Updates to safe contraceptive prescribing guidance – key points for pharmacists

GP with an interest in women’s health Dr Toni Hazell explains what practice and community pharmacists need to know about some important updates regarding safe contraceptive prescribing in the UK Medical Eligibility Criteria for Contraceptive use (UKMEC)

Gold-standard guidance on contraceptive safety in the UK has recently been updated, with some important changes that pharmacists in primary care should be aware of.¹

The guidance is the UK Medical Eligibility Criteria for Contraceptive use (UKMEC), produced by the College of Sexual and Reproductive Health (CoSRH), which guides prescribers on the relative safety of any given contraceptive method depending on the individual’s risk factors.

UKMEC – key principles

The updated version, published in December, follows the same principles as before, whereby methods are classified into four categories, numbered 1-4 (see below),¹ depending on the co-morbidity or personal characteristic being looked at.

Category 1: A condition for which there is no restriction for the use of the method.

Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks.

Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are available or not acceptable.

Category 4: A condition which represents an unacceptable health risk if the method is used.

Categories 1 (method is fine to use) and 4 (absolutely contraindicated) are straightforward, but the provision of contraception when methods are UKMEC Category 2 or 3 requires clinical judgement.

As such, two Category 2s in the same area – for example, relating to venous thromboembolism (VTE) risk – should prompt caution.

For Category 3, an experienced clinician may feel able to prescribe a method in this category – the balance may be tipped by other factors, such as: the patient having been unable to tolerate other methods; the UKMEC 3 risk factor being one that is resolving (for example weight which is consistently being lost); or the risks of pregnancy being so high for that particular woman that it is felt that more risk than usual can be tolerated in her contraception.

However, if there is more than one UKMEC 3 then the method would not usually be prescribed – the UKMEC says that ‘when an individual has multiple conditions scoring UKMEC 3 for a method, use of this method may pose an unacceptable risk; clinical judgement should be used in each individual case’. That said, we must remember that the UKMEC only covers the use of contraception. If a woman is getting an extra benefit from her method (such as management of endometriosis), that may affect the risk/benefit calculation.

Before looking at what’s new, safe use of the UKMEC depends on the user understanding a few important things about it:

• It covers safety, not efficacy.
• If a condition isn’t in UKMEC, that doesn’t mean that safe use of contraception can be assumed. Clinicians should consider seeking advice from secondary care or asking the Clinical Effectiveness Unit (CEU) of the CoSRH to review the evidence² – the latter service is available only for members and diplomates of the CoSRH.
• Ratings for initiation and continuation of a method may vary, reflecting differing risks associated with starting or continuing a method.

Changes to depot medroxyprogesterone acetate categories

The biggest single change is regarding depot medroxyprogesterone acetate (DMPA) injection.³ It has up to now been classed with other progestogen-only methods, but observational studies have shown that its VTE risk is higher than previously thought (though still lower than that of combined hormonal contraception; CHC). Table 1 outlines the changes; in some of these areas, other progestogen-only methods now have a lower UKMEC class than DMPA. Practices should consider reviewing all women who use DMPA before their next injection, to check that use is still appropriate.

Table 1. Changes to DMPA UKMEC categories by condition

Addition of four new conditions

Four areas have been added to the UKMEC; multiple sclerosis (MS), chronic kidney disease (CKD), sickle cell trait and the use of e-cigarettes. Details of the changes are outlined in table 2.

Table 2. UKMEC advice for four new conditions

Patients are often concerned about the possibility of hormonal contraception affecting their mood. Depression was previously UKMEC 1, but it has been removed from this version and there is now a statement about the effects of hormonal contraception on mood.⁶

The key points are as follows:

• Evidence is largely observational and often confounded; studies generally don’t focus on women with pre-existing mental health conditions.
• There is no clear evidence that any hormonal contraception worsens or improves mood, but some patients report mood change during the use of hormonal contraception. Such a change may not indicate direct causation.
• Healthcare professionals should do the following:
  • Explore other possible contributing factors and consider alternative contraception if the patient feels that their mood has been adversely affected by their contraception.
  • Counsel patients with pre-existing anxiety or depression to monitor their mood when starting hormonal contraception.

Other changes to categories or criteria

Finally, there are several smaller changes made in this version of the UKMEC:

• Stroke is no longer UKMEC 3 for continuation of the levonorgestrel intrauterine device (LNG-IUD); three observational studies have found no increased risk.
• More person-centred language is used for HIV; categories are now to do with whether the person is clinically well or unwell, and whether they are on or off treatment for HIV, rather than focusing on their CD4 count.
• Hypertension has been updated to include home and clinic blood pressure readings and to reflect NICE classification.
• High-risk human papilloma virus (HPV) infection is included in the same category as cervical intraepithelial neoplasia – the LNG-IUD, DMPA and CHC are UKMEC 2 for this cohort.
• The definition of ‘currently being treated for breast cancer’ has been clarified and includes the years taking tamoxifen or aromatase inhibitors as well as earlier treatment.
• Mycoplasma genitalium is included for the first time in the section on sexually transmitted infections. We generally cannot test for this in primary care, but if a patient is known to have current Mycoplasma genitalium infection, their rating for insertion of a new IUD rises to UKMEC 4 (with clinical symptoms or signs of infection) or UKMEC 3 if they are asymptomatic.

Summary key points

The UKMEC is a big document – it will take time for changes to take place, but everyone who prescribes contraception should be aware of what they need to look out for now. A pragmatic approach in primary care would be to:

• Search for everyone using DMPA and arrange a review before, or at the time of, their next injection.
• Search for everyone with MS or the more severe forms of CKD mentioned in UKMEC and review their notes to see if their contraception needs to be changed – this could be done virtually, with only those needing changes recalled.
• Highlight the need for opportunistic review of those who use CHC, to ask them if they use e-cigarettes.
• Search for those who have sickle-cell trait and are using CHC – recall them all for a clinical review.
• Consider covering the new UKMEC at a practice meeting (or circulating this article) so that everyone is aware of the issues for new prescriptions.

References

1. CoSRH. UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). December 2025
2. CoSRH. About the CoSRH Clinical Effectiveness Unit (CEU).
3. CoSRH. UKMEC 2025 Summary of key changes. December 2025
4. CoSRH. Progestogen-only Injectable Contraception. July 2023
5. National Osteoporosis Guideline Group UK. Clinical guideline for the prevention and treatment of osteoporosis. 2024
6. CoSRH. CoSRH Statement: Effect of Hormonal Contraception in Individuals with Anxiety and Mood (Affective) Disorder. December 2025

A version of this article was first published on our sister title Pulse