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GPs urged to review combined pill prescribing

GPs have been urged to review the prescribing of the combined contraceptive pill as research revealed many are taking ‘unacceptable risks’ by continuing to prescribe it in women with medical conditions such as hypertension and obesity.

The UK study into the prescribing of combined hormonal contraceptives in the UK estimated that, in 2010, over 174,000 women were prescribed a combined contraceptive pill despite having a risk factor rated as category three or four on the UK Medical Eligibility Criteria for Contraceptive Use.

The UKMEC criteria were published in 2006 and aim to guide safe provision of contraception to women with a variety of medical conditions, rated across categories one to four. Patients deemed to have a condition rated as category four should not be given contraception as it represents an ‘unacceptable risk’ to the patient.

Category three conditions generally feature risks that outweigh the benefits, and the decision to prescribe requires ‘expert clinical judgement or referral to a specialist contraceptive provider.’

The current study used the General Practice Research Database - now called the Clinical Practice Research Datalink - to extract data for women aged 15 to 49 years with at least one prescription for a combined hormonal contraceptive and who had at least one category three or four risk factor during a year.

There was a decreasing trend of high-risk women taking combined hormonal contraceptives post-introduction of the UKMEC criteria. In 2004, two years before the criteria were published, there were 16,121 high-risk combined contraceptive users registered in the GPRD, which fell significantly to 13,028 women in 2010, making up 7.3% of high-risk users in the GPRD that year aged 15 to 49 years.

This percentage was then used to formulate a UK wide estimate of 174,472 women prescribed a combined contraceptive despite a UKMEC category three or four risk factor.

Study lead Dr Paula Briggs, a GPSI in gynaecology and contraceptive lead for Southport and Omskirk Integrated Care Organisation, said the data showed improved adherence to the UKMEC criteria, but that GPs must still do better.

She said: ‘When we broke the data down, we found that there was an increase in the number of women prescribed combined hormonal contraceptives who were obese. It does not seem reasonable to take the risk with these patients when there are equally efficacious methods available.’

She added: ‘There are also a number of women who have been on the pill for a long time that are just slipping through the net.’

Dr Anne Connolly, a GPSI in gynaecology, Bradford, and chair of the Primary Care Women’s Health Forum, agreed that the risks were unnecessary.

She said: ‘I do a lot of teaching on contraception and am amazed by the high number of clinicians who do not know about and do not use the UKMEC.

‘Primary care clinician training on contraception is not prioritised and many nurses are doing the bulk of the work without any qualification. This is a serious concern when this study identifies so many women who should not be taking combined hormonal contraception, especially when there are so many safer alternatives for these women.

‘I think that the risks of contraception prescribing are not fully understood by many because of all the other pressures and clinical interest.’

Dr Amanda Britton, honorary secretary of the Faculty of Sexual and Reproductive Healthcare and a GP principal in Basingstoke, felt some responsibility should lie with commissioners.

She said: ‘This highlights the importance of education and easy availability of guidance. The FSRH is currently working with RCGP to improve accessibility to contraceptive and sexual health training  and also to deliver training for nurses. It is a role of commissioners to ensure that training is available to clinicians.’

Journal of Family Planning and Reproductive Health Care 2013, available online 7 January

UKMEC CATEGORYRISK CONDITION FOR COMBINED PILL
1Varicose veins, past ectopic pregnancy, history of pelvic surgery
2Uncomplicated congenital heart disease, insulin and non-insulin dependent diabetes, cervical cancer (awaiting treatment)
3Current gall bladder disease, adequately controlled hypertension, over 35 years and smoking less than 15 cigarettes per day
4Vascular disease, systolic BP equal to or over 160 mmHg, history of VTE

Readers' comments (5)

  • "the decision to prescribe requires ‘expert clinical judgement or referral to a specialist contraceptive provider.’" I think I just found the agenda here...

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  • Vinci Ho

    How about creating a score system based on UKMEC ( also including BMI) to justify the use of COC ? A bit like CHADS/CHA2DS-VAS score for Warfarin in AF or CVD risk score for statin ..... Obviously you need IT system modifications to include a calculator in the READ CODES

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  • How about discussing the risks with patients so they can decide what is an accpetable risk to them personally?

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  • PRIMIS provide a tool that audits all patients prescribed the combined oral contraceptive and checks whether those patients satisfy the UKMEC for the use of contraceptive methods. GP practices can access it (plus many other clinical audit and data quality tools) via a subscription-based service: http://www.primis.nottingham.ac.uk/index.php/services/membership/whats-included - if you're interested, contact us: enquiries@primis.nottingham.ac.uk

    Neil Walker
    PRIMIS

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  • Oral contraceptives and other hormonal impregnated devices cause weight gain. There is no consideration given to this aspect! As GPs you are aware of the NHS targeting "fat" people, the government is bemoaning this situation; think before you prescribe:- will it affect the waistline of my patient in the long term? If the answer is yes, then an alternative low risk method should be considered!!

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