How can I assess a patient's suitability for combined hormonal contraception?

To assess a patient's suitability for combined hormonal contraception (CHC), you should perform a general assessment to confirm its suitability ¹. This assessment applies to females aged 13 to 60 years ¹.

• General Assessment:

  Begin by discussing the patient's needs and personal circumstances, including their preferred method of contraception, future plans for children, personal beliefs, and partner/family attitudes towards contraception ¹. Provide comprehensive information on all contraceptive methods, including their efficacy, how they work, common adverse effects, possible drug interactions, health risks and benefits, and information on return to fertility after discontinuation ¹. This information should be presented in an easily understandable format ¹. Offer the method most acceptable to the patient, provided it is not contraindicated ¹.

  Exclude pregnancy before initiating any contraceptive method ¹,². Take a detailed medical history and perform a clinical examination to identify factors that could affect contraceptive choice ¹. These factors include comorbidities (e.g., hypertension, migraine), allergies (e.g., latex, anaesthetics), lifestyle factors (e.g., smoking), reproductive history (e.g., postpartum, breastfeeding), drug treatments (e.g., liver enzyme-inducing drugs), and age (e.g., approaching menopause or under 18 years) ¹. Additionally, check the patient's cervical screening history to ensure routine appointments have been attended ¹.

• UK Medical Eligibility Criteria (UKMEC):

  Crucially, check the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) to ensure the patient can safely use CHC ¹. For perimenopausal women, consider UKMEC categories for CHC use if cardiovascular risk factors are present, such as controlled or uncontrolled hypertension, vascular disease, current or history of ischaemic heart disease, stroke (including transient ischaemic attack), a BMI of 35 kg/m² or more, smoking in women aged 35 years and older, or multiple cardiovascular risk factors ¹.

  For specific conditions, CHC can generally be used: for idiopathic menorrhagia (UKMEC 1 or 2) ¹, for abnormal vaginal bleeding where benefits generally outweigh risks (UKMEC 2), though unexplained bleeding should be investigated ¹, for a history of ectopic pregnancy (UKMEC 1) ¹, and for uterine fibroids without distortion of the uterine cavity (UKMEC 1) ¹. If uterine fibroids cause distortion of the uterine cavity, other hormonal methods of contraception can still be used without restriction (UKMEC 1) ¹.

• Specific Considerations:

  Age: CHC is not contraindicated by age alone in perimenopausal women ¹. For girls under 18, all methods can be considered if there are no contraindications, but regular hormonal contraception should be avoided in sexually active girls who have not started menstruating ¹.

  Drospirenone: If considering a CHC containing drospirenone, note it is contraindicated in severe renal insufficiency and acute renal failure ¹. It should be avoided in individuals with known hyperkalaemia or untreated hypoaldosteronism, and those taking potassium-sparing diuretics or potassium supplements ¹. Monitoring of urea and electrolytes and blood pressure may be required in mild/moderate renal insufficiency or treated hypoaldosteronism, or in those with significant risk factors for chronic kidney disease, especially if over 50 years ¹.

  Drug Interactions: Be aware of potential drug interactions, particularly with liver enzyme-inducing drugs ¹.

  Premature Ovarian Insufficiency (POI): CHC can be offered as sex steroid replacement for POI, unless contraindicated ⁴. Explain the importance of continuing hormonal treatment until at least the age of natural menopause, that baseline disease risks are low under 40, that HRT may have a beneficial effect on blood pressure compared to combined oral contraceptives, and that both HRT and CHC offer bone protection, but HRT is not a contraceptive ⁴.

• Informed Consent:

  Ensure the patient is involved in discussions and makes informed decisions about their care ²,³. Counselling should be sensitive to cultural differences and religious beliefs ². For non-English speaking patients or those with sensory impairments or learning disabilities, ensure access to trained interpreters or advocates ². For young people under 16, consider the Fraser guidelines ²,³.