Combined_Oral_Contraceptive_Pill_Contraindications_Flashcards
What guides the decision to start a woman on the combined oral contraceptive pill?
The decision is guided by the UK Medical Eligibility Criteria (UKMEC).
What is UKMEC 1?
A condition for which there is no restriction for the use of the contraceptive method.
What is UKMEC 2?
Advantages generally outweigh the disadvantages.
What is UKMEC 3?
Disadvantages generally outweigh the advantages.
What is UKMEC 4?
Represents an unacceptable health risk.
What are examples of UKMEC 3 conditions?
More than 35 years old and smoking less than 15 cigarettes/day, BMI > 35 kg/m^2, family history of thromboembolic disease in first degree relatives < 45 years, controlled hypertension, immobility (e.g. wheelchair use), carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2), current gallbladder disease.
What are examples of UKMEC 4 conditions?
More than 35 years old and smoking more than 15 cigarettes/day, migraine with aura, history of thromboembolic disease or thrombogenic mutation, history of stroke or ischaemic heart disease, breastfeeding < 6 weeks postpartum, uncontrolled hypertension, current breast cancer, major surgery with prolonged immobilisation, positive antiphospholipid antibodies (e.g. in SLE).
How is diabetes mellitus diagnosed > 20 years ago classified?
It is classified as UKMEC 3 or 4 depending on severity.
What change occurred in 2016 regarding UKMEC classification?
Breastfeeding 6 weeks - 6 months postpartum was changed from UKMEC 3 to UKMEC 2.
summarise
Combined oral contraceptive pill: contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
family history of thromboembolic disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
Examples of UKMEC 4 conditions include
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
positive antiphospholipid antibodies (e.g. in SLE)
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
Changes in 2016
breast feeding 6 weeks - 6 months postpartum was changed from UKMEC 3 → 2
A 33-year-old woman presents to the GP requesting the combined oral contraceptive pill. She suffers with severe unilateral headaches and describes a sensation of pins and needles which spread up her arm before the headache onset. She smokes 10-20 cigarettes most weekends and has a BMI (body mass index) of 34 kg/m². There is a family history of thromboembolic disease in her younger sister. Which single part of the history represents the strongest contraindication to prescribing the combined oral contraceptive?
Patient age
BMI
Smoking history
Migraine with aura
Family history
Migraine with aura
The patient’s headache is strongly suggestive of a diagnosis of migraine. Migraine with aura is classified as UKMEC 4 (represents an unacceptable health risk in the prescription of the combined oral contraceptive pill). Although the majority of patients who experience aura describe visual phenomena, some have sensorimotor symptoms including paraesthesia, focal weakness or dysphasia.
The other elements of the history would certainly have an additive effect and should encourage a discussion about more appropriate options for contraception but migraine with aura is the single greatest contraindication.
A 25-year-old woman is to have an elective laparoscopic cholecystectomy in 8 weeks time. She takes no medications other than the combined oral contraceptive pill. What should be done with regards to her pill and her upcoming surgery?
Nothing, she can continue as normal
Stop the pill now, and restart as soon as she can tolerate oral intake after surgery
Stop the pill now, and restart 2 weeks after surgery
Stop the pill 4 weeks before surgery and restart 2 weeks after surgery
Stop the pill on the day of surgery and restart 2 weeks after surgery
Stop the pill 4 weeks before surgery and restart 2 weeks after surgery
This is a very common situation for surgical patients. The combination of undergoing surgery (especially abdominal or lower limb) and being on the pill are two independent and synergistic risk factors for venous thromboembolism, and so the pill must be stopped.
She clearly cannot continue as normal due to the elevated risk of venous thromboembolism. Stopping the pill now is too early, and would expose her to a higher risk of pregnancy, and restarting it as soon as she can tolerate oral intake is too early for the risks from the surgery to have returned to baseline. Stopping the pill on the day of the surgery would not remove the risk of clotting as she has been taking it up until her procedure and the clotting risk remains.
Stopping it 4 weeks before surgery allows a return to normal levels of coagulation, and restarting it 2 weeks after surgery allows the procoagulant effect of surgery to wear off, so this is the best answer.
A 32-year-old woman has come into your GP surgery requesting contraception. She is paralysed from the waist down from birth, but apart from that she has no other medical history of note and is fit and well with no symptoms. Which of the following is contraindicated due to her paralysis?
Combined oral contraceptive pill
Copper coil (implantable uterine device)
Depo-provera injection
Diaphragm
Female condom
Combined oral contraceptive pill
Wheelchair users should not be prescribed the COCP as first-line contraceptive, as they are ‘UKMEC 3’- risks outweigh benefits
Wheelchair users (as this woman is due to below waist paralysis), due to immobility, are at higher risk of DVT and PE than the general population, and that risk will be further increased by talking the COCP. It is currently UKMEC-3, which means it’s not forbidden, just advised against.
A 36-year-old woman attends her GP surgery seeking contraception. She smokes 20 cigarettes a day and has a body mass index of 25 kg/m². She denies a personal or family history of venous thromboembolism. She had a right-sided salpingectomy for an ectopic pregnancy six years ago. Which of the following methods of contraception would be contraindicated in this patient?
Copper IUD
Mirena intrauterine system
Combined oral contraceptive
Depot medroxyprogesterone acetate
Cerazette
Combined oral contraceptive
All methods of combined hormonal contraception, including the pill, patch and vaginal ring, are absolutely contraindicated in women over 35 smoking 15 cigarettes or more a day. The other four methods above can be used safely in this group.
