Shelley Raine explains why the UKMEC is so important in general practice and how to apply the recommendations when seeing women, both for the initiation of a contraceptive method and continuation of a treatment.

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Read this article to learn more about:

  • why UKMEC is so important in general practice
  • what the UKMEC classification categories actually mean
  • how to apply the recommendations when seeing women, both for initiation of a method and continuation of treatment.

What is the UKMEC?

The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) is a set of criteria that enable and support clinicians to deliver safe, evidence-based contraceptive care to women.1

An anecdotal saying within sexual and reproductive healthcare (SRH) is 'all modern methods of contraception are very safe, but not all women are safe to use them.' This guidance helps nurses (and doctors) to identify the methods that can safely be used by particular groups of women and when.

The UKMEC is useful for anyone seeing women for contraception care—whether this is for initiation of a method (prescribing or supplying against Patient Group Directions) or for repeat/follow up.

How was it developed?

The WHO developed and published the original medical eligibility for contraceptive use criteria (WHOMEC) in 1996 in an attempt to improve accessibility to contraceptive methods for women around the globe. This was achieved by a formal consensus process of international experts who agreed a set of criteria for a range of situations and medical conditions that might contraindicate certain contraceptive methods. These criteria have been revised and updated regularly—the fifth edition was published in 2015.2

The first UKMEC, published in 2006, was adapted from the WHO version using a similar consensus process based on published evidence and the collective knowledge of experts in SRH to reflect current knowledge and practice in the UK. The third edition, published in May 2016, takes into account new evidence included in the WHOMEC (fifth edition). These updates have been led by the Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Healthcare (FSRH) of the Royal College of Obstetricians and Gynaecologists.1

Why should it be used and how does it work?

Most women are well and able enough to use any contraception available. However, there are some health conditions that would pose a significant health risk when certain methods of contraception are used; the UKMEC provides a framework to check what these are.1,3 When issuing repeat pills or administering an injection, it is not sufficient to take a woman's blood pressure (BP) without checking if there is anything that might have changed the safe use of her method.1,3

Contraceptive methods covered by the UKMEC include all hormonal contraceptives, intrauterine methods, and emergency contraception (EC). Health and medical conditions, and situations related to these, are considered as part of the framework. Medical conditions, such as migraine, whether and how long a woman is postnatal, history of venous thromboembolism, and breast cancer are covered; health conditions include lifestyle (age and smoking). Each method is allocated one of four categories for each condition, or situation relating to a condition, to demonstrate its safety (see Table 1 below).1,3

Table 1: Definition of UKMEC categories and what this means in practice1,3
CategoryDefinitionWhat this means in practice
1 A condition for which there is no restriction for the use of the contraceptive method Use method in any circumstances
2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks Generally use the method but higher level judgement and more careful follow up required
3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method Probably don't use (needs expert judgement/specialist referral)
4 A condition which represents an unacceptable health risk if the contraceptive method is used Do not use

 

As part of the framework there are also categories for initiation of a method in women with specific conditions and continuation of a method in women who develop new medical conditions.1,3

What this means in practice:

  • For a combined hormonal method, a woman with a body mass index (BMI) of 30 would be UKMEC 2 (generally use) but a woman with a BMI of 35 would be UKMEC 3 (probably don't use)
  • A woman who has migraine with aura would be UKMEC 4 (do not use) for a combined hormonal method
  • For any hormonal method, a woman who currently has breast cancer would be UKMEC 4 but if she previously had breast cancer she would be UKMEC 3
  • A woman with a systolic BP greater than 160 or diastolic BP greater than 100 would be UKMEC 4 for combined hormonal methods but UKMEC 2 for the implant or progestogen-only pill
  • The progestogen-only pill can generally start to be used by a woman who has had a stroke in the past (UKMEC 2—initiation) but if she has had a stroke while using this method she would require expert clinical management (UKMEC 3—continuation).

Please refer to the full guideline for all other recommendations.

However, the UKMEC does not replace clinical judgement (knowledge, training, expertise) and it does not recommend or suggest a ‘best method’. Decisions about what methods to use should take into account clinical judgement and user preferences. The criteria are related to the safe use of a method in particular situations and are intended to be applied where methods are used for contraception; the criteria are not related to the efficacy of each method. When methods are used for clinical reasons (e.g. management of heavy periods) the risk:benefit profile may vary. It is of note that the categories should not simply be added together when assessing risk (e.g. 2 x UKMEC 2 does not automatically equate to UKMEC 4).1,3

What has changed?

Barrier methods, fertility awareness methods, and male and female sterilisation are no longer included in the third edition. It was felt these were more appropriately dealt with in the comprehensive method-specific guidance available from the FSRH website.4

The order in which methods are presented has changed so the long-acting reversible contraception (LARC) methods are presented first. The EC section has been amended to include ulipristal acetate (new method), and obesity has been added as a condition (new evidence).1

The section on drug interactions has been removed; as these are changing all the time this could adversely affect how up to date the guidance is. It was felt that they are more effectively dealt with by online drug-interaction checkers such as that provided on the Medscape website (signposted in UKMEC).1

New conditions have been added to reflect population-risk changes (bariatric surgery, organ transplant), increasingly recognised conditions (long QT syndrome), and rheumatoid arthritis.

Malaria (rarely seen) and Raynaud’s disease (reclassified) are among the conditions no longer included.1

What format is it available in?

For easy reference, on a day-to-day basis, most clinicians use the UKMEC 2016 summary sheets.3 Both these and the full document, a useful learning resource with more detailed information, are available for free from the FSRH website.1,3

The UKMEC guideline has been summarised by the Guidelines for Nurses team and will soon be available to view at www.GuidelinesforNurses.co.uk; this concise document provides key points for primary care.

Gold standard for safe prescribing of contraception

Since its introduction, the UKMEC has become the gold standard for the safe prescribing of contraception. Anyone who provides contraception services should be familiar with it and have easy access to the summary sheets for everyday reference when seeing women for contraceptive care.1,3 For nurses this will most often be when seeing women for repeat pills and injectables. Alongside the method-specific guidance that the FSRH produces, UKMEC supports clinicians in providing safe and up-to-date, evidence-based care to patients.1,3,4

Box 1: Other information, training, and services provided by the FSRH

  • Evidence-based clinical guidelines for all methods of contraception
  • Clinical standards for providing SRH services
  • Up-to-date training:
    • the FSRH Diploma and Letters of Competence in Intrauterine Techniques and Sub-dermal Implants (LoC IUT and LoC SDI)
      • in 2014 this training was extended to nurses
    • introductory-level training (SRH Essentials; see below)
      • aimed at practice nurses
  • Meetings and conferences.

More information can be found on the FSRH website

FSRH=Faculty of Sexual and Reproductive Healthcare; SRH=sexual and reproductive health

 

Box 2: SRH Essentials training

  • New introductory-level training (SRH Essentials) aimed at practice nurses
    • a 1-day course designed to support nurses working in primary care or other community settings
  • This course will give the skills and confidence to:
    • bring up the topic of contraception and sexual health with patients
    • assess and safely reissue (not start for the first time):
      • combined hormonal methods
      • progestogen-only pill
      • injection
    • assess whether a woman is at risk of pregnancy
    • decide which EC methods women may safely consider
    • identify when patients are at risk of an STI
    • decide when to refer to a GP, SRH colleague, or other service.

EC=emergency contraception; STI= sexually-transmitted infection; SRH=sexual and reproductive health

References

  1. The Faculty of Sexual and Reproductive Healthcare. UK Medical Eligibility Criteria for Contraceptive Use 2016. London: FSRH, 2016. Available at: http://ukmec.pagelizard.com/2016 (accessed 8 July 2016).
  2. World Health Organization. Medical eligibility criteria for contraceptive use, Fifth edition, 2015. Geneva: WHO, 2015. Available at: www.who.int/reproductivehealth/publications/family_planning/Ex-Summ-MEC-5/en/ (accessed 29 June 2016).
  3. The Faculty of Sexual and Reproductive Healthcare. UK Medical Eligibility Criteria Summary Table 2016. London: FSRH, 2016. Available at: http://ukmec.pagelizard.com/2016 (accessed 29 June 2016).
  4. Faculty of Sexual and Reproductive Healthcare. Current Clinical Guidance. London: FSRH, 2016. Available at: www.fsrh.org/standards-and-guidance/current-clinical-guidance (accessed 29 June 2016).