It is frustrating to understand UKMEC Summary when it comes to COCP (combined pills), POP (progesterone-only pills), Mirena and more. Is it UKMEC 3 or UKMEC 2? We surround ourselves with these questions until the mind stops telling us- “I am exhausted dude”.
FSRH UKMEC Guidelines are decent but during my PLAB 1, I spent hours understanding which was which. I finally came up with a table that solved everything.
First of all, we need to understand what exactly is UKMEC?
UKMEC Definition
UKMEC stands UK Medical Eligibility Criteria. It is a set of guidelines that categorize each contraception and its safety levels in different scenarios. FSRH released the last update file in 2016 for UKMEC criteria.
UKMEC Summary Understanding
First of all, I would want you to dump the word “UKMEC” from your mind and focus on simpler understanding. Simply understand it as follows:
| UKMEC Category | Simple Meaning | Definition of Category |
|---|---|---|
| Category 1 | Safe to Use | A condition for which there is no restriction for the use of the method |
| Category 2 | A bit Unsafe but still better | A condition where the advantages of the method generally outweigh the theoretical or proven risks |
| Category 3 | Not Safe to Use but can be used if no other options | A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of the method usually requires expert clinical and/or referral to a specialist contraceptive provider, since the use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable |
| Category 4 | Definitely NOT Safe to Use | A condition that represents an unacceptable health risk if the contraceptive method is used |
Focus on the “Simple Meaning” column. As we go through, we will be categorizing each contraceptive on these terms only rather than complicating the whole summary with UKMEC.
UKMEC Guidelines Table
We will look into four scenarios where a woman will require contraceptives. We have given the indications, contraindications, and notes related to the four scenarios. (Please Click the Picture to Zoom if on mobile)
| Scenario | <20 YO | Young Sexually Inactive | Young Sexually Active | Post-Partum |
|---|---|---|---|---|
| Indications | 1. COCP 2. POP 3. Nexplanon (Progesterone only implant) (Etonogestrel implant) | > Does not require contraception as she is sexually inactive | > Menorrhagia / Dysmenorrhoea or Fibroids NOT distorting the uterine cavity >> First line- IUS (Mirena) = Levonorgestrel Intrauterine System | 1. No contraception is required till 21 days after delivery 2. POP safe for breastfeeding |
| Contraindications | 1. IUS (Mirena) 2. Depo-Provera (IM medroxyprogesterone acetate)(given once every 3 months in gluteal or deltoid muscle)- Risk of osteoporosis in such a young age 3. IUD (Copper T) | > NONE | > Mirena contraindicated? >> COCP/POP/Implants (given no contraindications to COCP such as smoking, obesity, Hx of thromboembolism, migraine with aura) > Norethisterone or POP or implants | > COCP >> Breastfeeding- after 6 months >> Non-breastfeeding- after 6 weeks |
| Others | > If with learning disabilities >> COCP and POP are contraindicated (may forget to take pills) > Nexplanon (POI) is contraindicated if a woman wants to get pregnant sooner (e.g. 6 months) | > Menorrhagia only >> First line- IUS (Mirena) >> If want pregnancy soon or <20 YO- Tranexamic acid > If there is Dysmenorrhoea >> Mefenamic acid > If there is Metrorrhagia >> COCP > Menorrhagia in a female with Sickle Cell Disease >> Depo-Provera (IM progesterone) | > If there is uterine cavity distortion by fibroids (both IUCD and IUS contraindicated) >> Implants (e.g. Nexplanon) > Menorrhagia + Sickle cell disease >> Nexplanon> Depo-Provera IM | > NONE |
Before we go deep into the topic, let’s have a look at a small topic:
Pearl Index of Contraceptives
Mnemonic for Pearl Index- EIC-TC
| Letter | Contraceptive | Pearl Index |
|---|---|---|
| E | Etonogestrel implant | 0.05 |
| I | Intrauterine system- Mirena | 0.2 |
| C | COCP | 0.3 |
| T | Tubal ligation | 0.5 |
| C | Condoms | 2 |
UKMEC in VTE (Venous Thromboembolism)
Without Menorrhagia
- UKMEC 1 (safe to use)- IUCD
- UKMEC 2 (a bit unsafe but still better)- IUS (Mirena)
With Menorrhagia
- UKMEC 1- IUS
- UKMEC 2- IUCD
Key Note
- UAA if Family complete + Anaemia + Long term contraception required + IUS/IUD C/I
UKMEC with Anti-Epileptics
Firstly, you need to identify if the drug is an inducer or not. If it is, then the following are suitable: (assuming you are familiar with CRAP-GPS and SICKFACES.COM)
Cytochrome P-450 Enzyme Inducers and Inhibitors
- Inducers- Increase PCM Poisoning but Decrease COCP, INR
- CRAP GPS- Carbamazepine, Rifampin, Alcohol “Chronic”, Phenytoin, Griseofulvin, Phenobarbital, Sulphonylureas
- Inhibitors- Decrease PCM Poisoning but Increase INR and no effect on COCP
- SICK-FACES.COM- Sodium Valproate, Isoniazid, Cimetidine, Ketoconazole, Fluconazole, Alcohol (Acute drinking), Chloramphenicol, Erythromycin (macrolides: clarithromycin, azithromycin), Sulphonamides, Ciprofloxacin, Omeprazole, Metronidazole
- Anti-Epileptics that are enzyme inducers- Carbamazepine, Phenytoin and Phenobarbital
Indicated with Enzyme Inducers
- No Menorrhagia/ Metrorrhagia- Depo Provera
- Menorrhagia/ Metrorrhagia- IUS
Contraindicated with Enzyme Inducers
- COCP, POP, POI (progesterone-only implant)
Enzyme Inducers and Progesterone-only Contraceptives
If the patient is already taking enzyme inducers, then follow:
- Only Progesterone-only contraceptive- Do not use as the efficacy of the contraception is reduced
- Parenteral Progesterone-only contraceptive
- POI (Implanon, Nexplanon)- Do not use as the efficacy of the contraception is reduced
- Progesterone-only injectables (e.g. Depot Medroxyprogesterone acetate injections)- OK to use as the efficacy of the contraception is not affected
UKMEC Contraceptives in Breast Cancer
- Only IUD and Uterine Artery Ablation (UAA if menorrhagia)
UKMEC Summary for Contraceptives
- Wants to get pregnant
- Can use
- COCP, POP
- Not to use
- IUS, IUD, Implants, Depo-Provera
- Can use
- Does not want to get pregnant
- Metrorrhagia + Menorrhagia + Fibroids- IUS
- Metrorrhagia + Menorrhagia + Fibroids distorting cavity- COCP
- Migraine with aura/ Hx of PE – IUS (IUD and Nexplanon are not good for Menorrhagia)
- Metrorrhagia + Menorrhagia + Migraine with aura/ Hx of PE- Uterine artery ablation “Important”
- Hx of DVT / PE/ Thromboembolism event
- Contraindicated- COCP
- Safe- Copper IUD
- Safe with Menorrhagia- IUS
- Breast Cancer “Important”
- ONLY IUD AND UTERINE ARTERY ABLATION (UAA if menorrhagia)
- Depo-Provera (Medroxyprogesterone)
- Conception is only possible 8-10 months after the last dose
Scenarios for UKMEC
1. Age less than 20 years old
- Don’t prescribe IUS (Mirena) or Dep-Provera (IM Medroxyprogesterone acetate) or IUD (Copper T)
- Depo-Provera- Risk for osteoporosis at such a young age
- Many females who recently started on Depo-Provera (Progesterone-only-injections) or Mirena tend to initially have bleeding for more days than usual and vaginal spotting between cycles
- Most females become amenorrhoeic after 1 year of use (Oligomenorrhoea followed by Amenorrhoea)
- Irregular bleeding/ Vaginal spotting with Depo-Provera/ Mirena/ COCP
- Reassurance and advice the patient to come back if these unscheduled bleedings become problematic
- What if bleeding becomes problematic?
- COCP for 3 months (While still on Depo-Provera)
- Or: Mefenamic acid or Tranexamic acid for 5 days
- Vaginal spotting in COCP
- <3 months- Reassure
- >3 months- Switch to another contraceptive method
- IUS (Mirena) and Depo-Provera are not recommended if <20 YO
- Nexplanon (Progesterone only implant) “Etonogestrel implant” is safe <20 YO
- COCP and POP are also safe <20 YO
- In females with some learning difficulties
- Do not prescribe Pills (COCP, POP) as they may forget to take the pills
- Some important contraindications for the use of COCP
- Smoking
- Obesity (BMI>30 kg/m2)
- Hx of thromboembolism (DVT)
- Myocardial Infarction
- Learning difficulties (as they may forget to take the pills)
- Post-partum (if breastfeeding: CI for 6 months) (If not: CI for 6 weeks)
- Migraine with aura
- HTN (even if well-controlled)
- IUS (e.g. Mirena) and Progesterone-only implants (e.g. Nexplanon) are used for long-term contraception and should be avoided if a woman has intentions and plans to get pregnant in the near future (e.g. within 6 months)
- (UKMEC 4- Avoid) IUS (Mirena) can be used within 48 hours of delivery or after 4 weeks (28 days) of delivery (for fear of uterine perforation 2-28 days after birth). However, it should not be used if a woman intends to get pregnant in the near future as it provides long-term contraception.
- After giving birth, COCP is contraindicated in breastfeeding (for 6 months) and in non-breastfeeding (for 6 weeks)
2. After Delivery
- A breastfeeding female can start COCP after 6 months of delivery
- A non-breastfeeding female can start COCP after 6 weeks
- POP (Progesterone only pills) are safe in breastfeeding, they are given orally; not injections and they are short-term birth-control methods
- No contraceptive method is required post-partum for 21 days after delivery
- Depo-Provera (Medroxyprogesterone acetate) is an IM injection given once every 3 months. It is contraindicated in females <20 YO
- However, it is first-line in females with Sickle Cell Anaemia and Menorrhagia
Few definitions:
- Menorrhagia = Heavy menstruation
- Dysmenorrhoea = Painful menstruation
- Metrorrhagia = Irregular menses
3. In Young females Not sexually active
- Does not require contraception as she is sexually inactive
- Menorrhagia only
- First line- Mirena
- If want pregnancy soon or <20 YO- Tranexamic acid
- If there is Dysmenorrhoea- Mefenamic acid
- If there is Metrorrhagia- COCP
- Menorrhagia in a female with Sickle Cell Disease- Depo-Provera (IM progesterone)
4. Sexually active woman (require contraception)
- Menorrhagia/Dysmenorrhoea or Fibroids NOT distorting the uterine cavity
- First line- IUS (Mirena) = Levonorgestrel Intrauterine System
- Mirena contraindicated?
- COCP (given no contraindications to COCP such as smoking, obesity, Hx of thromboembolism, migraine with aura)
- or POP or implants
- If there is uterine cavity distortion by fibroids
- Implants (e.g. Nexplanon)
- If with Sickle cell disease and Menorrhagia
- Depo-Provera IM
Disclaimer
Please note, the above-mentioned information is for educational purposes only. We do not hold any responsibility for the use of any information available in this article for any practical application.
We urge on not to use any data here for yourself or someone you know, rather advise you to seek GP or a doctor if you need medical advice. This post is updated as of the date, however, future updates require making the data more precise.
This post is exclusively made for students preparing for PLAB 1 exam for the UK.
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