Updated UK contraceptive safety guidance – key points for GPs

GP with an interest in women’s health Dr Toni Hazell explains what GPs need to know about some important updates to the UK Medical Eligibility Criteria for Contraceptive use (UKMEC) which advises on safety of contraceptive methods

The recently updated UKMEC document is the gold-standard guidance on contraceptive safety in the UK.¹ Produced by the College of Sexual and Reproductive Health (CoSRH), the guidance had been due for an update for some time, with the previous version having been originally published in 2016 and not updated since 2019.

The newly updated version, published in December, has the same basic premise – methods are still classified into four categories, numbered 1-4 (see Box 1 below),¹ depending on the co-morbidity or personal characteristic being looked at.

Categories 1 and 4 are straightforward (indicating a contraceptive method is fine to use or absolutely contraindicated, respectively), but the provision of contraception when methods are UKMEC Category 2 or 3 requires clinical judgement.

Two plus two doesn’t always equal four here, but two Category 2s in the same area – for example, relating to venous thromboembolism (VTE) risk – should prompt caution.

It may be appropriate for an experienced clinician, who feels that they can apply expert clinical judgement, to prescribe a method which is UKMEC 3. The balance may be tipped by other factors, such as the patient having been unable to tolerate other methods, the UKMEC 3 risk factor being one that is resolving (for example weight which is consistently being lost), or the risks of pregnancy being so high for that particular woman that it is felt that more risk than usual can be tolerated in her contraception.

If there is more than one UKMEC 3 then prescribing would not usually be done – the UKMEC says that ‘when an individual has multiple conditions scoring UKMEC 3 for a method, use of this method may pose an unacceptable risk; clinical judgement should be used in each individual case’. However, we must remember that the UKMEC only covers the use of contraception. If a woman is getting an extra benefit from her method (such as management of endometriosis), that may affect the risk/benefit calculation.

Box 1. UKMEC category definitions

Category 1: A condition for which there is no restriction for the use of the method.

Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks.

Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are available or not acceptable.

Category 4: A condition which represents an unacceptable health risk if the method is used.

Before looking at what’s new, safe use of the UKMEC depends on the user understanding a few important things about it:

It covers safety, not efficacy.
If a condition isn’t in UKMEC, that doesn’t mean that safe use of contraception can be assumed. Consider seeking advice from secondary care or asking the Clinical Effectiveness Unit (CEU) of the CoSRH to review the evidence for you² – the latter service is available only for members and diplomates of the CoSRH.
Ratings for initiation and continuation of a method may vary, reflecting differing risks associated with starting or continuing a method.

Changes to depot medroxyprogesterone acetate categories

The biggest single change is probably in how we see use of the depot medroxyprogesterone acetate (DMPA) injection.³ It has generally been classed with other progestogen-only methods, but observational studies have shown that its VTE risk is higher than previously thought, although still lower than that of combined hormonal contraception (CHC). Table 1 shows the changes; in some of these areas, other progestogen-only methods now have a lower UKMEC class than DMPA. Practices should consider reviewing all women who use DMPA before their next injection, to check that use is still appropriate.

Table 1. Changes to DMPA UKMEC categories by condition

Condition	Previous category DMPA	New category DMPA
Postpartum with other risk factors for VTE	2	3
BMI >35	1	2
Superficial venous thrombosis	1	2
Known thrombogenic mutations	2	3
Ovarian cancer	1	2
Endometrial cancer	1	2
Inflammatory bowel disease	1	2
Sickle cell disease	1	2
Positive antiphospholipid antibodies	2	3

Addition of four new conditions

Four areas have been added to the UKMEC; multiple sclerosis (MS), chronic kidney disease (CKD), sickle cell trait and use of e-cigarettes. Details of the changes are outlined in Table 2.

Table 2. UKMEC advice for four new conditions

Clinical area	UKMEC advice
Multiple sclerosis	Risk is largely to do with immobility as a VTE risk factor, but it is also noted that those with MS have a 1.2-fold higher relative risk of fracture compared to the general population. DMPA reduces bone density⁴ and is therefore a UKMEC 2 for everyone with MS. CHC is a UKMEC 3 only for those with prolonged immobility. All other methods are a UKMEC 1.
Chronic kidney disease	Only those with nephrotic syndrome or on dialysis are discussed. They should not use CHC (UKMEC 4) due to VTE risk. DMPA is now UKMEC 3, because those with CKD have an increased risk of osteoporosis⁵ and combining this with the reduced bone density from DMPA use increases fracture risk. All other methods are a UKMEC 2.
Sickle cell trait Use of e-cigarettes	There is insufficient evidence for either of these to have their own UKMEC ratings. Both carry an increased risk of thrombosis (arterial for e-cigarettes and venous for sickle trait). The new document states: ‘UKMEC does not include use of e-cigarettes as there is insufficient evidence to establish associated risks. However, given the unknown long term cardiovascular risks with e-cigarettes alternatives to CHC should be prioritised’. It says similar for sickle trait, where alternatives to CHC should also be prioritised. The use of e-cigarettes is often not coded, so in practice, any review of women using CHC who vape may have to be opportunistic.

Patients are often concerned about the possibility of hormonal contraception affecting their mood. Depression was previously UKMEC 1, but it has been removed from this version and there is now a statement about the effects of hormonal contraception on mood.⁶

The key points are as follows:

Evidence is largely observational and often confounded; studies generally don’t focus on women with pre-existing mental health conditions.
There is no clear evidence that any hormonal contraception worsens or improves mood, but some patients report mood change during the use of hormonal contraception. Such a change may not indicate direct causation.
Healthcare professionals should do the following:
- Explore other possible contributing factors and consider alternative contraception if the patient feels that their mood has been adversely affected by their contraception.
- Counsel patients with pre-existing anxiety or depression to monitor their mood when starting hormonal contraception.

Other changes to categories or criteria

Finally, there are several smaller changes made in this version of the UKMEC:

Stroke is no longer a UKMEC 3 for continuation of the levonorgestrel intrauterine device (LNG-IUD); three observational studies have found no increased risk.
More person-centred language is used for HIV; categories are now to do with whether the person is clinically well or unwell, and whether they are on or off treatment for HIV, rather than focusing on their CD4 count.
Hypertension has been updated to include home and clinic blood pressure readings and to reflect NICE classification.
High-risk human papilloma virus (HPV) infection is included in the same category as cervical intraepithelial neoplasia – the LNG-IUD, DMPA and CHC are UKMEC 2 for this cohort.
The definition of ‘currently being treated for breast cancer’ has been clarified and includes the years taking tamoxifen or aromatase inhibitors as well as earlier treatment.
Mycoplasma genitalium is included for the first time in the section on sexually transmitted infections. We generally cannot test for this in primary care, but if a patient is known to have current Mycoplasma genitalium infection, their rating for insertion of a new IUD rises to UKMEC 4 (with clinical symptoms or signs of infection) or UKMEC 3 if they are asymptomatic.

Key points for GPs

The UKMEC is a big document – it will take time for changes to take place, but everyone who prescribes contraception should be aware of what they need to look out for now. A pragmatic approach in primary care would be to:

Search for everyone using DMPA and arrange a review before, or at the time of, their next injection.
Search for everyone with MS or the more severe forms of CKD mentioned in UKMEC and review their notes to see if their contraception needs to be changed – this could be done virtually, with only those needing changes recalled.
Highlight the need for opportunistic review of those who use CHC, to ask them if they use e-cigarettes.
Search for those who have sickle-cell trait and are using CHC – recall them all for a clinical review.
Consider covering the new UKMEC at a practice meeting (or circulating this article) so that everyone is aware of the issues for new prescriptions.