FSRH Guideline Combined Hormonal Contraception

1 FSRH Guideline Combined Hormonal Contraception January 2019 (Amended November 2020) | FSRH. Faculty of Sexual & Reproductive Healthcare (FSRH) provided funding to the Clinical effectiveness Unit (of the FSRH) to assist them in the production of this Guideline , Combined Hormonal Contraception (January 2019, amended November 2020). Published by the Faculty of Sexual & Reproductive Healthcare. Registered in England No. 2804213 and Registered Charity No. 1019969. Combined Hormonal Contraception first published in October 2011.

2 Copyright Faculty of Sexual & Reproductive Healthcare January 2019. Permission is granted to reproduce or transmit this document for non-commercial personal and non-commercial education use only. Commercial use of any kind, including copying, hiring and lending, is prohibited. Any reproduction of the whole of this document must reproduce this copyright notice in its entirety. Any reproduction of a part of this document must include a statement that it is reproduced under licence from FSRH and the notice Copyright Faculty of Sexual & Reproductive Healthcare.

3 January 2019. Published in the UK. From January 2019 the FSRH has published its electronic clinical guidelines on both its own website ( ) and as an electronic supplement to the BMJ Sexual & Reproductive Health (BMJ SRH) journal. The guidelines have the same content. If a Guideline is updated, the FSRH replace the version on its website and the BMJ Sexual & Reproductive Health (BMJ SRH). journal will ensure old versions of guidelines will clearly signpost the newer version. NICE has accredited the process used by the Faculty of Sexual & Reproductive Healthcare to produce this Guideline .

4 More information on accreditation can be viewed at accreditation. FSRH Guideline : CHC. Abbreviations used ATE arterial thromboembolism BMD bone mineral density BMI body mass index CEU Clinical effectiveness Unit CHC Combined Hormonal Contraception / contraceptive COC Combined oral Contraception / contraceptive CTP Combined transdermal patch CVR Combined vaginal ring DRSP drospirenone DVT deep vein thrombosis EC emergency Contraception EE ethinylestradiol FSH follicle-stimulating hormone FSRH Faculty of Sexual & Reproductive Healthcare GDG Guideline development group hCG human chorionic

5 Gonadotrophin HCP healthcare practitioner HFI hormone-free interval HMB heavy menstrual bleeding HR hazard ratio HRT hormone replacement therapy HSUPT high-sensitivity urine pregnancy test IRR incidence rate ratio IUS intrauterine system LARC long-acting reversible Contraception / contraceptive LH luteinising hormone LNG levonorgestrel MI myocardial infarction NET norethisterone NICE National Institute for Health and Care Excellence OC oral Contraception / contraceptive PCOS polycystic ovary syndrome PMDD premenstrual dysphoric disorder PMS premenstrual syndrome POP progestogen-only pill RCOG Royal College of Obstetricians and Gynaecologists RCT randomised controlled trial RR relative risk STI sexually transmitted infection UKMEC United Kingdom Medical Eligibility Criteria for contraceptive Use UPA ulipristal acetate UPSI unprotected sexual intercourse VTE venous thromboembolism WHO World Health Organization Copyright Faculty of Sexual & Reproductive Healthcare 2019 iii FSRH Guideline : CHC.

6 Grading of recommendations Please refer to Appendix 1 for a full explanation of the classification of evidence level and grading of recommendations. At least one meta-analysis, systematic review or randomised controlled trial (RCT). rated as 1++, and directly applicable to the target population;. or A A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results. A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results.

7 B or Extrapolated evidence from studies rated as 1++ or 1+. A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results;. C or Extrapolated evidence from studies rated as 2++. Evidence level 3 or 4;. D or Extrapolated evidence from studies rated as 2+. Good Practice Point based on the clinical experience of the Guideline development group. List of tables and boxes Table 1 Standard and tailored regimens for use of Combined Hormonal Contraception (CHC).

8 Table 2 Starting Combined Hormonal Contraception and requirement for additional contraceptive precautions Table 3a Switching from Hormonal contraceptive method to Combined Hormonal Contraception Table 3b Switching from non- Hormonal contraceptive method to Combined Hormonal Contraception Table 4 Percentage of women experiencing an unintended pregnancy within the first year of use with typical use and perfect use Table 5 European Medicines Agency estimated risk of developing venous thromboembolism (VTE) in a year according to type of Combined Hormonal contraceptive method used Table 6 Definition of categories for the UK Medical Eligibility Criteria for contraceptive Use (UKMEC).

9 Table 7 Recommendations for additional contraceptive precautions when switching from Combined Hormonal Contraception to another method Box 1 Criteria for reasonably excluding pregnancy Box 2 Suggested content of an initial Combined Hormonal Contraception consultation (links to subsequent sections). Box 3 Key messages for women considering use of tailored Combined Hormonal Contraception regimens Box 4 Women using Combined Hormonal Contraception : key indications for medical review iv Copyright Faculty of Sexual & Reproductive Healthcare 2019.

10 FSRH Guideline : CHC. Contents Abbreviations used iii Grading of recommendations iv List of tables and boxes iv Contents v Executive summary of recommendations x 1 Purpose and scope 1. 2 Identification and assessment of the evidence 1. 3 Introduction 2. 4 Summary, including changes to existing guidance 2. 5 What is Combined Hormonal Contraception ? 4. Hormonal content of Combined Hormonal Contraception 4. Estrogens 4. Progestogens 4. What methods of CHC are available in the UK? 5. How does CHC work? 5. 6 How is CHC used?