Relevant considerations

• 1.
  

  History of stroke whilst on progestogen-only contraception – continuation of any progestogen-only method is UKMEC 3.

  
  
• 2.
  

  Cardiac history and multiple risk factors for cardiovascular disease – Combined hormonal contraception (CHC) is UKMEC 3 due to the significant risk of thromboembolism and worsening of cardiac conditions.

  
  
• 3.
  

  Anticoagulation – may impact method choice due to effect on menstrual bleeding and procedural risks. Anticoagulants may be teratogenic or contraindicated in pregnancy, therefore, unplanned pregnancy should be avoided.

  
  
• 4.
  

  Memory challenges – may affect the suitability user dependent methods such as pills or injectables.

  
  
• 5.
  

  Dexterity changes – reduced hand dexterity may limit the use of barrier methods or those requiring frequent user action.

Cardiac disease

Pregnancy in women with cardiac disease may pose significant risks, including maternal death, preterm delivery, growth restriction, stillbirth and infant mortality. Effective contraception is crucial to prevent unplanned pregnancies or allow for preconception planning and risk minimization.

The unique challenges faced by women with significant cardiac disease may include; heightened risks of thromboembolism, haemodynamic instability, potential interactions with medications, and being anticoagulated. Impaired cardiac function, dilated heart chambers, arrhythmias and Virchow’s triad (stasis, endothelial injury and hyperviscosity) can further increase the risk of clot formation.

Contraceptive choice requires individualized consideration of pregnancy wishes and risk, method efficacy and potential non-contraceptive benefits whilst balancing these with the woman’s feelings and preferences. Multidisciplinary involvement may be required to reach a tailored plan.

Combined hormonal contraception (CHC) methods, such as the combined pill, patch or ring, increase the thrombotic risk approximately two-fold compared to non-users. CHC may also increase blood pressure and cause fluid retention which may exacerbate certain cardiac conditions. Data is mixed on whether CHC increases the risk of myocardial infarction (MI) compared to non-users and likely depends on other independent risk factors such as smoking, hypertension, hypercholesterolaemia, diabetes and overweight or obesity. Multiple risk factors for cardiovascular disease makes the CHC methods a UKMEC 3.

The progestogen only injectable contraceptives (POICs) are associated with adverse effects on lipid profiles by reducing HDL levels which may persist for some time after discontinuation. POICs are also the only method causally linked with weight gain and a reversible decrease in bone mineral density. For women on anticoagulation, preparations administered subcutaneously (Sayana press) may be preferable to intramuscular preparations.

Certain cardiac conditions increase the risk of infective endocarditis. While 2015 NICE and 2014 FSRH guidelines do not recommend routine antibiotic prophylaxis for intrauterine device (IUD) procedures, the European Society of Cardiology guidelines advise antibiotic prophylaxis for high risk patients. Therefore, we recommend discussion with cardiology to assess whether antibiotic prophylaxis is appropriate.

Women on anti-coagulation face an increased bleeding risk with insertion of an SDI or IUD, however, this is not an unacceptable risk. Recent anticoagulation monitoring is advised but there is no need to stop or alter the dose if the patient is within their target range. The procedure can be performed in a community setting but must be by an experienced clinician.

Cervical stimulation during the IUD insertion procedure may cause bradycardia, arrhythmias or vasovagal reactions which may pose a higher risk for some cardiac patients. These women should have an intrauterine method fitted in a hospital setting.

Female sterilization by occlusion of the fallopian tubes is a permanent and irreversible method of contraception and usually requires a general anaesthetic (GA) necessitating a full anaesthetic assessment for higher risk patients. Patients should be informed that the intrauterine methods, the progestogen only subdermal implant (SDI) and male sterilization are as effective, or more effective, alternatives.

Whilst cardiac disease is not a contraindication to the use of barrier methods or natural family planning, their higher rates of failure make them inappropriate where the risk of pregnancy presents an unacceptable risk.

Cerebrovascular disease

A history of cerebrovascular events, including ischaemic stroke, haemorhagic stroke and TIA, significantly impacts contraceptive decisions due to thrombotic risks and potential risks of unplanned pregnancy.

In the context of previous stoke the use of CHC methods is UKMEC 4 and is absolutely contraindicated due to the significant increased risk of thrombosis and possibly increasing blood pressure.

The use of POICs in the context of previous stroke is UKMEC 3. Although progestogen only methods generally carry a lower thrombotic risk than CHC, the high dose nature of POIC methods has been linked to increased thrombosis risk and a negative impact on HDL cholesterol and therefore increase cardiovascular and stroke risks.

Generally the use of POP, SDI or the levonorgestrel releasing IUD (LNG-IUD) would be considered a UKMEC 2 for women with a history of ischaemic stroke. However, if the stroke occurred while using a progestogen only method then continuation of any progestogen only method then becomes a UKMEC 3. However, the duration of use of the method in relation to the onset of disease should be considered when determining if continuation is appropriate.

The use of a copper IUD (Cu-IUD) device in the context of a previous stroke would be a UKMEC 1 and may be the safest option. However, if the patient is anticoagulated it may exacerbate any heavy menstrual bleeding and associated anaemia.

Residual stroke symptoms, such as memory issues or reduced dexterity, may create practical challenges with certain methods such as pills or barrier methods.

Lifestyle considerations

Lifestyle factors can influence the suitability of contraceptive methods by compounding existing risks.

Smoking, particularly in women over the age of 35, significantly increases the risk of cardiovascular disease, VTE, MI and stroke. CHC is therefore a UKMEC 3 or 4 depending on the number of cigarettes smoked per day.

Cannabis use is associated with adverse cardiovascular outcomes, independent of its frequent combination with tobacco or nicotine. Cannabis itself has a negative effect on the cardiovascular system, which increases the risk of VTE, stroke and cardiovascular disease.

Alcohol intake has a complex dose-dependent effect on cardiovascular risk which should also be considered. Even within the recommended limits of <14 units per week there may be a potential negative impact on blood pressure, lipid profiles and contribution to weight gain. In the context of pre-existing cardiac disease, alcohol consumption may exacerbate the impact of cardiomyopathy and arrhythmias.

Recommendations for Case 1

Given the complex medical history of this 44 year old patient, the following recommendations were made:

• 1.
  

  CHC – UKMEC 4 – It is absolutely contraindicated due to the significant risk of thrombosis associated with her history of ischaemic stroke and cardiovascular risk factors.

  
  
• 2.
  

  POP – UKMEC 3 – After consultation with her cardiologist and stroke physician, the patient resumed the POP despite its UKMEC 3 classification for continuation. The risks were mitigated by her ongoing anticoagulation therapy.

  
  
• 3.
  

  Cu-IUD – UKMEC 2 – As a non-hormonal, highly effective method, the CU-IUD would be the preferred method if fitted within a hospital setting. It is UKMEC 2 relating to her impaired cardiac function. However, the use of anticoagulation may have exacerbated heavy menstrual bleeding. The patient declined this option.

  
  
• 4.
  

  LNG-IUD and SDI – UKMEC 3 for continuation after an ischaemic stroke. However, these methods were considered viable options if used alongside anticoagulation and would have been preferable in terms of lower user dependent failure rates. Additionally, the LNG-IUD may have had additional benefits in terms of reducing menstrual bleeding. The patient declined these options.

  
  
• 5.
  

  POICs – UKMEC 3 – Associated with an increased risk of thrombosis related to the high dose of progestogen and potential adverse effects on lipid profiles and possible weight gain may exacerbate cardiovascular risk.

  
  
• 6.
  

  Barrier methods – While not contraindicated they may be less suitable due to the high failure rates and associated risks of an unplanned pregnancy in this case. Dexterity issues may also affect practicalities. However, they could be used as a back-up method in addition to her progestogen only pill.

  
  
• 7.
  

  Female sterilization – This was discussed given the patients desire for no further pregnancies and the risks associated with an unplanned pregnancy. However, due to the possible increased risks with a general anaesthetic in her case she would need referral for combined assessment by the anaesthetic and gynaecology teams.

  
  
• 8.
  

  Lifestyle advice – reinforce stop smoking advice and offer support as previously discussed by both cardiology and stoke teams.

Relevant considerations

• 1.
  

  Inflammatory bowel disease (IBD) – Consider mobility limitations, malabsorption issues, history of surgical interventions, extra-intestinal disease manifestations, and associated conditions such as osteoporosis, all of which play a critical role in guiding contraceptive choices.

  
  
• 2.
  

  Raised BMI – Obesity is strongly linked to adverse health outcomes such as cardiovascular disease (CVD) and metabolic disorders, which are important considerations when choosing contraception. Furthermore, certain contraceptive methods may offer additional health benefits for women with a higher BMI.

Inflammatory bowel disease

IBD, which includes Crohn’s disease and ulcerative colitis, poses unique challenges for women of reproductive age, particularly when it comes to contraception. These chronic conditions characterized by inflammation of the gastrointestinal tract, with varying degrees of severity, are often associated with significant morbidity. The prevalence of IBD is rising globally, with an estimated 0.3% of the population affected, including a significant proportion of women in their childbearing years. People of any age can get IBD but it is usually diagnosed between the ages of 15 and 40 years. In the UK alone, more than 300,000 people are living with IBD, many of whom are women of reproductive age. These women face complex considerations in selecting contraception, as disease activity, medications, and associated risks must all be taken into account.

In women with IBD, oral contraceptives, including POP and combined oral contraceptive pills (COCP), may be less reliable in the presence of malabsorption caused by severe small bowel disease, surgical resection, or episodes of vomiting or diarrhoea. Crohn’s disease, a chronic and relapsing form of IBD, is characterized by transmural granulomatous inflammation that can affect any part of the gastrointestinal tract, most commonly the ileum, colon, or both. Unlike ulcerative colitis, Crohn’s disease often presents with skip lesions, where healthy bowel segments are interspersed between areas of active inflammation. The clinical course is typically marked by periods of exacerbation and remission. While large bowel disease generally does not affect the efficacy of oral contraceptives, small bowel involvement with malabsorption in Crohn’s disease can compromise their reliability.

POP is therefore a UKMEC 2 and CHC, which includes COCP, is UKMEC 2. However, there is no evidence to suggest that the effectiveness of the combined patch, combined ring, progestogen-only injectables, implants, or intrauterine methods is impacted in women with IBD.

Health professionals will need to consider the potential effects of IBD-related conditions, such as VTE and osteoporosis. Clinical factors which can elevate the risk of a VTE event in patients with IBD include; active or extensive disease, recent surgery (especially colorectal procedures), prolonged hospitalization and the use of medications such as corticosteroids. In patients with increased risk of VTE any CHC method should be avoided. It would be categorized as a UKMEC 4 in certain circumstances, for example for individuals undergoing major surgery with prolonged immobilization. In contrast, non-hormonal methods and progestogen only methods do not increase the risk of VTE and may be preferred options.

Crohn’s disease is a cause of secondary osteoporosis. Osteoporosis and osteopenia are more prevalent in individuals with IBD, so women should be evaluated for additional risk factors and informed about the impact of their condition on bone mineral density (BMD). When considering the use of POIC, its potential effects on BMD should be balanced against its benefits, such as reliable contraceptive efficacy unaffected by malabsorption or drug interactions. For women opting to use POIC reassessment should occur at least every two years.

There are other considerations including a theoretical concern that some rectally administered IBD medications could reduce the effectiveness of latex condoms if the medication comes into contact with the genital skin.

Sterilization can be considered when other contraceptive methods are not appropriate. However, previous pelvic or abdominal surgery may increase the risks associated with laparoscopic sterilization. A large prospective multicenter cohort study, as part of the Collaborative Review of Sterilization, found that women with a history of abdominal or pelvic surgery were twice as likely to experience complications during laparoscopic sterilization compared to those with no prior surgical history.

A thorough assessment of the severity of a patient’s IBD and the extent of their treatment is crucial. This may involve asking detailed questions and, if necessary, confirming information with the patient’s GP or the specialist managing their IBD.

BMI

When addressing obesity and contraception, several factors need to be considered. For instance: Does an increased BMI impact the efficacy of certain contraceptive methods? How safe are different contraceptive options for women with elevated BMI? Does contraceptive use contribute to weight gain in women with higher BMI?

There is no reduction in efficacy for the Cu-IUD, LNG-IUD, SDI, POIC, POP, COCP, or vaginal ring. There may be reduced efficacy for the contraceptive patch for women with weight above 90 kg.

The main safety concerns for women with obesity using contraception are cardiovascular risks associated with exogenous oestrogen, such as VTE, acute MI, and ischaemic stroke. The risk of VTE increases progressively with a BMI above 30 kg/m ² and is even higher in those with a BMI ≥35 kg/m ² . Baseline VTE risk in obese women is approximately twice that of women with a normal BMI. There is limited safety data is available regarding contraceptive use in women with a BMI ≥40 kg/m ² .

According to the UKMEC, obesity alone does not contraindicate the use of POIC, (UKMEC 1). However, when obesity is combined with additional cardiovascular risk factors, such as smoking, diabetes, or hypertension POIC is a UKMEC 3.

The risk of further weight gain is something that is often a critical deciding factor for those already struggling with their weight. In the general population, there is no evidence that CHC, POP, SDI, Cu-IUD, or LNG-IUD cause weight gain. Additionally, no specific evidence exists linking these methods to weight gain in women who are overweight or have obesity. POICs are also the only method causally linked with weight gain.

Therefore, obesity influences contraceptive choices. However, It is important to note that, unless explicitly stated, the UKMEC does not account for the presence of multiple medical conditions simultaneously. Evaluating a woman’s suitability for a contraceptive method when multiple factors are involved requires clinical judgment, informed by the available evidence and guidance. In this case, obesity is present alongside another medical condition with other risk factors, further emphasizing the need for individualized assessment.

Recommendations for Case 2

• 1.
  

  CHC – recommended to avoid in this patient due to multiple risk factors for cardiovascular disease, increased risk of VTE, current smoker and BMI of 37. The UKMEC for BMI ≥35 kg/m ² is UKMEC 3 and UKMEC 3 for multiple cardiovascular risk factors. In the context of inflammatory bowel disease the use of CHC is a UKMEC 2, however, there are also concerns about potential poor absorption if an oral preparation were used.

  
  
• 2.
  

  POP – recommended to avoid in this patient. Although safe (UKMEC 1) concerns exist due to the potential for reduced absorption.

  
  
• 3.
  

  SDI – would be suitable for this patient. Care should be taken to select an insertion site which does not have any sign of infection or inflammation

  
  
• 4.
  

  POICs – not recommended in the context of multiple risk factors for cardiovascular disease (UKMEC 3) and existing risk factors for osteoporosis including poorly controlled disease, small bowel resection and a long history of smoking.

  
  
• 5.
  

  LNG-IUD – would be a suitable method as it is long acting, reversible and highly effective. UKMEC 2 in the context of multiple risk factors for cardiovascular disease

  
  
• 6.
  

  Cu-IUD – would be a suitable method as it is long acting, reversible and highly effective. UKMEC 1

  
  
• 7.
  

  Female sterilization – Should be considered permanent and irreversible. High risk due to previous surgery. LARC methods can be more effective and carry less risk.

Relevant considerations

• 1.
  

  Benign liver haemangioma – Consider the impact of hormonal contraception methods which may potentially worsen liver haemangiomas.

  
  
• 2.
  

  Migraine with aura – Consider the risks of hormonal contraceptive methods due to the link with increased risk of ischaemic stroke.

Liver disease

Liver disease in women of reproductive age presents a complex set of challenges for patients and healthcare teams. Conditions such as cirrhosis, liver adenoma, liver cancer, autoimmune hepatitis, viral hepatitis and non-alcoholic fatty liver disease may all impact liver function. This is particularly important when considering hormonal contraception as liver disease can impact both the safety and efficacy of these methods by affecting metabolism. Additionally, hormonal contraception may exacerbate certain liver conditions.

Medications used to manage liver disease may also interact with contraceptive methods, making it essential to tailor the contraceptive choices to the medical and drug history, and personal preferences, of each individual.

A liver adenoma is a benign liver tumour which may grow in response to oestrogen exposure, increasing the risk of complications such as rupture or malignant transformation. Therefore, CHC, including COCP, patches and vaginal rings are UKMEC 4, representing an unacceptable health risk.

Safer options for women with liver adenomas include: progestogen-only methods including POP, implants, injectables, and LNG-IUDs, which are UKMEC 3.

However, the safest option would be to use a non-hormonal Cu-IUD which is UKMEC 1 or other non-hormonal options such as condoms, diaphragms or female sterilization for women who have completed their families.

It is important to note the difference between liver haemangiomas and adenomas in the context of contraception. They are both benign liver lesions but differ significantly in the characteristics, clinical implications and interactions with hormonal contraception.

Haemangiomas are the most common benign liver tumours and are comprised of a collection of blood vessels. Generally, they remain stable and asymptomatic and are less susceptible to influence by hormonal contraception, although oestrogen containing contraception may rarely cause them to grow. The risk of complications from haemangiomas is usually low and therefore the restrictions on the use of hormonal contraception are less strict.

In contrast, liver adenomas are hormone sensitive, benign tumours which may grow in response to oestrogen exposure. They are more susceptible to serious complications such as rupture, haemorrhage or malignant transformation, particularly in women using oestrogen containing contraception. Hence, combined contraception is contraindicated in women with liver adenomas (UKMEC 4). Progestogen only contraception methods, whilst safer, do still carry some risks and are therefore UKMEC 3. The safest option would be for these women to use non hormonal contraceptive methods such as the Cu-IUD or barrier methods.

Understanding the differences in benign liver tumours and other liver conditions is essential for safely managing contraception use in women with these conditions.

Migraine

Migraine can pose a challenge when selecting appropriate contraception for women of reproductive age. Hormonal contraception, particularly those containing oestrogen, may exacerbate migraine symptoms and can increase the risk of serious complications in some women. However, due to concern about safety some women with migraine may be unnecessarily declined CHC methods.

The first step in managing these patients is to determine if the headache in question is migraine or another category of headache. Migraine typically presents with unilateral, throbbing pain, sensitivity to light and sound, and nausea.

Migraines can broadly be divided into 2 categories; those with aura and those without. This distinction is crucial as it directly impacts the safety and suitability of contraceptive options. To identify if migraine is migraine-with-aura the patient should be asked about additional symptoms which typically precede the headache, such as visual disturbances including flashing lights or blind spots, sensory changes such as numbness or tingling, or speech changes. Symptoms of aura typically occur 5–60 minutes before the headaches begins.

For women with migraine without aura the use of CHC is generally considered safe unless the migraines worsen with use. CHC is UKMEC 2 for migraine without aura meaning the advantages outweigh the risks. However, it is essential to monitor the patient for any changes in migraine pattern or type as an increased frequency or severity in migraine may suggest the method is not suitable and development of new symptoms of aura would require an immediate re-evaluation of the method due to safety concerns. Progestogen only methods including pills, implants, injections and LNG-IDUs and Cu-IUDs are considered safe, UKMEC 1, meaning there is no restriction on use.

By contrast, for women with migraine with aura the use of CHC represents an unacceptable health risk (UKMEC 4) due to the increased risk of ischaemic stroke. The presence of aura represents an underlying cerebrovascular sensitivity which potentially increases the risk of stroke, and this risk is significantly increased when using oestrogen.

Progestogen-only methods are a safer option for women with migraine with aura. The POP, implants, injectables and levonorgestrel releasing intrauterine device are UKMEC 2. The non hormonal copper intrauterine device is a UKMEC 1, as are barrier methods.

Recommendations for Case 3

• 1.
  

  CHC – combined pills patches or ring – UKMEC 4 – avoid in this patient due to increased risk of stroke associated with migraine with aura. Presence of liver haemangioma also makes this option less preferred as oestrogen may rarely cause them to grow.

  
  
• 2.
  

  POP – UKMEC 1 – can continue with this method until a LARC method is established.

  
  
• 3.
  

  POICs and SDI – UKMEC 2 for migraine with aura. No impact on liver haemangioma. Would be a suitable option for this patient. The implant has a lower failure rate, longer duration of action and fewer adverse side effects which may make it preferable depending on patient choice.

  
  
• 4.
  

  LNG-IUD – UKMEC 2 for migraine with aura. No impact on liver haemangioma. Would be a suitable option for this patient.

  
  
• 5.
  

  Cu-IUD – UKMEC 1 – suitable for this patient – it is non-hormonal and highly effective with a long duration of action.

  
  
• 6.
  

  Female sterilization – inappropriate for this patient as it is permanent and irreversible and she has future fertility wishes.

  
  
• 7.
  

  Barrier methods – Can continue using alongside POP until a LARC method is established. Not suitable for long term use due to the patient’s preference for a highly effective long term method.

Practice points

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