Assess and counsel a high-risk patient requesting contraception, applying current eligibility criteria

In one line

For a high-risk woman, the contraceptive decision is a risk–risk trade-off: the absolute risk of the method must be weighed against the far larger risk of an unintended pregnancy in her specific condition, and the eligibility framework (WHO MEC / UKMEC) is the tool you use to argue it — never a substitute for clinical judgement when she carries multiple problems.

The method basics are covered in the Intermediate course: contraceptive modalities and postpartum contraception. The harder layer is judgement — the multimorbid woman, the framework's edges, the drug interactions, and the consultant call when two guidelines disagree.

Assessment

Frame every high-risk consult around four questions: how dangerous is pregnancy for her, how effective must the method be, which methods are her condition's contraindications, and what does she want? Asking them is routine; resolving them when the answers conflict is the harder consultant task.

• Quantify the pregnancy risk first. Pregnancy is the comparator the MEC categories are built against. In pulmonary hypertension, peripartum cardiomyopathy with residual dysfunction, severe valvular disease or Fontan circulation, maternal mortality is high enough that the most effective method (LARC or sterilisation) is the safety priority, not estrogen avoidance alone. The modified WHO cardiac classification (mWHO IV) names the conditions in which pregnancy is contraindicated — and those are precisely the women for whom a failed method is a catastrophe, so effectiveness, not estrogen-avoidance, is the dominant variable.
• History: the condition and its severity/control; thrombotic, cardiac, cerebrovascular, hepatic and oncological history; migraine phenotype (aura = focal neurology, not just severe headache); current drugs (enzyme-inducers, ART, bosentan, lamotrigine, anticoagulants); smoking; BMI; parity and future fertility wishes; HIV status and PrEP use; and any malabsorptive bariatric surgery (Roux-en-Y / biliopancreatic diversion), which undermines every oral hormonal method.
• Examination/investigation is condition-directed: BP (a true ≥160/100 is a hard CHC contraindication), BMI, and — for cardiac patients — current functional status and echo data, because peripartum cardiomyopathy is sub-categorised by recovery of ventricular function.
• Interpretation: a UKMEC/WHO MEC category 3 does not mean "no" — it means risks usually outweigh benefits and the method may still be the best available option after specialist input. Category 4 is an unacceptable risk. Two separate category-2 conditions are not additive into a 4; you re-appraise the woman as a whole.

The advanced judgement: where the framework runs out

The category tables are built for single conditions. The multimorbid woman breaks that assumption, and three judgement principles separate a consultant answer:

• Categories are not additive — but the highest one is binding. A woman who is both obese (BMI ≥35, CHC category 3) and a smoker over 35 (CHC category 3–4) is not a "category 6". You take the most restrictive relevant category as the floor, then re-appraise holistically: multiple concurrent category-2/3 cardiovascular risk factors push CHC firmly to category 4 because the biology (compounding arterial risk) is genuinely synergistic, whereas two unrelated category-2 conditions are not. Distinguish risk factors that share a mechanism (additive or supra-additive) from those that do not.
• Initiation versus continuation can diverge. Several conditions carry a lower category for continuing a method a woman already uses than for starting it — a new migraine-with-aura in an established CHC user, for instance, is a stop-and-switch, but the framework's continuation column exists because the act of stopping is itself not risk-free if it precipitates an unplanned pregnancy. Quote the column you are actually in.
• The condition's trajectory matters more than its label. "SLE" is not one MEC entry — it splits by antiphospholipid-antibody (aPL) status, disease activity and immunosuppression. aPL-positive (with or without clinical SLE) makes CHC category 4 regardless of how quiet the lupus is, because the thrombotic driver is the antibody, not the flare. Take the relevant sub-phenotype, not the diagnosis, to the table.

Management

Structure counselling as method now → review → definitive plan, anchored to the eligibility categories (1 = no restriction; 2 = advantages generally outweigh risks; 3 = risks usually outweigh advantages, needs expert judgement; 4 = unacceptable risk).

The high-risk conditions that bar combined hormonal contraception (CHC) almost all permit progestogen-only methods and the copper IUD. Estrogen drives the arterial- and venous-thrombotic excess; remove it and most doors reopen.

*Category numbers follow WHO MEC 6th ed (2025) / UKMEC 2025. Ranges reflect "initiation vs continuation" or severity sub-categories. DMPA is now UKMEC 3 for current or past VTE (a small observational VTE signal, upgraded from 2 in UKMEC 2025), so read the DMPA column here as the VTE-specific category. *Copper-IUD insertion carries a vasovagal-syncope risk that is dangerous in severe pulmonary hypertension or single-ventricle physiology — insert with cardiac cover/sedation, or prefer the implant.

Subtype-specific management — the conditions the Final drills

• Cardiac disease: the etonogestrel implant is often the method of choice — highly effective, estrogen-free, no insertion-related haemodynamic risk. The implant and the LNG-IUS avoid estrogen-associated thrombosis and carry no demonstrated venous thromboembolism excess. Discuss DMPA separately, because it now carries a small observational VTE signal (UKMEC 2025). Avoid the vasovagal hit of intrauterine insertion in the most fragile (Eisenmenger, severe PAH) unless done under monitoring with full resuscitation capability — a single vasovagal syncope can collapse a fixed-output circulation. Where definitive contraception is wanted in mWHO III–IV disease, laparoscopic tubal occlusion under general anaesthesia carries its own anaesthetic risk in these women; a Mirena or implant placed at the time of another planned procedure (or hysteroscopic/postpartum) often beats interval sterilisation. See Cardiac disease in pregnancy.
• VTE / thrombophilia / Postpartum haemorrhage survivors on anticoagulation: estrogen-free throughout. The LNG-IUS is additionally useful to control anticoagulation-related heavy menstrual bleeding — a genuine therapeutic two-for-one. A woman on a DOAC or warfarin with heavy menses should be offered the LNG-IUS as treatment, not merely tolerated as contraception.
• Severe/poorly controlled hypertension or established arterial disease (overlapping Hypertension in pregnancy antihypertensives and Early-onset severe pre-eclampsia): CHC is category 4; DMPA is category 3 in established vascular disease (a small, possibly adverse lipid/vascular effect), so the implant, POP or LNG-IUS are preferred over DMPA here, and LARC plus counselling on the high pregnancy risk is the plan.
• Polyendocrine metabolic ovarian syndrome (PMOS) (previously PCOS) with obesity (BMI ≥35): CHC is category 3, not absolute — weigh metabolic/VTE risk against the non-contraceptive benefit (cycle control, endometrial protection); the LNG-IUS gives endometrial protection without the estrogen load and is the pragmatic default when BMI and metabolic risk make estrogen unattractive.
• Obesity and the malabsorption traps. Obesity per se does not blunt the implant, injectable or intrauterine methods — but it changes two things the framework hides. First, levonorgestrel emergency contraception loses efficacy with rising weight (signal of reduced effect from around 70–75 kg; ulipristal holds longer but is also weight-sensitive), so the copper IUD is the emergency method of choice in a heavier woman, and ulipristal is preferred over LNG orally. Second, after malabsorptive bariatric surgery the combined and progestogen-only pills drop to category 3 — counsel a non-oral method (implant, injectable, LNG-IUS, Cu-IUD).
• Women living with HIV (PVT framing): for a woman living with HIV who is clinically well on ART, the hormonal methods (implant, DMPA, POP, CHC) are category 1, but the Cu-IUD and LNG-IUS are category 2 (WHO MEC 6 and UKMEC 2025). The rule that all methods including the IUDs are category 1 belongs to the separate group of women at high risk of HIV who are HIV-negative — that is where the precautionary DMPA caveat was removed in 2019 after ECHO. On top of the HIV categories, the real issue is drug interactions: efavirenz lowers implant/POP/CHC levels (each MEC 2 while DMPA stays 1), whereas dolutegravir — SA first-line — has no clinically important hormonal interaction, though that does not convert the IUDs' HIV category to 1. PrEP (oral TDF/FTC or the dapivirine ring) does not restrict any method. Always counsel dual protection (condoms for STI/HIV) and offer emergency contraception access.