QuestionSBA
QuestionChoice
This is UKMEC Category 1 (no restriction on use) unless the patient is a known carrier of gene mutations associated with breast cancer.
10017228
c
Family history of breast cancer
QuestionChoice
This is UKMEC Category 2 (but would be UKMEC Category 4 if the patient was over 35).
10017230
e
Smoking 20 cigarettes a day
QuestionChoice
This is the only UKMEC Category 4 (absolute contraindication) option on the list for the combined oral contraceptive pill, due to the risk of thrombotic complications.
10017226
a
Antiphospholipid syndrome
QuestionChoice
This is UKMEC Category 1 (no restriction on use), although enzyme-inducing anti-epileptic drugs may reduce the effectiveness of oral contraceptives, so an alternative form of contraception (such as a patch) may be recommended.
10017227
b
Taking anti-epileptic medications
QuestionChoice
This is UKMEC Category 2 (advantages generally outweigh risks) and is therefore not an absolute contraindication.
10017229
d
Rheumatoid arthritis
Concept
Chapter
# Overview


There are numerous contraindications and cautions related to the use of the combined hormonal contraception (CHC) including the combined oral contraceptive pill (COCP), combined contraceptive transdermal patch and the vaginal ring.


The UK Medical Eligibility Criteria (UKMEC) provides guidance on the suitability of contraception options:


- UKMEC 4: a situation where the use of the method of contraception represents an unacceptable health risk
- UKMEC 3: a situation where the theoretical or proven risks usually outweigh the advantages of using the method
- UKMEC 2: a situation where the advantages of using the method generally outweigh the risks
- UKMEC 1: a situation for which there is no restriction for the use of the method


# UKMEC 4 conditions for use of combined hormonal contraception


These are conditions or situations where the use of combined hormonal contraception represents an unacceptable health risk:


- <6 weeks postpartum and breastfeeding
- <3 weeks postpartum, not breastfeeding, with other risk factors for VTE
- Age ≥35 and smoking ≥15 cigarettes/day
- Consistently elevated blood pressure (systolic ≥160 mmHg or diastolic ≥100 mmHg)
- Vascular disease (e.g. coronary heart disease, peripheral vascular disease intermittent claudication, hypertensive retinopathy)
- Current or past ischaemic heart disease (including angina)
- Current or past stroke (including TIA)
- History of VTE (including PE and DVT)
- Current VTE (even if on anticoagulation)
- Planned major surgery with prolonged immobilisation
- Known thrombogenic mutations (e.g. factor V Leiden)
- Complicated valvular and congenital heart disease (e.g. with pulmonary hypertension)
- Cardiomyopathy with impaired cardiac function
- Atrial fibrillation
- Migraine with aura, at any age
- Current breast cancer
- Severe or decompensated liver disease e.g. cirrhosis
- Certain liver tumours e.g. hepatocellular adenoma, malignant hepatocellular carcinoma)
- Systemic lupus erythematosus (SLE) with positive antiphospholipid antibodies
- Any other condition with positive antiphospholipid antibodies


# UKMEC 3 conditions for use of combined hormonal contraception


These are situations where the theoretical or proven risks usually outweigh the advantages of using combined hormonal contraception.


- <3 weeks postpartum, not breastfeeding, without other risk factors for VTE
- 3-6 weeks postpartum, not breastfeeding, with other risk factors for VTE
- Age >35 years and smoking <15 cigarettes/day
- Age >35 and stopped smoking <1 year ago
- BMI ≥35 kg/m2
- History of bariatric surgery, With BMI ≥35 kg/m2
- Adequately controlled hypertension
- Consistently elevated blood pressure (systolic >140–159 mmHg or diastolic >90–99 mmHg)
- Complicated organ transplant (e.g. if graft failure or rejection)
- Multiple risk factors for cardiovascular disease (e.g smoking, diabetes, hypertension, obesity, dyslipidaemia)
- Undiagnosed breast mass or symptoms (for initiating CHC)
- Carriers of known breast cancer gene mutations (e.g. BRCA1/BRCA2)
- Past breast cancer
- Diabetes with nephropathy, retinopathy, neuropathy or other vascular disease
- Viral hepatitis with acute flare (for initiating CHC)
- Family history of VTE in a first-degree relative age <45 years
- Immobility (unrelated to surgery) (e.g. wheelchair use, debilitating illness)
- Migraine without aura, at any age (continuing CHC)
- History (≥5 years ago) of migraine with aura, any age
- Gallbladder disease (if symptomatic or receiving medical therapy)
- History of cholestasis thought to be due to CHC


# UKMEC 2 conditions for use of combined hormonal contraception


These are situations where the advantages of using CHC generally outweigh the risks


- Age ≥40 years
- ≥6 weeks to <6 months postpartum and primarily breastfeeding
- 3 to <6 weeks postpartum and not breastfeeding
- Age <35 years and smoking
- Age ≥35 years and stopped smoking ≥1 year ago
- BMI ≥30–34 kg/m2
- History of bariatric surgery with BMI ≥30‒34 kg/m2
- Uncomplicated organ transplant
- History of high blood pressure during pregnancy
- Dyslipidaemia
- Family history of VTE in a first-degree relative age ≥45 years
- Planned major surgery without prolonged immobilisation
- Superficial venous thrombosis
- Uncomplicated valvular or congenital heart disease (i.e. not on medication, asymptomatic, not requiring regular cardiology review)
- Cardiomyopathy with normal cardiac function
- Long QT syndrome
- Non-migrainous (mild or severe) headache (continuation of CHC)
- Migraine without aura, at any age (initiation of CHC)
- Idiopathic intracranial hypertension (IIH)
- Unexplained vaginal bleeding
- Cervical intraepithelial neoplasia (CIN)
- Cervical cancer, awaiting treatment/surgery
- Undiagnosed breast mass/breast symptoms (continuation of CHC)
- Diabetes with no vascular disease
- Previous gallbladder disease treated by cholecystectomy
- Asymptomatic gallbladder disease
- History of pregnancy related cholestasis
- Acute flare of viral hepatitis (continuation of CHC)
- Focal nodular hyperplasia of the liver
- Inflammatory bowel disease (IBD) (including Crohn’s disease and ulcerative colitis)
- Sickle cell disease
- Rheumatoid arthritis
- Systemic lupus erythematosus (SLE) without positive antiphospholipid antibodies


Multiple conditions that are UKMEC 2 may overall make the risks outweigh the benefits.


# References


[Click here to see the UKMEC summary sheet on contraception](https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/)
2609
3453
Contraindications to combined hormonal contraception
Topic
27
Genitourinary medicine
15989
Antiphospholipid syndrome is an absolute contraindication for the combined oral contraceptive pill due to increased thrombotic risk.
A 21-year-old female would like to discuss contraceptive options. Her preference is for the combined oral contraceptive pill as she is aware it can be beneficial in the treatment of acne, and she wants a form of contraception which is readily reversible.

Which of the following represents an absolute contraindication for the combined oral contraceptive pill?
a