3. Contraception and Special Groups

Contraception and Special Groups

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

There are separate articles on Contraception and the Mature Woman, Contraception and Young People and Postpartum Contraception.

  • Women with a body mass index (BMI) greater than 30 should be counselled regarding an increased risk of venous thromboembolism (VTE), and consider contraceptive methods other than the combined oral contraceptive pill (COCP).
  • The absolute risk of pregnancy using both COCPs and progestogen-only pills (POPs) has been shown to increase in women having a BMI greater than 27.3, suggesting a possible reduction in efficacy of hormonal contraception.[1] However, other studies have not found any influence of body weight on the risk of accidental pregnancy with either form of oral contraceptive.[2]
  • Diaphragms and caps should be checked if the woman gains or loses 3 kg or more in weight.
  • BMI over 35 kg/m2: methods that should not be used are the COCP, combined contraceptive patch and combined contraceptive vaginal ring.
  • Weight greater than 70 kg: POPs, except desogestrel, may be less effective in women who weigh more than 70 kg.
  • Weight greater than 90 kg: the combined contraceptive patch should not be used.
  • 'Heavier women': the progestogen-only contraceptive implant may need to be removed earlier than the licensed three years (this is a recommendation from the manufacturer but there is no definite evidence for this).

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  • Drugs which induce liver enzymes can reduce the efficacy of combined hormonal contraception, POPs and implants but do not appear to reduce the efficacy of progestogen-only injectables or the the levonorgestrel-releasing intrauterine system (LNG-IUS).[3]
  • Drugs which induce liver enzymes include:
  • COCP - all women should be advised to switch to a contraceptive method unaffected by enzyme inducers (eg progestogen-only injectable, copper IUCD (Cu-IUCDs) or LNG-IUS). Rifampicin and rifabutin are such potent enzyme-inducing drugs that extra contraceptive precautions or a switch are essential.

    If the woman does not wish to change:
    • If on a short-term course of an enzyme-inducing drug (not rifampicin and rifabutin):
      • She should take a combination of oral contraceptives to provide a daily intake of ethinylestradiol 50 micrograms or more (unlicensed use),[3] using an extended or tri-cycling regimen with a pill-free period of no more than 4 days, continued for the duration of the course and for 4 weeks afterwards. Breakthrough bleeding may indicate inadequate oestrogen levels - the dose can be increased to a maximum of ethinylestradiol 70 micrograms.[3]
      • If she stays on her previous COCP, she should take extra contraceptive precautions (eg sheath) for the duration of the course of enzyme inducer and for 4 weeks afterwards.
    • Long-term course of an enzyme-inducing drug:
      • Rifampicin and rifabutin are such potent enzyme-inducing drugs that an alternative method of contraception is always recommended.
      • Take a combination of oral contraceptives to provide a daily intake of ethinylestradiol 50 micrograms or more (maximum 70 micrograms) - unlicensed use.
      • Tricycling (taking 3 or 4 packets without a break followed by a short tablet-free interval of four days) is recommended.
      • Appropriate contraceptive measures are required for 4 weeks (the BNF says 8 weeks) after stopping the enzyme-inducing drug.
    • Contraceptive patches:
      • Additional contraceptive precautions are required whilst taking the enzyme-inducing drug and for four weeks after stopping.
      • If concomitant administration runs beyond the three weeks of patch treatment, a new treatment cycle should be started immediately without a patch-free break.
      • For women taking long-term enzyme-inducing drugs, another method of contraception should be considered.
  • POP:
    • Advise alternative contraceptive methods.
  • Progestogen-only implants:
    • May continue with progestogen-only implants with additional contraceptive protection, such as condoms, when taking liver enzyme-inducers and for four weeks after they are stopped.
  • Progestogen-only emergency contraception:
    • Take a total dose of 3 mg levonorgestrel as a single dose as soon as possible and within 72 hours of unprotected sex.
    • Use of ulipristal acetate (UPA) is not advised in women using enzyme-inducing drugs or in those who have taken them in the preceding 28 days.
    • Consider the use of a Cu-IUCD, which is unaffected.

Women with history of migraine with aura or who develop migraine with aura:

  • Methods that can generally be started: POP, progestogen-only implants and injectables, and the LNG-IUS.
  • Methods that are not usually recommended to continue with, if women develop migraine with aura while using them: POP, progestogen-only implants and injectables, and the LNG-IUS.
  • Methods that should not be used: COCP, the combined contraceptive patch, and combined contraceptive vaginal ring.

Women who develop migraine without aura (<35 years of age):

  • Methods that are not usually recommended: continuation of COCP, the combined contraceptive patch, and combined contraceptive vaginal ring.

Women with migraine without aura (≥35 years of age):

  • Methods that are not usually recommended: initiation of COCP, the combined contraceptive patch and combined contraceptive vaginal ring.
  • Methods that should not be used: continuation of COCP, the combined contraceptive patch and combined contraceptive vaginal ring in women who develop migraine without aura while taking combined hormonal contraceptives.

Women with diabetes and nephropathy, retinopathy, neuropathy or any other vascular disease, and those who have had diabetes for more than 20 years:

  • Methods that should not usually be used: progestogen-only injectables. COCP, the combined contraceptive patch and the combined contraceptive vaginal ring.

Women with hypertension that is adequately controlled, or with consistently increased systolic blood pressure over 140 mm Hg and below 160 mm Hg, or diastolic blood pressure over 90 mm Hg and below 95 mm Hg, without vascular disease:

  • Methods that are not usually recommended: COCP, the combined contraceptive patch and combined contraceptive vaginal ring.

Women with consistently increased systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥95 mm Hg, without vascular disease:

  • Methods that should not be used: COCP, the combined contraceptive patch and combined contraceptive vaginal ring.

Women with hypertension and vascular disease:

  • Methods that are not usually recommended: progestogen-only injectables.
  • Methods that should not be used: COCP, the combined contraceptive patch and combined contraceptive vaginal ring.

Women over 35 years who smoke or have stopped smoking in the past 12 months:

  • Methods that should not be used: COCP, combined contraceptive patch and combined contraceptive vaginal ring.
  • Methods that are not usually recommended: progestogen-only injectables.
  • Methods that should not be used: COCP, combined contraceptive patch and combined contraceptive vaginal ring.

Women with known thrombogenic mutations or a history of VTE:

  • Methods that should not be used: COCP, the combined contraceptive patch, and the combined contraceptive vaginal ring.

Women taking anticoagulants for VTE:

  • Methods that are not usually recommended: progestogen-only injectables and implants, cu-IUCDs, and the LNG-IUS.
  • Methods that should not be used: COCP, the combined contraceptive patch and the combined contraceptive vaginal ring.

Women with idiopathic menorrhagia:

  • Consider the LNG-IUS (Mirena®) as the first-line option, COCP as the second-line option, and POP and progestogen-only injectables as third-line options.

Women with uterine fibroids:

  • With distortion of the uterine cavity: cu-IUCDs and the LNG-IUS should not be used.
  • Women with current pelvic inflammatory disease: cu-IUCDs and the LNG-IUS should not be inserted. There is generally no need for removal if the woman wishes to continue their use.
  • Women with a current purulent cervicitis, chlamydial infection, or gonorrhoeal infection: cu-IUCDs and the LNG-IUS should not be inserted. There is generally no need for removal if the woman wishes to continue their use.
  • Women at very high risk of exposure to gonorrhoeal or chlamydial infection: insertion of a cu-IUCD or the LNG-IUS is not usually recommended. There is generally no need for removal if the woman wishes to continue its use.
  • For women with learning disabilities there is high use of injectable contraceptives and IUCDs. However, management of contraceptive needs of young women with an intellectual disability is similar in most cases to the management of non-disabled women.[4]
  • However, a person with learning disability or mental impairment may still be competent to make an informed choice regarding method of contraception and be able to use any method reliably.[5]
  • It is therefore essential to consider the individual circumstances and wishes of women with learning disabilities and not necessarily opt for those methods that do not require the understanding and involvement of the user.
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Further reading & references

  1. Holt VL, Scholes D, Wicklund KG, et al; Body mass index, weight, and oral contraceptive failure risk. Obstet Gynecol. 2005 Jan;105(1):46-52.
  2. Vessey M; Oral contraceptive failures and body weight: findings in a large cohort study.; J Fam Plann Reprod Health Care. 2001 Apr;27(2):90-1.
  3. Drug Interactions with Hormonal Contraception, Faculty of Sexual and Reproductive Healthcare (2011)
  4. Arscott K, Dagnan D, Kroese BS; Assessing the ability of people with a learning disability to give informed consent to treatment. Psychol Med. 1999 Nov;29(6):1367-75.
  5. Grover SR; Menstrual and contraceptive management in women with an intellectual disability. Med J Aust. 2002 Feb 4;176(3):108-10.
Original Author: Dr Colin Tidy Current Version: Peer Reviewer: Dr Hannah Gronow
Last Checked: 28/09/2011 Document ID: 2005  Version: 24 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.