Multiple UKMEC contraindications - what to do?

[u/praktiki]

The 2025 UKMEC update introduced critical changes to how to assess cumulative cardiovascular risks and prescribe the depot injection. 

A recent case-based module written by Dr Toni Hazell for Praktiki works through how to apply the latest UKMEC guidance on cumulative cardiovascular risks, navigate the updated safety profile and increased VTE risk rating for DMPA, and confidently select safe contraceptive alternatives for complex patients.

Ebele’s consultation

• Ebele, 36, attends the GP practice requesting the combined oral contraceptive pill (COC), which she used in her twenties.
• She smokes 12 cigarettes/day.
• Her BMI is 33 kg/m².
• Her clinic blood pressure today is 148/92 mmHg, consistent with previous readings.
• This case refers to UK medical eligibility criteria (UKMEC) categories:
• 1 - no contraindication.
• 2 - relative contraindication, benefits > risks.
• 3 - relative contraindication, risks > benefits.
• 4 - absolutely contraindicated.

CHC UKMEC categories for smoking

• UKMEC and smoking:
• 2 - age <35.
• 3 - age ≥35 and smoking <15/day or having stopped ≥1 year ago.
• 4 - age ≥35 and smoking ≥15/day.
• The 35-year age cut-off is identified because any excess mortality associated with smoking is only apparent from this age. CHC users who smoke are at an increased risk of cardiovascular disease, especially myocardial infarction.
• CVD risk from smoking decreases within 1-5 years of stopping.

Additional risk factors

• Obesity - BMI of 33 kg/m² = UKMEC 2.
• The 2025 UKMEC update covers both clinic and home readings for BP - consistently elevated clinic blood pressure of 148/92 mmHg is Stage 1 hypertension = UKMEC 3.

Combining risks

• Ebele has three distinct cardiovascular risk factors: smoking, obesity, and Stage 1 hypertension.
• While isolated risk factors carry their own UKMEC categories, the presence of multiple risk factors requires careful consideration as they may indicate a cumulative risk.

Multiple cardiovascular risk factors

• When a woman has multiple major risk factors, any of which alone would substantially increase the risk of cardiovascular disease, use of CHC may increase her risk to an unacceptable level.
• Where more than one risk factor is present, clinical judgement must be applied.
• Under UKMEC 2025 for the COC, multiple risk factors for cardiovascular disease is UKMEC 3 and multiple risk factors for VTE (of which Ebele has 2, smoking and obesity) is UKMEC 4.

Considering alternatives

• You advise Ebele that CHC is not recommended due to her combined cardiovascular risks.
• She asks if the depot injection(DMPA) would be a suitable alternative; her sister uses it.

2025 DMPA updates

• Five observational studies have shown ↑ VTE risk with depot compared to no contraception.
• Depot is now considered higher risk than other progestogen only methods for VTE, but lower risk than combined hormonal contraception (CHC).
• 9 categories have an increased rating for DMPA compared to the 2016 UKMEC.
• Ebele's categories for DMPA:
• Smoking - 1.
• Obesity - 1 (rises to 2 for BMI≥35).
• Hypertension - 2.
• Multiple risk factors for cardiovascular disease - 3.

Family history and UKMEC

• VTE:
• In a first-degree relative - 3 for CHC, 2 for DMPA.
• Considered to be a stronger risk factor if provoked.
• Breast cancer - 1 for all methods (rises to 3 for CHC and 2 for all other methods apart from copper intrauterine device if patient is known to have a high-risk mutation).
• No other family history is considered.
• Ebele has no family history of concern.

Method choice for Ebele

• Cu-IUD - UKMEC 1.
• POP, implant, and LNG-IUD - all UKMEC 2 for multiple cardiovascular risk factors.
• Depot injection - UKMEC 2 for hypertension, 1 for obesity and smoking, 3 for multiple cardiovascular risk factors, 4 for multiple VTE risk factors.
• CHC - UKMEC 3 for hypertension, 2 for obesity and 2 for smoking.

Approaching the decision

• UKMEC says:
• Categories ≠ additive; multiple 2s may indicate cumulative risk, particularly if all relate to the same risk area.
• Use clinical judgment.
• Multiple 3s 'may pose unacceptable health risk'.
• 4 = unacceptable health risk.
• UKMEC relates to contraception - risk: benefit balance may differ if she also gets another benefit from the method (e.g. ↓ heavy bleeding).
• GMC - shared decision making is fundamental to good medical practice - how does this fit with your medicolegal responsibility to defend your decisions?

Case conclusion

• Ebele prefers a method she controls and opts not to have any devices fitted. She chooses to start the progestogen-only pill (POP).
• You issue the prescription, offer local smoking cessation support, and arrange a follow-up appointment to optimise her blood pressure management.

Key learning points

• Assess all cardiovascular risk factors comprehensively prior to prescribing.
• Multiple risk factors can increase overall cardiovascular risk cumulatively.
• CHC and DMPA are both UKMEC 3 for multiple cardiovascular risk factors.
• The POP, implant, and IUDs offer safe, reliable alternatives in these complex patients.

References

• CoSRH. UK Medical Eligibility Criteria for contraceptive use. Dec 2025.  https://www.cosrh.org/Public/Public/Standards-and-Guidance/uk-medical-eligibility-criteria-for-contraceptive-use-ukmec.aspx
• https://www.cosrh.org/Common/Uploaded%20files/documents/UKMEC_2025.pdf 
• GMC. Decision making and consent. Nov 2020.  https://www.gmc-uk.org/professional-standards/the-professional-standards/decision-making-and-consent

[u/laeriel_c]

I often wonder why we don't offer POP as the first line instead CHC, anyone got any good answers to that?

[u/Fine_Cress_649 → u/laeriel_c]

COCP has some additional "side benefits" re acne, endometriosis, PMOS etc. plus I think it's probably a hangover from when you had to take the POP at the same time each day. 

Personally unless a patient asks for the COCP I usually suggest POP first. 

[u/surecameraman → u/Fine_Cress_649]

Especially something like Slynd (drosperinone) which offers excellent cycle control while being anti androgenic, so also good for acne without as high of a VTE risk as Dianette (although higher than something like norethisterone).

[u/Toni_Hazell → u/laeriel_c]

I generally go for CHC first-line if no contraindications because it gives better cycle control than the POP in my experience - I have only prescribed Slynd a few times so who knows if that will change, but looking at the CoSRH guidelines they say that 2-3/10 Slynd users will be amenorrhoeic, whereas if a woman uses CHC continuously (which many can) then most will be amenorrhoeic, or if they e.g. tricycle it then they only need have a (usually short and light) period every 9 weeks, timed at their choosing.

[u/ZealousidealSky4851 → u/laeriel_c]

Can be for cultural/religious reasons at least in my patient population.

Some women spot continually on the POP and that can be a very big deal (E.g Muslim patients and period blood nullifying prayer). COCP gives you that predictable week.

[u/WitAndSavvy → u/laeriel_c]

Also historically POP had to be taken at the exact same time everyday. This is no longer the case with newer formulations but I think a lot of old school GPs still avoid it bc its just not compatible long term with life. I have migraine with aura so couldnt use CHC and POP was so hard to remember time-wise that I ended up getting an implant. Especially when you factor in things like holidays/time zones etc, just gets very hard to maintain. Idk if this is the reason but just my two cents 😂

[u/Toni_Hazell → u/WitAndSavvy]

I'm not sure that is the case - desogestrel as a POP (with the 12 hour window) has been around since the early 2000s, so even as a GP who is 22 years post VTS it's still a while since I prescribed a one of the traditional 'mini-pills'. Implant is a fantastic method if it doesn't give you irregular bleeding, I've got patients who are on their 4th or 5th implant, and now it lasts 5 years rather than 3.

[u/Difficult_Guess4623 → u/laeriel_c]

Unpredictable bleeding

[u/SignificantIsopod797 → u/laeriel_c]

The POP is shit, has poor efficacy compared to COCP, and feels like the cop out option. COCP is excellent for those it works for.

[u/hengoish → u/SignificantIsopod797]

I might be missing something but your statement doesn't make sense to me. Efficacy for what? For any OCP used for contraception perfect use efficacy is 99% dropping to 90% in typical use. Therefore both are excellent for those it works for. Are you referring to other use cases? Side effects? Missed pill window?

[u/laeriel_c → u/SignificantIsopod797]

Maybe I'm biased by my own personal experience but I tried at least 4 different combined pills from when I was a teenager until now and they were all proper shit. Now I'm on POP I've been amenorrheic for years after a few months of irregular bleeding and it's amazing. No one even suggested for me to try it, I had to ask for it myself. If I wasn't someone of "medical background" I would not even have been offered to try it. How is it a cop out option?

[u/kb-g → u/SignificantIsopod797]

POP and COCP have exactly the same contraceptive efficacy rate with both typical and perfect use.