UKMEC 2016 – guidance for Nurses

The UK Medical Eligibility Criteria (UK MEC 2016) is the authoritative, ‘go-to’ reference for clinicians providing contraceptives safely across the life course. In line with the release of the 2016 UKMEC, we are launching this key guidance for nurses, which we hope will help them to make the most of the new tool, enabling them to identify which methods can safely be used by which women and when.

The UKMEC is a set of guidance criteria that enable and support clinicians to deliver safe, evidence-based contraceptive care to women.

An often repeated saying in sexual and reproductive health care (SRH) is that ‘all modern methods of contraception are very safe, but not all women are safe to use them’. This guidance helps nurses (and doctors) to identify which methods can safely be used by which women and when.

Where does it come from? How was it developed?

The original medical eligibility criteria were developed and published by the WHO (World Health Organization) in 1996 in an attempt to improve accessibility to contraceptive methods for women around the globe. This was achieved by a formal consensus process of international experts who agreed a set of criteria for a range of situations and medical conditions that might contraindicate contraceptive methods. These have been revised and updated regularly with the fifth edition being published in 2015 (available from the WHO website).

The first UKMEC was adapted from the WHO version in 2005/6 with a similar consensus process using published evidence and the collective knowledge of experts in SRH to reflect current knowledge and practice in the UK. The third edition, published in May 2016, supersedes the second version (2009) and takes into account new evidence included in the WHOMEC (fifth edition). These updates have been led by the Clinical Effectiveness Unit (CEU) of the Faculty of Sexual and Reproductive Healthcare (FSRH).

What has changed from the second edition?

Barrier methods, fertility awareness methods and male and female sterilisation are no longer included. It was felt these were more appropriately dealt with in the comprehensive method-specific guidance available from the FSRH website.
The order in which methods are presented in the document and summary sheets has changed so the LARC (Long Acting Reversible Contraception) methods are presented first. The Emergency Contraception (EC) section has been amended to include ulipristal acetate (new method since 2006) and obesity has been added as a condition (new evidence).

The section on drug interactions has been removed. It was felt that as these are changing all the time this could adversely affect how up-to-date guidance was and these are more effectively dealt with by online drug interaction checkers (such as Medscape), which are signposted in the guidance.

New conditions have been added to reflect population risk changes (bariatric surgery, organ transplant), increasingly recognised conditions (long QT syndrome) and rheumatoid arthritis.

Malaria (rarely seen) and Raynaud’s disease (reclassified) are among the conditions no longer included.

What format is it available in?

For day-to-day use most clinicians use the summary sheets for easy reference. The summary sheet and the full document are available in digital format in the Standards and Guidance section of the FSRH website.

Please note that the digital version is open access, but only FSRH members can download and print the UKMEC 2016.

Who should use it?

Anyone who is seeing women for contraception care whether this is for initiation of a method (prescribing or supplying against PGDs) or for repeat/follow up. It is not sufficient to just do a woman’s blood pressure and issue repeat pills or administer an injection without checking if there is anything that might have changed her safe use of her method.

Why should it be used?

Most women are well and able to use any available contraception at any time. However there are some health conditions that would pose a significant health risk when certain methods are used. The UKMEC give an easy way to check what these are.

How does it work?

Methods include: all hormonal contraceptives; intrauterine methods; and EC. Health conditions cover lifestyle (age and smoking) as well as medical conditions such as migraine, whether and how long post-natal, history of VTE (venous thrombo-embolism), breast cancer etc. Use of each method in each situation or medical condition is then allocated one of four categories as below.

In addition there are categories for Initiation of a method by a woman with a specific condition and Continuation of a method in a woman who develops a new medical condition.

What does all this mean in practice?

So for example:

1. 1. Looking at a combined hormonal method a woman with a BMI of 30 would be a UKMEC 2 (generally use) but if she had a BMI of 35 this would be a UKMEC 3 (probably don’t use); a woman who has migraine with aura would be a UKMEC 4 (Do Not Use); 
2. 2. A woman with current breast cancer would be a 4 for any hormonal method but it would be a 3 if she had breast cancer in the past.

3. A woman with a systolic BP greater than 160 or diastolic greater than 100 would be a UKMEC 4 for combined hormonal methods but a 2 for the implant or progestogen only pill.
4. A woman who has had a stroke in the past can generally start and use the progestogen only pill (UKMEC 2 - Initiation) but if she has a stroke while already using it this becomes a UKMEC 3 for Continuation and would require expert clinical management.

What does it not do?

The UKMEC does not replace clinical judgement (knowledge, training, expertise) nor does it recommend or suggest a ‘best method’. Decisions about what methods to use should take into account clinical judgement and user preferences. The criteria are related to the safety of use of a method in particular situations not the efficacy and are intended to be applied where methods are used for contraception. When methods are used for clinical reasons (e.g. management of menstrual disorders such as heavy periods) the risk/benefit profile may vary. It should be noted that the categories should not simply be added together when assessing risk – for example 2 x UKMEC 2 do not automatically equate to a UKMEC 4.

Where can I get more information?

As well as the UKMEC, we produces evidence-based Clinical Guidelines for all methods of contraception, Clinical Standards for providing SRH services, develops and maintains training and organises meetings and conferences.

In conclusion

Since its introduction, the UKMEC has become seen as the gold-standard for the safe prescribing of contraception. Anyone who provides contraception services should be familiar with it and have easy access to the summary sheets for everyday reference if seeing people for contraceptive care. For nurses this will most often be when seeing women for repeat pills and injectables. Alongside the method-specific guidance that the FSRH produces this supports clinicians in providing safe and up-to-date, evidence-based care to patients.

By Shelley Raine, Nurse Specialist in Contraception.

This article was first published in 'Guidelines for Nurses' on 31 July 2016.