This is an update from the FSRH on the use of combined hormonal contraception (CHC). There are a couple of elements in here that are new. I shall list these, then give the check-list of what they think we should be covering in the initial consultation.
For me, the biggest single learning point was that we don't have to bring a woman back at 3m after initiation of CHC. Annual follow up is fine and this follow up doesn't have to be face to face (see below for more details on this).
A really useful aspect of this guideline is that there are numerous tables which summarise starting and switching routines, efficacy of various contraceptive methods etc. The appendix also contains a list of all the UKMEC criteria for CHC, which is very useful. One to keep a link to on your desktop maybe...
Things that are new, or are emphasised more in this update.
Assessing patients for suitability.
This can be done using a check-list proforma.
Weight and patch efficacy.
There is some limited evidence that the patch is less effective in women > 90kg. This does not affect the pill or ring.
The COC (combined oral contraceptive) could be less effective after bariatric surgery. Evidence is too limited to make a definite recommendation, but women should be advised of this and that they should consider a non oral form of contraception.
First-line CHC choice.
Consider using a pill with ≤ 30 mcg oestrogen and either levonorgestrel or norethisterone. These pills have the lowest VTE risk.
For quite a long time the FSRH has supported using CHC outside of the normal 21/7 regimen (on monophasic pills / patches and rings). They are now advising that we tell women about these regimens at initiation of the pill. We should advise women that this usage is unlicensed. I shall go into more detail about the options for this below.
Efficacy of the pill.
We should advise women of how effective the pill is, both in perfect use and in typical use. With perfect use there is < 1% (about 0.3%) failure rate (so fewer than 1 in 100 women per year using CHC will fall pregnant). With typical use, there is a 9% failure rate (so 9 out of 100 women using CHC in the first year will fall pregnant).
Ischaemic heart disease (IHD) and thrombotic CVA.
There is a very small increased risk of IHD and thrombotic CVA with CHC use. Women should be advised of this. The risk appears to be greater with increased oestrogen dose.
Benefits of CHC.
Among the well known benefits, CHC is associated with a reduced risk of colon cancer.
Long acting contraception (LARC).
Advise women of the LARC options. A significant number of women may opt for LARC instead.
There is no need to follow women up at 3m, unless you have a specific reason for doing so (eg co-morbidities that need monitoring). Annual follow up is otherwise fine (even after initiation of the CHC). Follow up does not have to be done face to face (though BP should be checked either by a health care professional or on a validated machine eg in the surgery waiting room).
These have been advocated for quite a while, but we are now being encouraged to counsel women about these when we first start the pill. The patient.co.uk leaflet has a good bit about the options for doing this, which will make it easier to describe to women. Tailored regimens are generally well accepted and can reduce side-effects. The theory is that a reduced pill free interval (PFI) should reduce pregnancy rates on the pill, but this hasn't been borne out in studies.
Bear in mind that this can only be done for monophasic pills (ie most of the ones we use, that have a steady state combination of oestrogen and progesterone).
So what are the options?
- Extended use. Tricycling (eg 3 packs together, then 4 or 7d off).
- Shortened PFI to 4d. This can be part of an extended use regimen, or after the normal 21d.
- Flexible extended use. Any regimen with fewer PFIs. The timing of the PFI can be fixed or variable. Women should continue with the CHC until they have 3-4d of break through bleeding, then they should have a 4d PFI.
- Continuous use. Some women may just choose to continue with their CHC without a break, though most women will get break through bleeding by doing this.
Things to cover at the initial consultation
Assess a woman's suitability
- Check her history, lifestyle factors (eg smoking) vs the UKMEC.
- Factors that could affect efficacy (eg other medications, weight, bariatric surgery).
Things to counsel the woman about
- Effectiveness (perfect and typical use).
- Factors that may affect efficacy (eg diarrhoea and vomiting, missed pills etc).
- Non-contraceptive benefits.
- Health risks (VTE, IHD, breast cancer, cervical cancer).
- Side-effects (Bleeding patterns changing and mood being affected. Note that there is no causal link with depression, headaches, weight gain, change in libido or a reduced return to fertility).
Discuss other suitable methods (eg LARC).
Choose COC vs patch vs ring.
Regimens. Advise on tailored regimens.
Give up to a year's worth of CHC.
Follow up at least annually. Check for any change in their medical history that could affect eligibility for CHC. Blood pressure and BMI should be checked. BMI can be self-reported. BP should be taken by a health care professional, or on a validated machine (eg pharmacy / GP surgery). The follow up does not have to be face to face.