In this summary
How is CHC used?
- Tailored combined hormonal contraceptive (CHC) regimens can reduce the frequency of withdrawal bleeds and can reduce withdrawal symptoms associated with the hormone-free interval (HFI); however, unscheduled bleeding is common
- Women should be given information about both standard and tailored CHC regimens to broaden contraceptive choice
- Women should be advised that use of tailored CHC regimens is outside the manufacturer’s licence but is supported by the Faculty of Sexual & Reproductive Healthcare (FSRH)
- Women should have access to clear information (either written or digital) to support tailored CHC use
When can CHC be started?
- CHC containing ethinylestradiol (EE) can be started by medically eligible women up to and including Day 5 of a natural menstrual cycle without the need for additional contraceptive protection
- CHC containing EE can be quick started by medically eligible women at any other time (with advice to use additional contraceptive precaution for 7 days) if:
- it is reasonably certain that the woman is not pregnant
- a high sensitivity urine pregnancy test is negative (even if there is a risk of pregnancy from unprotected sexual intercourse [UPSI] in the last 21 days). A follow up high sensitivity urine pregnancy test is required 21 days after the last UPSI
How effective is CHC?
Contraceptive effectiveness of CHC
- Contraceptive effectiveness of all CHC is similar
- If used perfectly, CHC is very effective for contraception. With typical use, CHC is less effective for contraception than long-acting reversible contraception (LARC)
- Women requesting CHC should be informed about the effectiveness (with both typical and perfect use) of CHC and other contraceptive methods, including the superior effectiveness of LARC
Is contraceptive effectiveness of CHC affected by obesity/weight?
- Most evidence suggests no association between weight/body mass index (BMI) and effectiveness of combined oral contraceptives (COC)
- Limited evidence suggests a possible reduction in patch effectiveness in women ≥90 kg
Is contraceptive effectiveness of CHC affected by bariatric surgery?
- Women who have had bariatric surgery should be advised that the effectiveness of COC could be reduced
What drug interactions are important to consider in relation to CHC?
- Women using enzyme-inducing drugs should be informed that the contraceptive effectiveness of CHC could be reduced during use of the enzyme-inducer and for 28 days after stopping
- Women using enzyme-inducing drugs should be offered a reliable contraceptive method that is unaffected by enzyme-inducers
- Women taking lamotrigine should be advised that CHC may interact with lamotrigine; this could result in reduced seizure control or lamotrigine toxicity. The risks of using CHC could outweigh the benefits
Antibiotics (non enzyme-inducing)
- Additional contraceptive precautions are not required when antibiotics that do not induce enzymes are used in conjunction with CHCs
Progestogen receptor modulators
- Women should be advised to wait 5 days after taking ulipristal acetate for emergency contraception (UPA-EC) before starting CHC. Women should be made aware that they must use condoms reliably or abstain from sex during the 5 days waiting and then until their contraceptive method is effective
Severe diarrhoea or vomiting
- Women using COC should be advised that contraceptive effectiveness could be reduced by vomiting or severe diarrhoea
Incorrect use of CHC
- See FSRH Guidance on Incorrect use of combined hormonal contraception
Non-contraceptive health benefits associated with CHC use
- Use of CHC for contraception may also be associated with non-contraceptive health benefits
- Use of CHC can reduce heavy menstrual bleeding (HMB) and menstrual pain and improve acne
- Use of CHC may be beneficial for women with premenstrual syndrome (PMS) symptoms
- Use of CHC (particularly continuous CHC regimens) can reduce risk of recurrence of endometriosis after surgical management
- CHC can be used for management of acne, hirsutism and menstrual irregularities associated with polycystic ovary syndrome (PCOS)
- CHC use is associated with a significant reduction in risk of endometrial and ovarian cancer that increases with duration of CHC use and persists for many years after stopping CHC
- Use of CHC is associated with a reduced risk of colorectal cancer
Health risks associated with CHC use
- Women should be informed about the health risks associated with use of CHC
Venous thromboembolism (VTE) (including deep vein thrombosis and pulmonary embolism)
- Current use of CHC is associated with increased risk of VTE; some CHC formulations are associated with a greater risk of VTE than others, dependent on progestogen type and estrogen dose
- Women should be advised that use of CHC is associated with an increased risk of VTE, but the absolute risk of VTE for an individual CHC user remains very small
Arterial thromboembolic disease
- Current use of CHC is associated with a very small increased risk of myocardial infarction (MI) and ischaemic stroke that appears to be greater with higher doses of estrogen in COC
- Women should be informed that current use of CHC is associated with an increased risk of MI and ischaemic stroke but that that these events are still extremely uncommon in CHC users
- Use of CHC by women with significant additional risk factors for arterial disease should be strongly cautioned or avoided
- Women should be advised that current use of CHC is associated with a small increased risk of breast cancer which reduces with time after stopping CHC
- Women should be advised that current use of CHC for more than 5 years is associated with a small increased risk of cervical cancer; risk reduces over time after stopping CHC and is no longer increased by about 10 years after stopping
What should be done in an initial CHC consultation?
- The flowchart below summarises the suggested content of an initial consultation with a woman who requests CHC. The consultation should focus on provision of safe, effective contraception that suits a woman’s requirements and that could also provide non-contraceptive benefits. Such a consultation is, however, an important opportunity to assess whether a woman is already at risk of pregnancy and could require emergency contraception or pregnancy testing, to assess STI risk and offer advice and testing, and to remind women about the importance of cervical screening
Suggested content of an initial combined hormonal contraception consultation
- Please see full guideline for further details on the topics given in the flowchart
Assessment of suitability of CHC for an individual woman
- Use of suitable self-completed checklists for medical eligibility appears to be accurate and acceptable to women
- Assessment of medical eligibility for CHC should include medical conditions, lifestyle factors and family medical history
- A drug history should identify:
- any prescribed or non-prescribed drug that could affect the effectiveness of the contraceptive
- any prescribed or non-prescribed drug that could itself be affected by the contraceptive
- A recent, accurate blood pressure recording should be documented for all women prior to first CHC prescription
- BMI should be documented for all women prior to CHC prescription
- Pelvic examination is not required prior to initiation of CHC
- Breast examination, cervical screening, testing for thrombophilia, hyperlipidaemia or diabetes mellitus and liver function tests are not routinely required prior to initiation of CHC
- Women for whom CHC is unsuitable should be offered alternative effective contraception
Choosing type and formulation of CHC
- COC containing ≤30 μg EE in combination with levonorgestrel or norethisterone is a reasonable first-line choice of CHC to minimise cardiovascular risk
Other important supporting information
- Women should be provided with written information or a link to a trusted online resource to support safe, effective CHC use
Duration of CHC prescription
- HCP can prescribe up to 12 months’ supply of CHC for women who are initiating or continuing CHC
What follow-up is required for women continuing with use of CHC?
What follow-up arrangements are appropriate?
Women should be advised that routine annual review of their contraception is recommended during CHC use
What should be done at CHC follow-up?
- Medical eligibility, drug history, method adherence and method satisfaction should be reassessed at follow up. BMI and blood pressure should be recorded
What specific advice is required for women using CHC?
CHC use during travel
- Women using CHC should be advised about reducing periods of immobility during travel
CHC use at high altitude
- Women trekking to high altitudes (above 4500 m or 14,500 feet) for periods or more than 1 week may be advised to consider switching to a safer alternative contraceptive method
Surgery/periods of immobilisation
Women should be advised to stop CHC and to switch to an alternative contraceptive method at least 4 weeks prior to planned major surgery or expected period of limited mobility
What recommendations are there regarding stopping CHC?
How long can women use CHC?
CHC can be used by medically eligible women for contraception until age 50 years
Use of CHC in the perimenopause
Use of CHC as an alternative to hormone replacement therapy (HRT)
- CHC can be considered for use by medically eligible women until age 50 as an alternative to HRT for relief of menopausal symptoms and prevention of loss of bone mineral density as well as for contraception
full guideline available from…
Faculty of Sexual and Reproductive Healthcare
Reproduced with permission from the Faculty of Sexual and Reproductive Healthcare (FSRH). Combined hormonal contraception. January 2019. Copyright © FSRH.
First included: February 2012, updated February 2019.
A quick reference guide is available for all members of the FSRH: www.fsrh.org/standards-and-guidance/documents/fsrh-combined-hormonal-contraception-quick-reference-summary/