WHAT'S NEW IN CONTRACEPTION

Whats new in ...

Contraception
Anna Glasier

The development of new methods of contraception takes a long time. No new methods have become
available in the UK in recent years and there are none on the near horizon. Activity in the arena of
contraception has recently focussed on the production of guidelines designed to improve contraceptive
prescribing among health professionals. New data on the effect on unintended pregnancy and abortion
rates of increased access to hormonal emergency contraception has cast doubt on the benefits of EC on
public health outcomes.
Keywords bone; contraception; emergency contraception; guidelines; medical eligibility

The UK Medical Eligibility Criteria

Most contraceptive users are young, medically fit, and can use any method safely.
However, a few medical conditions are
associated with theoretical increased
health risks with certain contraceptives
particularly hormonal methods either
because the method adversely affects the
condition or because the condition, or its
treatment, affects the contraceptive. For
example, the combined pill may increase
the risk of a diabetic woman developing
cardiovascular complications and antiretroviral drugs used to treat AIDS may
interfere with the efficacy of hormonal
contraceptives. Some physiological conditions, such as age and breastfeeding, and
behaviours such as heavy smoking, may
also affect the theoretical safety of some
methods. Since most trials of new contraceptives deliberately exclude subjects with
serious medical conditions, heavy smokers,
breastfeeding women and women at the
extremes of reproductive age, there is
very little direct evidence on which to
base prescribing advice. In an attempt to
produce a set of international norms for
providing contraception safely to women

and men with a range of conditions which

may contraindicate one or more methods,
the World Health Organization (WHO)
developed a system addressing medical
eligibility criteria (MEC) for contraceptive
use.1 The WHOMEC (which are updated
regularly) are intended for use by policy
makers and programme managers. Recognizing that national health policies, needs
and resources vary considerably around
the world, WHO expected national organisations to adapt the guidelines for use in
their own country. During 2005/06, the
Faculty of Family Planning and Reproductive Healthcare (FFPRHC) undertook a formal consensus process designed to adapt
the WHOMEC for use in the UK.2 In late
2006, a hard copy of the UK Medical Eligibilty Criteria (an A4-sized reference book,
together with laminated copies of the summary tables for day-to-day use in clinics)
was sent to every general practice, family planning and genito-urinary medicine
clinic in the UK. The guidance UKMEC is
also available on the FFPRHC website.2
Using
evidence-based
systematic
reviews and expert opinion, conditions
are classified into one of four categories
(Table 1). Category 1 includes conditions

Anna Glasier MD DSc FRCOG FFPRHC OBE is Lead Clinician for Sexual Health in NHS Lothian, UK,
and Honorary Professor at the Universities of Edinburgh and London, UK. She qualified from
Bristol University and trained in obstetrics and gynaecology in Edinburgh and Winchester,
subspecialising in reproductive medicine. Her research interests include contraception, including
patterns of use and service delivery, and abortion. Competing interests: none declared.

MEDICINE 35:6

348

for which there is no restriction for the use

of the method, while category 4 includes
conditions which represent an unacceptable health risk if the contraceptive is used
(absolutely contraindicated). Classification
of a condition as category 2 indicates that
the method may generally be used but that
more careful follow-up is required. Category 3 conditions are those for which risks
of the contraceptive generally outweigh
the benefits (relatively contraindicated).
Provision of a method to women with category 3 conditions requires careful clinical
judgement since use is not recommended
unless there is no acceptable alternative. In
these circumstances, the provider should
seek advice from an expert. For some
conditions, the MEC distinguish between
a method being started for the first time
(initiation) and its continuation. If, for
example, a women develops for the first
time migraine with aura while she is using,
say, Depo Provera (Pharmacia), continuation of Depo Provera falls into category
3 (the theoretical risks outweigh the benefits). If a woman who already has migraine
with aura wants to start using Depo Provera, the condition is regarded as category 2 the benefits of using the method
outweigh the theoretical risks (Table 2).

The NICE guideline on long-acting

reversible methods
In October 2005 the National Institute for
Health and Clinical Excellence (NICE)
published a guideline on long-acting

2007 Elsevier Ltd. All rights reserved.

WHAT'S NEW IN CONTRACEPTION

UK Medical Eligibilty Criteria classification categories

1 A condition
2 A condition
3 A condition
4 A condition

for which there is no restriction for the use of the contraceptive method
where the advantages of using the method generally outweigh the theoretical or proven risks
where the theoretical or proven risks usually outweigh the advantages of using the method
which represents an unacceptable health risk if the contraceptive method is used.

Table 1

reverisble methods of contraception

(LARC).3 While modern methods of contraception are effective at preventing pregnancy if they are used perfectly, methods
which rely on consistent and correct use
are associated with higher failure rates
when they are used typically. Long-acting
methods, which do not require the user

to take action any more frequently than

every four weeks, include intra-uterine
devices and systems (which last at least
5 years), contraceptive implants (which
last at least three years), progestogen
only injectables (Depo Provera lasting
12 weeks and norethisterone enanathate
lasting 8 weeks) as well as the combined

c ontraceptive vaginal ring, which provides

contraceptive protection for four weeks
but which is not licensed in the UK.
There is good evidence that the use of
LARC is associated with a lower risk of unintended pregnancy.4,5 The uptake of LARC is
low in Britain; only 10% of women aged
16 to 49 were using any LARC in 2005/06,

UK Medical Eligibility Criteria prescribing progestogen-only contraceptives to women with common

neurological conditions
Condition

Category
POP

DMPA

Clarifications/evidence
IMP

Neurological conditions
Headaches
a) non-migrainous (mild or severe)
b) Migraine
i) without aura, age < 35 years
ii) without aura, age 35 years
iii) with aura, at any age

1
2

2
3

2
2

2
3

2
2

2
3

c) Past history of migraine with

aura, at any age

Epilepsy

Depressive disorders
Depression

Classification depends on accurate diagnosis of those severe

headaches that are migrainous and those that are not. Nonmigrainous headaches include tension-type, cluster or rebound
headaches
Aura (focal symptoms) indicates ischaemia: homonymous
hemianopia, unilateral paraesthesia and/or numbness, unilateral
weakness; and aphasia or unclassifiable speech disorder. Visual
symptoms progress from fortification spectra (a star-shaped figure
near the point of fixation with scintillating edges) to scotoma
(a bright shape which gradually increases in size). Flashing lights
are not focal symptoms. Aura occurs before the onset of headache
Any new headaches or marked changes in headaches should
be evaluated. Classification is for women without any other risk
factors for stroke. Risk of stroke increases with age, hypertension,
and smoking
If a woman is taking liver enzyme inducing anticonvulsants, refer
to the section on drug interactions. Certain anticonvulsants lower
the efficacy of POP and implant
The classification is based on data for women with selected
depressive disorders. No data on bipolar disorder or postpartum
depression were available. There is a potential for drug
interaction between certain antidepressant medications and
hormonal contraceptives.
Evidence: POPs did not increase depressive symptoms in women
with depression compared to baseline.

I, initiation; C, continuation; POP, progestogen-only pill; DMPA, depot medroxyprogesterone acetate; NET-EN, noretisterone ethanate; IMP, implanon.

Table 2

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WHAT'S NEW IN CONTRACEPTION

compared with 23% of women using

the oral contraceptive pill and 21% the
condom.6 Recognizing both the potential of
LARC to reduce unintended pregnancy rates
and the low use, NICE developed a detailed
guideline giving evidence-based recommendations about all LARC methods available
in the UK. The guideline is lengthy; arguably the most important recommendations
relate to those which promote the use of
LARC and draw attention to the cost effectiveness of all LARC methods compared
with oral contraception and condoms
(Table 3).
Guidance on Depo Provera and bone
mineral density
Many people are still confused about the
advice that the Medicine and Healthcare
Products Regulatory Agency (MHRA) issued
in November 2004 about the use of Depo
Provera.7 In response to a growing body
of evidence that use of Depo Provera is
associated with a reduction in bone mineral
density (BMD), the MHRA advised that:
in adolescents Depo Provera may be
used as a first-line contraceptive, but
only after other methods have been discussed with the patient and considered
to be unsuitable or unacceptable
the committee also recommended
careful re-evaluation of the risks and
benefits of treatment in women of all
ages who wish to continue use of Depo
Provera for more than two years
finally, the committee on safety of
medicines (CSM) advised that women
who had significant lifestyle or medical
risk factors for osteoporosis should consider other methods of contraception.

Some people are interpreting this advice to

mean that young people cannot use Depo
Provera, and that for all women, use
should be restricted to 2 years. A meeting
of experts at WHO, held in 2005, reviewed
all of the evidence on the effect of Depo
Provera on BMD.8 The conclusions of the
meeting are shown in Table 4.
So what should we be advising to
women who want to use or who are using
Depo Provera? There should be no restriction on longterm use of Depo Provera
among women aged 18 to 45 who are
otherwise eligible to use it. They should be
reviewed every two years and reminded
about loss of BMD. Unless new significant
risk factors for osteoporosis (e.g. use of
steroids, BMI <18) have arisen, they can
continue Depo Provera if they wish to.
Neither BMD nor serum estradiol concentrations need be measured.
Among people under the age of 18
years, the advantages of using Depo
Provera generally outweigh the theoreti
cal safety concerns regarding fracture
risk. As the CSM recommends, Depo Provera can be used if other methods have
been discussed and rejected. Adolescents
too should be reviewed after 2 years but
there is no absolute limit on the duration of the use by teenagers. Remember,
teenage pregnancy also leads to loss of
bone.
Among women over the age of 45 years,
the advantages of starting Depo Provera
for the first time for contraception are
generally outweighed by the theoretical
concerns about fracture risk since the risk
of pregnancy is diminishing at that age.
For women who are already using Depo

Recommendations from the NICE guideline on long-acting reversible

contraception
1 Women requiring contraception should be given information about and offered a
choice of all methods, including long-acting reversible contraception (LARC) methods.
2 Women should be provided with the method of contraception that is most acceptable
to them provided it is not contraindicated.
3 Contraceptive service providers should be aware that:
all currently available LARC methods (intrauterine devices [IUDs], the intrauterine
system [IUS], injectable contraceptives and implants) are more cost effective than
the combined oral contraceptive pill even at 1 year of use
IUDs, the IUS and implants are more cost effective than the injectable contraceptives
increasing the uptake of LARC methods will reduce the number of unintended
pregnancies
Table 3

MEDICINE 35:6

350

Provera, the risks of continuation should

be discussed, but if the woman wishes to
continue she should generally be allowed
to do so.

Emergency contraception
Emergency contraception (EC) was made
available as a pharmacy-only medicine in
2001. This action has not increased overall
use of EC, but has reduced the number
of women who go to their GP to get it.9
Most women who have an unintended
pregnancy still do not use emergency
contraception. In 2005/06, 5% of women
of reproductive age and 15% of women
aged 1617 said they had used EC in the
last year. 6 Around 10 to 12% of women
presenting for abortion claim to have used
EC to try to prevent that pregnancy.10,11
However, among women attending for
antenatal care, less than 2% use it to try
to prevent pregnancy despite 10% saying
the pregnancy was unintended and 25%
being somewhat ambivalent about their
desire to be pregnant.11
To be effective EC, must be used
within 72 hours of intercourse and it is
probably most effective when it is taken
with 24 hours of sex. It can be difficult
to get EC within this time frame and it
is expensive (25) when purchased from
a pharmacy. A number of studies have
been undertaken in which women have
been given a supply of EC to keep at
home thus removing all the barriers to
access.10 All of the studies demonstrate
a two- to three-fold increase in the use
of EC. Six of them looked at pregnancy
or abortion rates as an end point.1217
None showed any effect on the number
of pregnancies or the abortion rate when
women who had a supply of EC to keep
at home (and were much more likely to
use it) were compared with women who
had to go to a doctor or pharmacy to get
EC. Even though advanced provision did
result in increased use, still at least 3 out
of 4 women who had EC at home did not
use it when they put themselves at risk
of pregnancy. When women were asked
why they did not use EC, in the majority
of cases it was because they did not recog
nize (or acknowledge) that they had put
themselves at risk of pregnancy.
If randomized trials have shown no
effect on pregnancy or abortion rates, this
does not mean that it is not worth promoting (or using) emergency contraception.

2007 Elsevier Ltd. All rights reserved.

WHAT'S NEW IN CONTRACEPTION

Conclusions of the World Health Organization technical consultation on

the effect of hormonal contraception on bone health
Depo Provera use reduces BMD in women who have attained peak bone mass (PBM)
and impairs the acquisition of bone mineral among those who have not yet attained PBM
The loss of BMD is small - 5 to 7% of BMD in the hip and the spine is lost after two
years. The rate of loss subsequently appears to decrease over time
When Depo Provera is discontinued, BMD is restored to within the normal range
unless women have reached menopause when they may not have time to regain BMD
It is not clear whether the loss in BMD among adolescents prevents attainment of
potential peak bone mass
Insufficient data exists to assess whether Depo Provera use modifies the absolute risk
of fracture in the reproductive years or in postmenopausal life
Since the effect on bone mineral density is largely reversible, any lifetime increase in
fracture risk is likely to be small
Table 4

As a public health strategy to reduce

unintended pregnancy and abortion rates,
the potential of EC has almost certainly
been overestimated. As long as only one
in ten women use it when they have put
themselves at risk of pregnancy it is not
going to make a measurable difference
to abortion rates. However, for an individual woman who has put herself at risk
of pregnancy (having had an accident
with contraception or unprotected sex)
EC is considerably better than nothing.
So, women who have unprotected sex
or who have had an accident with their
chosen method of contraception should
be encouraged to use EC, and we should
continue to make it easily available.
However, women need to understand
that EC is much less effective than other
contraceptive methods, and if they really
want to prevent pregnancy they should
be using a contraceptive method during
sex or preferably before it.

References
1 World Health Organization. Medical
eligibility for contraceptive use, 3rd edn.
Geneva: WHO, 2004.

MEDICINE 35:6

2 Faculty of Family Planning and

Reproductive Healthcare. UK medical
eligibility criteria for contraceptive use
(UKMEC 2005/2006). Available at:
http://www.ffprhc.org.uk/admin/
uploads/298_UKMEC_200506.pdf
[Accessed 2 April 2007].
3 National Institute for Health and Clinical
Excellence. Long-acting reversible
contraception. London: NICE,
October 2005. www.nice.org.uk
4 Darney PD, Callegari LS, Swift A, Atkinson ES,
Robert AM. Condom practices of urban
teens using Norplant contraceptive implants,
oral contraceptives and condoms for
contraception. Am J Obstet Gynecol 1998;
180: 92937.
5 Santelli JS, Lindberg LD, Finer LB, Singh S.
Explaining recent declines in adolescent
pregnancy in the United States: the cont
zribution of abstinence and improved contra
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6 Taylor T, Keyse L, Bryant A. Contraception
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for National Statistics, 2006.
7 Updated prescribing advice on the effect
of Depo-Provera contraception on bones.
Available at: http://www.mhra.gov.uk/
home/idcplg?IdcService=SS_GET_
PAGE&nodeId=238 [Accessed 2 April 2007].

351

8 World Health Organization. Technical

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Available at: WHO, 2006. http://www.who.
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docs/hc_bonehealth/consultation_rpt.pdf;
2006 [Summary Report].
9 Marston C, Meltzer H, Majeed A. Impact
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emergency hormonal contraception
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repeated cross sectional surveys. BMJ
2005; 331: 27175.
10 Glasier A. Emergency contraception is it
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11 Lakha F, Glasier A. Unintended pregnancy
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12 Glasier A, Baird DT. The effects of SelfAdministering Emergency Contraception.
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13 Glasier A, Fairhurst K, Wyke S, et al.
Advanced provision of emergency
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14 Hu X, Cheng L, Hua X, Glasier A. Advanced
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2007 Elsevier Ltd. All rights reserved.