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Sexual Health

Contraception

Contraceptive care is a person-centred process of assessing pregnancy risk, medical eligibility, interactions and preferences, then providing the acceptable method that best meets the person's priorities.

In a nutshell

Choose contraception by pregnancy risk, UKMEC safety, interactions and the person's priorities. Make the copper IUD the first emergency option discussed, quick-start suitable hormonal contraception when appropriate, and use the exact method-specific algorithm after incorrect use.

The F2 approach1,2

First ask whether emergency contraception is needed. Then exclude or manage pregnancy risk, screen safety with UKMEC, check interactions, compare acceptable methods and provide the chosen method promptly.

  • Do not make a person fail a pill before discussing an implant or intrauterine method, and do not pressure them to choose LARC.1
  • Assess confidentiality, capacity, Fraser competence where relevant, safeguarding and reproductive coercion.1

Method comparison2,1,12,5,11,13,14,15,16,17

Approximate first-year typical-use pregnancy rates help explain why method choice and adherence both matter.

MethodTypical-use pregnancy rateDuration or actionHigh-yield point
Etonogestrel implantFewer than 1 in 1005 yearsUnpredictable bleeding; enzyme inducers reduce effectiveness
Copper IUDFewer than 1 in 1005 or 10 years by device; a device with at least 300 mm2 copper inserted from age 40 can remain until menopauseHormone-free; may make bleeding heavier; most effective emergency contraception
LNG-IUDFewer than 1 in 1003, 5 or 8 years by device; a 52 mg device inserted from age 45 can remain to age 55 for contraceptionUsually lighter bleeding; a 52 mg device used for HRT endometrial protection lasts 5 years
DMPA injectionAbout 4 in 100Repeat about every 13 weeksWeight gain, small bone-density loss that usually recovers, delayed fertility return; review at least every 2 years
CHC or POPAbout 7 in 100Daily, weekly or monthly user actionCHC has oestrogen risks; POP type determines missed-pill window
External or internal condomUser-dependent; external condom about 13 in 100Every episode of sexReduces STI transmission; use a compatible lubricant
Diaphragm or cap with spermicideUser-dependentEvery episode of sexRequires correct fitting and use; does not protect against STIs
Fertility-awareness methodUp to about 23 in 100Daily cycle observationsEffectiveness varies greatly with method, teaching and correct use
Sterilisation or vasectomyVery effectivePermanentConfirm an informed permanent choice and discuss possible future regret; continue contraception until semen clearance after vasectomy

Emergency contraception6,18

Offer the copper IUD as the most effective option: within 5 days after the first unprotected intercourse in a natural cycle or within 5 days after the earliest likely ovulation, whichever is later. If fitting is delayed, give oral EC at referral in case insertion does not occur. Oral options are ulipristal acetate 30 mg within 120 hours or levonorgestrel 1.5 mg within 72 hours; LNG can be considered off-label at 72 to 96 hours. Oral EC is ineffective after ovulation.

  • At weight over 70 kg or BMI over 26 kg/m2, consider UPA or off-label LNG 3 mg; explain that evidence for the double LNG dose is uncertain.6
  • Weight does not reduce copper-IUD efficacy while it is correctly positioned, but higher BMI is associated with increased IUC expulsion; explain expulsion signs and what to do if threads change.6,5
  • With an enzyme inducer now or in the previous 28 days, prefer a copper IUD; if unsuitable or declined, LNG 3 mg is an off-label option of uncertain effectiveness and UPA is not recommended.6,8
  • Avoid UPA in severe asthma controlled with oral glucocorticoids; recent progestogen may also reduce UPA effectiveness.6
  • Repeat oral EC if vomiting occurs within 3 hours. The same oral agent can be used again in the same cycle, but do not give LNG in the 5 days after UPA. If LNG was taken in the previous 7 days, UPA may be less effective: offer a copper IUD or consider repeat LNG.6
  • No interruption of breastfeeding is needed after a single dose of UPA-EC or LNG-EC.18,6

Quick-start

  1. 1. Assess pregnancy and EC

    A negative test cannot exclude pregnancy from recent intercourse. Ask about every unprotected episode in the last 21 days and offer EC if indicated.7,6

  2. 2. Decide whether pregnancy is reasonably excluded

    Reasonable certainty applies after no intercourse since the start of the last normal period or pregnancy event; correct, consistent use of reliable contraception; the first 5 days of a normal period; under 21 days postpartum when not breastfeeding; full or near-full breastfeeding with amenorrhoea under 6 months postpartum; the first 5 days after abortion, miscarriage, ectopic pregnancy or gestational trophoblastic disease treatment; or no intercourse for over 21 days with a negative high-sensitivity test.7

  3. 3. Start only a suitable quick-start method

    If pregnancy cannot be excluded, CHC, POP or an implant can usually be quick-started after a negative test and individual assessment, with a repeat test at least 21 days after the latest unprotected intercourse. Use DMPA only if other suitable methods are unacceptable or unsuitable because it cannot be removed and fetal-safety data are limited. Do not quick-start co-cyprindiol or insert an IUD unless a copper IUD meets EC criteria. Offer an acceptable bridging method if the preferred option is unavailable.7,6

  4. 4. Give additional precautions

    Use condoms or abstain for 7 days after standard CHC, implant, injection, drospirenone POP or LNG-IUD, and for 2 days after traditional or desogestrel POP, unless starting or switching rules confer immediate cover. Copper IUD protection is immediate.7,4,5

  5. 5. Account for oral EC

    After UPA, generally wait 5 days before starting or restarting hormonal contraception; after LNG, start immediately. Use precautions during the delay and until the new method becomes effective.6

Incorrect or missed use

Standard combined pill

For a standard 21/7 monophasic COC after correct preceding use, one missed active pill usually needs no extra precautions. A late restart leaving at least 9 completed days since the last active pill, or 2 or more missed pills, requires 7 days of condoms after restarting; assess EC when week 1 or the hormone-free interval is compromised. Omit the next hormone-free interval after misses in the final active week, and manage more than 7 missed pills as a new start. Use product-specific guidance for other packs.10

Traditional or desogestrel POP

A traditional POP is missed when more than 3 hours late and desogestrel when more than 12 hours late. Take the most recent missed pill, continue, and use condoms for 48 hours. Consider EC for intercourse after the pill became missed and before 48 hours of correct use has been re-established.4,6

Drospirenone POP

A drospirenone active pill is missed when more than 24 hours late. Take the most recent missed active pill, continue the 24-active/4-placebo pack and use condoms until 7 consecutive active pills have been taken. Assess EC from the timing of UPSI and missed pills; if any of the final 7 active pills were missed, omit the placebo interval and start the next pack.4,6

Patch, ring, injection or device

Use the method-specific algorithm. For DMPA, more than 14 weeks after the previous injection is late: assess pregnancy and EC for UPSI after week 14, give the injection if appropriate, use condoms for 7 days and repeat a pregnancy test 21 days after the latest UPSI. Expired or displaced devices also require pregnancy-risk and EC assessment.10,6,5,11

UKMEC safety points2

Category 1 means no restriction, 2 advantages generally outweigh risks, 3 risks usually outweigh advantages and needs specialist judgement, and 4 is an unacceptable health risk.

CharacteristicKey categoriesClinical meaning
Current migraine with auraCHC 4Do not use CHC; new aura while using it needs prompt review
Migraine with aura 5 or more years agoCHC 3Remote aura remains a relative contraindication and needs an alternative or specialist judgement
Migraine without auraCHC initiation 2; continuation 3Reassess a new or changing migraine diagnosis
Current or previous VTECu-IUD 1; LNG-IUD, implant and POP 2; DMPA 3; CHC 4DMPA is not thrombotically neutral in UKMEC 2025
Smoking age 35 or olderCHC 3 if fewer than 15 cigarettes/day; CHC 4 if 15 or more/dayOffer safer alternatives and smoking support
Former smoker age 35 or olderCHC 3 if stopped under 1 year ago; CHC 2 if stopped at least 1 year agoConfirm when smoking stopped rather than recording only ex-smoker status
HypertensionCHC 3 if controlled, clinic 140-159/90-99 or home 135-149/85-94; CHC 4 if clinic at least 160/100 or home at least 150/95Record the measurement setting and do not initiate CHC without an accurate blood pressure
BMI 35 kg/m2 or aboveCHC 3Use individual risk assessment and discuss alternatives
Current breast cancerCu-IUD 1; hormonal methods 4Currently being treated is category 4; seek specialist advice
Breast cancer after completed treatmentCu-IUD 1; hormonal methods 3UKMEC 2025 has no 5-year waiting threshold; use specialist judgement

Contraception after pregnancy2,6,5,4,11

Postpartum timing depends on breastfeeding, VTE risk and the method; do not replace these thresholds with a generic instruction to wait.

SituationKey action or UKMEC category
CHC while breastfeedingUnder 6 weeks: 4; 6 weeks to under 6 months: 2; from 6 months: 1
CHC when not breastfeedingUnder 3 weeks: 4 with VTE factors, 3 without; 3 to under 6 weeks: 3 with factors, 2 without; from 6 weeks: 1
POP or implant postpartumCategory 1 and can start immediately
DMPA in the first 6 weeksBreastfeeding: 2; not breastfeeding: 2 without additional VTE factors, 3 with them
Intrauterine contraception postpartumUp to 48 hours: 1; over 48 hours to under 4 weeks: 3; from 4 weeks: 1; postpartum sepsis: 4
Pregnancy risk and EC postpartumNo EC before day 21; from day 21 assess EC unless all LAM criteria apply. A copper IUD can be used from day 28
After abortion, miscarriage, ectopic pregnancy or GTD treatmentProvide ongoing contraception immediately where possible; assess EC for UPSI from day 5

Practical prescribing and review

Choosing and pausing CHC

If CHC is chosen, a preparation with no more than 30 micrograms ethinylestradiol plus levonorgestrel or norethisterone is a reasonable initial choice to minimise cardiovascular risk. Stop CHC at least 4 weeks before planned major surgery or expected limited mobility and arrange an alternative.3

Regimen and age

Offer tailored, extended or continuous CHC regimens when preferred: monthly withdrawal bleeding has no health benefit. Eligible users should switch from CHC at age 50; POP can usually continue until age 55, when contraception can stop.3,4

Device duration and review

A copper IUD containing at least 300 mm2 copper and inserted from age 40 can remain until menopause, then remove 1 year after the final period if aged at least 50 or 2 years if younger. A 52 mg LNG-IUD inserted from age 45 can remain to 55 for contraception, but replace after 5 years when used for HRT endometrial protection. Review POP annually and DMPA at least every 2 years.5,4,11

IUC fitting

Before insertion, discuss anticipated pain and available analgesia or local anaesthesia. After immediate postpartum insertion, arrange a 4- to 6-week check; interval IUC does not need routine attendance solely to remain effective.5

Interactions that change management

  • Enzyme-inducing antiseizure medicines, rifampicin or rifabutin, some antiretrovirals and St John's wort reduce the effectiveness of CHC, every POP, the implant and oral EC. The copper IUD, LNG-IUD and DMPA are not affected by enzyme induction when medically eligible; interaction precautions continue for 28 days after stopping the inducer.8,6
  • CHC can substantially lower lamotrigine concentrations, with rebound during a hormone-free interval or after stopping; POP may increase lamotrigine exposure. Guidance also raises possible reduced contraceptive effectiveness with CHC, POPs and the implant, whereas DMPA and IUDs are unaffected. Seek specialist advice; if CHC is unavoidable, monitoring and continuous use may reduce level fluctuation.8
  • Tirzepatide users taking oral contraception should add a barrier method or switch to a non-oral method for 4 weeks after starting and for 4 weeks after every dose increase. Other GLP-1 medicines have no demonstrated direct interaction, but vomiting or diarrhoea can impair oral absorption.9
  • Non-enzyme-inducing antibiotics do not require extra contraceptive precautions unless vomiting or diarrhoea affects oral-method absorption.8
  • Do not use drospirenone POP in severe renal impairment or acute renal failure. Generally avoid it with known hyperkalaemia, untreated hypoaldosteronism, potassium-sparing diuretics, aldosterone antagonists or potassium supplements. Treated hypoaldosteronism, mild or moderate renal impairment, ACE inhibitors or angiotensin-II receptor blockers require caution and may warrant blood pressure, renal function and electrolyte checks.4,8
  • Medicines that raise gastric pH, including proton-pump inhibitors, H2-receptor antagonists and antacids, may reduce UPA exposure. Prefer a copper IUD; within 96 hours LNG is an alternative, or explain the uncertainty if UPA is used.8,6

Urgent review and red flags

Contraceptive side effects are usually non-urgent, but suspected thrombosis, pregnancy with an intrauterine device, infection, device displacement or safeguarding concerns require timely action.

  • Emergency assessment: unilateral painful swollen leg, sudden chest pain or breathlessness, haemoptysis, focal neurological deficit or new aura while using CHC.2,3
  • Urgently locate any pregnancy with an IUD in situ and exclude ectopic pregnancy. If an intrauterine pregnancy is under 12 weeks, remove the device when threads are visible or it can be retrieved easily from the cervical canal, whether or not the pregnancy will continue; explain that removal improves outcomes but carries a small miscarriage risk.5
  • Missing or changed IUD threads, suspected expulsion or a non-palpable implant requires additional protection, pregnancy and EC assessment, and device location by an appropriately trained service.5,12,6
  • Pelvic pain, fever, purulent discharge or severe bleeding after insertion needs prompt assessment. If PID is diagnosed, start current BASHH treatment and review in 48 to 72 hours. Retain the IUD if improving; if not, usually consider removal after accounting for UPSI in the previous 7 days, EC, pregnancy risk and replacement contraception.5,19

Exam traps

  • UKMEC is a safety tool, not an effectiveness score or a substitute for an interaction check.
  • Current migraine with aura is CHC category 4; a history of aura 5 or more years ago is category 3. Migraine without aura is initiation category 2 but continuation category 3.
  • DMPA is category 3 with current or previous VTE and has about a 4% typical-use failure rate, so not every progestogen-only method is thrombotically neutral or adherence-independent.
  • Oral emergency contraception does not work after ovulation; the copper IUD is the most effective emergency option.
  • UPA is not always the best oral EC: recent progestogen, immediate restart priorities, severe oral-steroid-dependent asthma and enzyme inducers can change selection.
  • One missed standard 21/7 COC pill usually needs no extra precautions only after correct preceding use; a late restart that leaves at least 9 completed days since the last active pill is a high-risk extended hormone-free interval.
  • A negative pregnancy test today cannot exclude a pregnancy resulting from recent unprotected intercourse.
  • Risk-based asymptomatic STI screening at IUD insertion does not require waiting for results, but known asymptomatic chlamydia is initiation category 3 and current symptomatic chlamydia, gonorrhoea, purulent cervicitis or PID is category 4.
  • UKMEC 2025 uses currently being treated versus completed breast-cancer treatment; it no longer uses a 5-year disease-free threshold.
  • A higher-dose LNG-IUD used for HRT endometrial protection has a shorter replacement interval than its contraceptive or age-based duration.

Key sources

  1. NICE, Long-acting reversible contraception (CG30)Published 26 Oct 2005 | Updated 2 Jul 2019
  2. College of Sexual and Reproductive Healthcare, UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) 2025 (UKMEC 2025)Published 8 Dec 2025
  3. FSRH Clinical Guideline: Combined Hormonal Contraception, January 2019, amended October 2023
  4. FSRH Clinical Guideline: Progestogen-only Pills, August 2022, amended April 2026Updated 30 Apr 2026
  5. FSRH Clinical Guideline: Intrauterine Contraception, March 2023, amended January 2025
  6. FSRH Clinical Guideline: Emergency Contraception, March 2017, amended July 2023Updated 11 Jul 2023
  7. FSRH Clinical Guideline: Quick Starting Contraception, April 2017Published 1 Apr 2017
  8. FSRH Clinical Guidance: Drug Interactions with Hormonal Contraception, May 2022Published 5 May 2022
  9. MHRA, GLP-1 medicines for weight loss and diabetes: what you need to knowPublished 5 Jun 2025 | Updated 5 Feb 2026
  10. FSRH CEU: Recommended Actions after Incorrect Use of Combined Hormonal Contraception, March 2020, amended 6 July 2021Updated 6 Jul 2021
  11. FSRH Clinical Guideline: Progestogen-only Injectables, December 2014, amended July 2023Updated 11 Jul 2023
  12. CoSRH CEU statement: Extension of use of the etonogestrel implant (Nexplanon) to 5 yearsPublished 13 May 2026
  13. NICE, Contraception quality standard: contraceptive information and methods (QS129)Published 8 Sept 2016
  14. NHS, What is female sterilisation?Updated 14 Feb 2024
  15. Gloucestershire Hospitals NHS Foundation Trust, Female sterilisation
  16. NHS, What is a vasectomy?Updated 28 Feb 2024
  17. NHS, Recovering after a vasectomyUpdated 28 Feb 2024
  18. FSRH Statement: Ulipristal Acetate and Breastfeeding, January 2025Published 24 Jan 2025
  19. BASHH, United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease, 2019 interim update (BASHH PID 2019)Updated 26 Jan 2019
  20. CoSRH Statement: Meningioma and Progestogens, 4 June 2026Published 4 Jun 2026

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.