Members Evidence Request - Supporting Clinical Practice

The Clinical Effectiveness Unit (CEU) provides an evidence-based enquiry service for FSRH members. The CEU will conduct a literature review and summarise the available evidence in relation to a particular medical condition and/or contraceptive method.


Recent Questions and Answers that have been submitted to the CEU can be seen below. Please note, the full answer includes references to more information and guidance.

The FSRH CEU has produced a quick guide on conducting systematic literature reviews to answer clinical questions (log in to access the guide). This brief and easy-to-use guide aims to support FSRH members to conduct a systematic literature search/review to answer clinical enquiries they may have. The process described in this guidance is adapted from the process used by the FSRH CEU when responding to enquiries made via the members evidence request service.

How to Submit a Members' Evidence Request

How do I get access to the Members' Evidence Request?

  • please log in to ‘My FSRH’ and
  • click on ‘Members' evidence request’ to search for questions or submit your own question.

This service is available to current FSRH members (Diplomates, Associates, Members, Fellows). 

I haven't set up a log in yet - what should I do?

If you are an FSRH member and have not yet created your ‘My FSRH’ account, please click the ‘Register’ button on the top right of this website and follow the steps to gain access to your account. Please use an email address that we will have contacted you on previously.

Once you have registered you will be able to access the full service and search the database as shown in the video. 

 

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Example Question One

I have a young patient aged 18 who is keen to try CHC - her mother had a DVT postnatal at age 37 - she has tried Desogestrel and is troubled with irregular bleeding. Not keen on implant or intrauterine methods. Is she still regarded as UKMEC 3 if her mother's DVT was provoked? As with HRT does the same apply with lower risk using patch/ring CHC? 

Response:

Use of CHC by a woman with a first degree relative who has had a VTE event under the age of 45 is UKMEC3: risks generally outweigh benefits for contraceptive use[1]. No distinction is made on the basis of whether the VTE event was provoked or unprovoked - the evidence is inadequate to allow such a distinction to be made. Although women are at increased risk of VTE after childbirth, most post natal women do not have VTE events. An individual who has such an event could potentially have predisposing genetic factors that put her at increased risk of VTE; she could have an inherited thrombophilia that has triggered the VTE event and could also affect her daughter.

The combined contraceptive patch and ring appear to be associated with a HIGHER risk of VTE than combined oral contraception[2]. This contrasts with the apparently lower VTE risk associated with transdermal HRT than with oral HRT.

The risk of VTE is likely to be small, but VTE events can be fatal. Given that there is a choice of effective contraceptive alternatives that are not associated with increased VTE risk (some are more effective for contraception than CHC), these should be considered first line. UKMEC 3 indicates that provision of CHC in this situation requires expert clinical judgement and/or referral to a specialist contraceptive provider. If CHC is the only contraceptive option that is acceptable to a fully informed woman, the prescriber (in consultation with the woman) should weigh the risk associated with CHC use against risk associated with unplanned pregnancy.

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Example Question Two

A new patient requested a repeat of her COC (prescribed in USA). She experiences occasional episodes of unilateral loss of vision lasting approximately 10 minutes and accompanied by a headache. Her symptoms are suggestive of retinal migraine. Is this a concern for use of CHC? 

Response:

There is no evidence relating specifically to health risk associated with use of combined hormonal contraception (CHC) by women with retinal migraine. However, the International Classification of Headache Disorders 3rd Edition (ICHD-3)[1], published 2018, classifies retinal migraine as migraine with aura:-

Image Migraine

The UKMEC (2016) [2] recommends that use of CHC by women with any migraine with aura is UKMEC4 (a condition which represents an unacceptable health risk if the method is used) because of potentially increased risk of ischaemic stroke. There is inadequate evidence to distinguish between types of migraine with aura.

If a woman has new onset of migraine without aura during use of CHC, continued use of CHC is UKMEC3 (risks generally outweigh benefits). FSRH CEU cannot tell you if the symptoms that your patient is experiencing represent migraine/migraine with aura - that is your clinical judgement to make, supported by neurology if required.

FSRH Guideline ‘Combined Hormonal Contraception’ (2019) [3] summarises the evidence on which this recommendation is based, including “A 2016 systematic review concluded that the fair to poor quality evidence identified suggests an increased risk of stroke amongst CHC users with migraine compared with non-users of CHC who have migraine, and that the effect on ischaemic stroke risk of migraine and CHC are additive.”

FSRH CEU notes that LARC methods, which offer more effective contraception than CHC, are UKMEC category 1 or 2 for use by women who have migraine with aura. If there is doubt regarding diagnosis of migraine/ migraine with aura, alternatives to CHC should be considered.

The International Classification of Headache Disorders 3rd Edition (ICHD-3) defines and sets out diagnostic criteria for retinal migraine as follows: “1.2.4 Retinal migraine Description: Repeated attacks of monocular visual disturbance, including scintillations, scotomata or blindness, associated with migraine headache. Diagnostic criteria: A. Attacks fulfilling criteria for 1.2 Migraine with aura and criterion B below B. Aura characterized by both of the following: 1. fully reversible, monocular, positive and/or negative visual phenomena (e.g. scintillations, scotomata or blindness) confirmed during an attack by either or both of the following: a. clinical visual field examination b. the patient’s drawing of a monocular field defect (made after clear instruction) 2. at least two of the following: a. spreading gradually over ≥5 minutes b. symptoms last 5–60 minutes c. accompanied, or followed within 60 minutes, by headache C. Not better accounted for by another ICHD-3 diagnosis, and other causes of amaurosis fugax have been excluded.”

ICHD-3 also states:- “Retinal migraine is an extremely rare cause of transient monocular visual loss. Cases of permanent monocular visual loss associated with migraine have been described. Appropriate investigations are required to exclude other causes of transient monocular blindness.” It is assumed that other causes have been excluded when considering the diagnosis in this case.

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Example Question Three

Is an IUS a reasonable method of contraception to use in a woman with Klippel-Trenaunay-Weber syndrome given the possible risk of visceral bleeding associated with vascular malformation?  

Response:

The FSRH CEU conducted a review of the literature and identified no evidence relating to contraception use by women with Klippel-Trenaunay-Weber (KTW) syndrome.

There are a number of case studies in the literature of intrauterine vascular malformations/haemangiomas/angiomatosis in women with KTW, including instances resulting in haemorrhage.-7 The FSRH CEU suggests that non-intrauterine methods could be more suitable for women with KTW to avoid risk of bleeding associated with insertion of an intrauterine device.

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Please note: The advice given by the CEU should be considered as guidance only and is meant to be used alongside clinical judgement to guide clinical practice or policy. Questions that are a matter of clinical judgment and not evidence should be directed to local sexual and reproductive health leads.