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

45 year old lady has had endometrial ablation done privately for heavy bleeding. Told by the consultant she doesn’t need ongoing contraception as ablation means very unlikely to conceive. True?

Response:

Clinical guidance [1-3] notes that endometrial ablation is not contraceptive, therefore ongoing contraception is required unless a woman has been confirmed to be postmenopausal or has undergone female sterilisation.

A recent 2017 systematic review [4] which examined pregnancy after endometrial ablation identified 274 pregnancies from 99 sources, of which 78 were case reports. The women identified were aged 26–50 years (mean 37.5 ± 5 years) and conceived a median of 1.5 years after ablation (range: 3 weeks prior to 13 years after). Where data were available, 80–90% of these women were not using contraception at time of conception. High rates of pregnancy complications were reported; Of the women identified from observational studies, 85% ended in termination, miscarriage or ectopic pregnancy. Pregnancies that continued (case report and non‐case report sources) had high rates of preterm delivery, caesarean delivery, caesarean hysterectomy, and morbidly adherent placenta. Case reports also frequently described preterm premature rupture of membranes, intrauterine growth restriction, intrauterine fetal demise, uterine rupture, and neonatal demise.

National Institute for Health and Care Excellence (NICE) Guideline Heavy Menstrual Bleeding: Assessment and Management [1] recommendation 1.4.6 notes ‘[A]dvise women to avoid subsequent pregnancy and use effective contraception, if needed, after endometrial ablation [2007]’ The American College of Obstericians and Gynecologist (ACOG) Guidelines on Endometrial Ablation [2] also recommends (based primarily on consensus and expert opinion) that ‘ [P]hysicians should counsel premenopausal patients undergoing endometrial ablation to use appropriate contraception’.

FSRH Clinical Guideline Contraception for Women Aged over 40 Years [3] provides comprehensive guidance relating to contraceptive choices for women in this age group; with regard to the use of levonorgestrel-releasing intrauterine system, the guideline notes that ‘HCPs should use clinical judgement as to whether LNG-IUS insertion with hysteroscopy following endometrial ablation should be attempted. Women should be carefully counselled regarding the potential risks of the procedure.

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Example Question Two

I have a 36 yr patient who is about to start treatment for a Hodgkins lymphoma. Proposed agents are- Bleomycin, Doxorubicin, Vinblastine and Dacarbazine.

She requires contraception. I felt CHC were not appropriate, she had bleeding with implant in the past and does not want IUC. At present she is on POP as she has not started treatment and as far as I am aware progestogens are not contra indicated in Hodgkins Lymphoma.

She is keen to try depot. Is there any information/advice regarding depot with HL and this chemotherapy regime?

Response:

The CEU conducted a literature review and did not identify any studies which examined the use of contraception by women with Hodgkin lymphoma.

Venous thromboembolism (VTE) risk is elevated in individuals with cancer, compared to those without cancer [1,2] (it is the second leading cause of death in (solid) cancer patients undergoing chemotherapy).[3] One large study based on a hospital discharge database reported a rate of VTE of 4.7% amongst the 10,075 patients with Hodgkin lymphoma. Amongst patients receiving chemotherapy (for any cancer), the rate of VTE increased significantly from 3.9% to 5.7%. [2]

There is no evidence relating directly to safe use of any contraceptive method by women with Hodgkin lymphoma undergoing chemotherapy. Given that cancer and chemotherapy are associated with elevated risk of VTE, when supporting your patient to make contraceptive choices, you may wish to consider that combined hormonal contraception (CHC) is itself a risk factor for VTE; progestogen-only contraceptives and the copper IUD are not associated with increased VTE risk and may be more effective for contraception than CHC.

No drug interactions are listed for bleomycin, doxorubicin, vinblastine or dacarbazine and contraceptive hormones.

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Example Question Three

I would be grateful for some advice on how to use the UKMEC in terms of the scoring system. For example if one factor was not an outright UKMEC 3 or 4 but there were several UKMEC 2 or 1 would we add each individual score or when it comes to more than one area would we use clinical judgement?

Response:

The introduction to UKMEC2016 explains correct use of UKMEC guidance. We have explained further below to try to support your understanding.

1. UKMEC categories relate to use of contraceptive methods for contraception, NOT for other indications.
2. UKMEC categories 1-4 relate to safety of use of contraceptive methods by women with UKMEC conditions, but NOT to effectiveness.
3. The list of UKMEC conditions is not exhaustive. A condition that is not included in UKMEC could still potentially make use of a contraceptive method inadvisable.
4. Women with multiple UKMEC conditions:-
• UKMEC scores should NEVER simply be added.

• A woman with any number of conditions that are UKMEC1 for use of a contraceptive method can use the contraceptive method without restriction.

• The relevance of a UKMEC2 condition must be considered in the context of any other UKMEC2 or 3 conditions that the woman has for use of the method. UKMEC2 indicates that the benefits of use of a method generally outweigh risks. However, in contrast to UKMEC1 it indicates a possible safety concern if a woman has other risk factors for the same adverse health event. A woman may have several UKMEC2 conditions relating to health risks that are completely independent of one another: those risks are not cumulative. But for a woman with several UKMEC2 conditions that all relate to the same health risk, a prescriber may consider that their combined risk outweighs contraceptive benefit – especially if there are safer effective alternatives.

E.g. A woman requests CHC. She is 43 years old (UKMEC2), has a BMI of 32kg/m2 (UKMEC2) and her mother had a pulmonary embolism at age 46 (UKMEC2). Each of these three UKMEC2 conditions does not, on its own contraindicate use of CHC. However, age, obesity, family history of PE and use of CHC are all independent risk factors for VTE and a prescriber could consider that use of CHC represents an unacceptable total risk; alternative effective contraceptive methods that are not associated with increased risk of VTE should be considered. A woman who is breastfeeding her four month old baby and has migraine without aura and cervical intraepithelial neoplasia also has three UKMEC2 conditions for use of CHC. However, each of the UKMEC2 conditions relates to a different potential health risk. Together, they do not cumulatively increase any one health risk. Benefits are likely to outweigh risks.

• A UKMEC3 category indicates that the risks associated with use of a method for contraception generally outweigh benefits; where safer contraceptive alternatives are available, these should be used. If safer alternatives are not available, or are not acceptable, use of a method for which the woman is UKMEC3 may be considered by an expert provider, in consultation with the woman. When making such a prescribing decision, any other UKMEC2 or 3 conditions that the woman has which relate to the same health risk must be taken into consideration and the woman must be fully informed. Many UKMEC3 conditions relate to use of CHC: given the range of safer, effective, progestogen-only alternatives, CHC is best avoided in most UKMEC3 circumstances.

• UKMEC4 indicates that use of the method by a woman with the health condition concerned is associated with unacceptable health risk and alternative effective contraception should be used.

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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.