEC of 1.

Question 4

Combined oral contraceptive pill: comorbidities

Migraine

Answer 4

• The COCP is contraindicated (i.e. UKMEC 4) in patients with a history of migraine with aura.
• For patients who have migraines without aura the recommendation by the FSRH is that the COCP is UKMEC 3 for continued prescribing and UKMEC 2 for initiation.
• Progestogen only methods such as the progestogen-only pill (POP), implant and injection are UKMEC 2 and are hence better choices.

Question 5

Combined oral contraceptive pill: comorbidities

Epilepsey

Answer 5

There are a number of factors to consider for women with epilepsy:

• the effect of the contraceptive on the effectiveness of the anti-epileptic medication
• the effect of the anti-epileptic on the effectiveness of the contraceptive
• the potential teratogenic effects of the anti-epileptic if the woman becomes pregnant

Given the points above, the FSRH recommend the consistent use of condoms, in addition to other forms of contraception.

For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:

• UKMEC 3: the COCP and POP
• UKMEC 2: implant
• UKMEC 1: Depo-Provera, IUD, IUS

For lamotrigine:

• UKMEC 3: the COCP
• UKMEC 1: POP, implant, Depo-Provera, IUD, IUS

If a COCP is chosen then it should contain a minimum of 30 µg of ethinylestradiol.