Table Of Contents:
Executive summary of recommendations
1 Purpose and scope
2 Identification and assessment of the evidence
3 Introduction
4 Summary, including changes to existing guidance
5 What is combined hormonal contraception?
5.1 Hormonal content of combined hormonal contraception
5.1.1 Estrogens
5.1.2 Progestogens
5.2 What methods of CHC are available in the UK?
5.3 How does CHC work?
6 How is CHC used?
6.1 Standard CHC regimens
6.1.1 Combined oral contraception
6.1.2 Combined transdermal patch
6.1.3 Combined vaginal ring 6 6.2 Tailored CHC regimens
6.2.1 Suggested tailored CHC regimens
6.2.2 Contraceptive effectiveness of tailored CHC regimens
6.2.3 Safety of tailored CHC regimens
6.2.4 Bleeding patterns with extended CHC regimens
6.2.5 Tailored CHC regimens and symptoms associated with the HFI
6.2.6 Return to fertility after use of extended CHC regimens
6.2.7 Acceptability of tailored CHC regimens
6.2.8 Offering tailored CHC regimens
6.3 When can CHC be started?
6.3.1 Starting CHC at the beginning of a natural menstrual cycle
6.3.2 Quick starting CHC
6.3.3 Summary of advice for starting CHC
6.3.4 Switching to CHC from other contraceptive methods
7 How effective is CHC?
7.1 Contraceptive effectiveness of CHC
7.2 What can affect contraceptive effectiveness of CHC?
7.2.1 Is contraceptive effectiveness of CHC affected by obesity/weight?
7.2.2 Is contraceptive effectiveness of CHC affected by bariatric surgery?
7.2.3 What drug interactions are important to consider in relation to CHC?
8 Incorrect use of CHC
8.1 Combined oral contraception
8.2 Combined transdermal patch
8.3 Combined vaginal ring
9 Non-contraceptive health benefits associated with CHC use
9.1 Heavy menstrual bleeding
9.2 Menstrual pain
9.3 Acne
9.4 Premenstrual symptoms
9.4.1 EE/DRSP COC for management of premenstrual symptoms
9.4.2 Other COC for management of premenstrual symptoms
9.4.3 Extended COC regimens for management of premenstrual symptoms
9.5 Vasomotor symptoms
9.6 Bone health
9.7 Endometriosis
9.8 Polycystic ovary syndrome
9.9 Effect of CHC use on cancer risk and mortality
9.9.1 Endometrial cancer
9.9.2 Ovarian cancer
9.9.3 Colorectal cancer
9.9.4 Mortality
10 Health risks associated with CHC use
10.1 Venous thromboembolism (VTE) (including deep vein thrombosis and pulmonary embolism)
10.1.1 Effect of progestogen type on VTE risk
10.1.2 Effect of dose of EE on VTE risk
10.1.3 Effect of estrogen type on VTE risk
10.1.4 Effect of route of administration on VTE risk
10.1.5 Women with inherited thrombophilias
10.2 Arterial thromboembolic disease
10.2.1 CHC use and risk of myocardial infarction
10.2.2 CHC use and risk of ischaemic stroke
10.2.3 Estrogen dose and risk of ATE
10.2.4 Progestogen type and risk of ATE
10.2.5 Estrogen type and risk of ATE
10.2.6 Route of administration and risk of ATE
10.2.7 Additional risk factors for ATE
10.3 CHC use and risk of haemorrhagic stroke
10.4 Breast cancer
10.4.1 CHC use and risk of breast cancer
10.4.2 Family history of breast cancer
10.4.3 Genetic mutations relevant to breast cancer risk
10.5 Cervical cancer
11 Side effects associated with CHC use
11.1 CHC and headache
11.2 Unscheduled bleeding with CHC (breakthrough bleeding)
11.2.1 Differences in bleeding pattern between routes of CHC administration
11.2.2 Differences in bleeding patterns between formulations of oral contraceptives
11.2.3 Differences in bleeding patterns between CHC regimens
11.3 Mood
11.4 Weight gain
11.5 Effect on libido
11.6 Return to fertility
12 What should be done in an initial CHC consultation?
12.1 Assessment of suitability of CHC for an individual woman
12.1.1 Assessment of medical eligibility for CHC
12.1.2 Assessment of factors that could affect contraceptive effectiveness
12.1.3 Women for whom CHC is unsuitable
12.2 Choosing a method of contraception
12.3 Choosing type and formulation of CHC
12.4 Choosing a regimen for CHC use
12.5 Other important supporting information
12.6 Duration of CHC prescription
12.6.1 Combined oral contraception
12.6.2 Combined transdermal patch
12.6.3 Combined vaginal ring
13 What follow-up is required for women continuing with use of CHC?
13.1 What follow-up arrangements are appropriate?
13.1.1 What should be done at CHC follow-up?
13.2 Online and remote provision of CHC
14 What specific advice is required for women using CHC?
14.1 CHC use during travel
14.1.1 VTE risk during travel
14.1.2 Adherence to CHC when crossing time zones
14.2 CHC use at high altitude
14.3 Surgery/periods of immobilization
15 What recommendations are there regarding stopping CHC?
15.1 How long can women use CHC?
15.1.1 Use of CHC by women aged over 40 years
15.1.2 Duration of CHC use
15.2 Switching to another method of contraception
15.3 Planning pregnancy
15.3.1 Return of fertility
15.3.2 Preconception care
15.3.3 Unplanned pregnancy during CHC use
16 Use of CHC in the perimenopause
16.1 Use of CHC as an alternative to HRT
16.2 Transition to HRT