Contraception in High Risk Women

In women with medical disorders, especially in developing world, the use of effective and safe contraception to prevent an unplanned pregnancy, plays an important role in reducing maternal morbidity and mortality.

For every medical condition, there are 4 categories to assess medical eligibility criteria (MEC) for use of a method of contraception.

Category 1: No restriction to the use of method.

Category 2: The advantages outweigh the risks.
The method can be used but more careful follow up required.
Category 3: The risks outweight the advantages.
Not recommended unless other methods not available.

Category 4: Unacceptable health risk. Do not use.

In women with medical disorders, the risks of unplanned pregnancies must be considered to decide the most effective and acceptable method.


The use of long acting reversible contraception (LARC) such as Cu-IUD, LNG-IUS or IMP, 

is highly recommended if:

  • If the medical disorder increases the risk to a woman’s health from an unintended pregnancy, or

  • If medication used have possible teratogenic effects.

Women on medication that are Enzyme-inducing drugs may decrease contraceptive efficacy.

 

Use DMPA, Cu-IUD or LNG-IUS during medication and for FOUR WEEKS AFTER.

Anti-epileptics:
carbamazepine, eslicarbazepine, fosphenytoin, oxcarbazepine, phenobarbital, phenytoin, primidone, rufinamide, topiramate

Anti-bacterials:
rifabutin, rifampicin

Anti-retrovirals:
ritonavir, ritonavir-boosted protease inhibitors, efavirenz, nevirapine        

     

Others:
St John’s wort, modafinil, bosentan, aprepitant

The use of COC increases the risk of venous thromboembolic disease but the absolute risk is small.

Varicose veins

 

The use of COC increases the risk of venous thromboembolic disease but the absolute risk is small.

Obesity


(BMI >= 30 for Caucasian population or
BMI >= 27.5 for Malaysian population)

The use of COC increases the risk of venous thromboembolic disease but the absolute risk is small.

Smoker


COC users who smoked and aged >=35 years have increased risk of cardiovascular disease, when compared to COC users who do not smoke. This risk of cardiovascular disease decreases 1-5 years after cessation of smoking.

Dyslipidaemia


The use of COC increases the risk of venous thromboembolic disease but the absolute risk is small.

Cardiovascular diseases


The use of COC increases the risk of venous thromboembolic disease but the absolute risk is small.

Valvular and Congenital Heart Disease

  • Uncomplicated : UKMEC 1 for both Copper & LNG – IUCD

  • Complicated, : ( eg pulmonary hypertension, history of subacute bacterial endocarditis) :UKMEC 2 for both Coppper & LNG-IUCD


Uncomplicated cases are when:

  • No requirement for cardiac medication

  • Woman is asymptomatic

  • Cardiology review required annually or less

If in doubt, discuss with cardiologist

Prophylaxis against bacterial endocarditis is no longer indicated for women with Artificial Heart valves or previous endocarditis when inserting or removing IUCD.

However, this does not necessarily mean that there is no risk.

Neurological condition

Breast and Ovarian diseases


The risk of breast cancer in women of reproductive age is small. The use of COC increases the risk of breast cancer but the absolute risk is small.

Uterine diseases


Hormonal contraception reduces the risk of endometrial cancer. The use of COC reduces the risk of uterine fibroids

Endometrial and Ovarian Cancer

  • COC use reduces the risk of developing endometrial cancer.

  • While awaiting treatment, women may use COC.

Liver diseases

Venous thromboembolism

1.20 Contraception in High Risk Women

Diabetes


The use of COC increases the risk of venous thromboembolic disease but the absolute risk is small

Diabetes


The use of COC increases the risk of venous thromboembolic disease but the absolute risk is small

Autoimmune diseases


The use of COC increases the risk of venous thromboembolic disease but the absolute risk is small

Contraception in High Risk Women

Cancer and Sexually transmitted Disease

  • Young people may be advised that COC`s use is not associated with an overall increase risks of Cancer.

  • Conversely COC`s use reduces the risk of Ovarian, Endometrial and Colonic Cancer.

  • The correct and consistent use of condoms should be advised to reduce the risks of STI’s

References

  1. UK medical Eligibility Criteria for Contraceptive Use 2016

  2. Contraceptive Choices for Women with Cardiac Disease- Faculty of Sexual and Reproductive Healthcare Clinical Guidance, Clinical Effectiveness Unit, June 2014

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