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.
A person-centred contraceptive consultation1,13,2,7
Begin with the person's reproductive intention and priorities, not with a preferred product. Establish whether emergency contraception is required, whether pregnancy can reasonably be excluded, and whether medical conditions or medicines restrict safety or effectiveness. Explain all suitable options in accessible language, including typical-use effectiveness, bleeding changes, non-contraceptive benefits, procedure requirements, control over stopping, return to fertility and STI protection. Check capacity, confidentiality, safeguarding and reproductive coercion. Provide the acceptable method promptly and document shared decision-making.
Choosing between methods2,1,12,5,11,3,4,13,14,15,16,17
| Method | Typical use | Duration | Bleeding and benefits | Important limitations |
|---|---|---|---|---|
| Etonogestrel implant | Fewer than 1 pregnancy per 100 users in year 1 | 5 years from UK licence extension on 13 May 2026 | Bleeding is unpredictable; dysmenorrhoea may improve | Enzyme inducers reduce effectiveness; trained insertion and removal |
| Copper IUD | Fewer than 1 pregnancy per 100 users in year 1 | 5 or 10 years depending on device; a device with at least 300 mm2 copper 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 | Hormone-free | May increase bleeding and pain; insertion risks and no STI protection |
| 52 mg LNG-IUD | Fewer than 1 pregnancy per 100 users in year 1 | 8 years for contraception; if inserted at age 45 or older, may remain until age 55 | Bleeding usually becomes lighter; useful for heavy menstrual bleeding | Initial irregular bleeding; insertion risks; replace after 5 years when used for HRT endometrial protection |
| Lower-dose LNG-IUD | Fewer than 1 pregnancy per 100 users in year 1 | 19.5 mg device 5 years; 13.5 mg device 3 years | Usually lighter bleeding, but less amenorrhoea than 52 mg devices | Not interchangeable with 52 mg devices for heavy bleeding or HRT indications |
| DMPA injection | About 4 pregnancies per 100 users in year 1 | Repeat about every 13 weeks | Irregular bleeding initially; amenorrhoea becomes common | Weight gain, small bone-density loss that usually recovers, delayed fertility return and category 3 with VTE history |
| Combined pill, patch or ring | About 7 pregnancies per 100 users in year 1 | Daily, weekly or monthly action | Predictable bleeding; can improve pain, heavy bleeding and acne | Oestrogen-related VTE, stroke and cardiovascular restrictions; interactions and user error |
| Progestogen-only pill | About 7 pregnancies per 100 users in year 1 | Daily; traditional and desogestrel POPs are continuous, while drospirenone uses 24 active then 4 placebo pills | Useful when oestrogen is unsuitable; irregular bleeding is common | Different 3-hour, 12-hour and 24-hour missed-pill windows; enzyme-inducer interaction |
| External or internal condom | User-dependent; external condom about 13 pregnancies per 100 users in year 1 | Each episode of sex | Hormone-free and user-controlled | Use correctly every time; use compatible lubricant; failure possible |
| Diaphragm or cap with spermicide | User-dependent | Each episode of sex | Hormone-free and user-controlled | Requires fitting, instruction and correct use; does not protect against STIs |
| Fertility awareness or LAM | Variable and highly user-dependent | Daily observations or strict postpartum criteria | No drug or device exposure | Requires teaching and consistent use; LAM only while amenorrhoeic, fully or nearly fully breastfeeding and under 6 months postpartum |
| Vasectomy or female sterilisation | Very effective but not infallible | Permanent | No ongoing hormones | Confirm an informed permanent choice and discuss possible future regret; contraception continues after vasectomy until semen clearance |
How the methods work
Combined hormonal contraception
Progestogen-only pills
All POPs thicken cervical mucus. Desogestrel and drospirenone primarily inhibit ovulation more consistently than traditional levonorgestrel or norethisterone pills, which explains their different missed-pill windows.4
Implant and injectable
Intrauterine contraception
Copper's main actions are toxic effects on sperm and ova and impaired sperm transport, preventing fertilisation. LNG-IUDs chiefly thicken cervical mucus and suppress the endometrium. Neither method terminates an established pregnancy.5
Assessment before provision
- Ask about reproductive intention, preferred duration and route, control over stopping, bleeding priorities, non-contraceptive benefits and future fertility plans.1
- Record the last menstrual period, usual cycle, all unprotected intercourse in the previous 21 days, current contraception and any incorrect use. Assess EC before quick-starting.6,7
- Review VTE, migraine, cardiovascular disease, blood pressure, smoking, BMI, breast cancer, liver disease, interacting medicines and any other relevant UKMEC characteristic.2,8
- Record blood pressure and BMI before CHC. Do not require routine pelvic or breast examination, cervical screening, thrombophilia screening, lipids, glucose or liver tests merely to start hormonal contraception.3
- For intrauterine insertion, assess STI risk and perform the required pelvic examination. If asymptomatic and infection is not known, screen on the day without delaying insertion. Known asymptomatic chlamydia is initiation category 3 and is generally treated first, although an emergency IUD may be inserted when treatment starts; current PID, purulent cervicitis, gonorrhoea or symptomatic chlamydia is category 4 for initiation.5,1
- Before IUC insertion, explain anticipated pain and offer a choice of suitable analgesia or local anaesthesia; do not imply that severe pain must simply be tolerated.5
- Provide confidential care, assess capacity and Fraser competence where relevant, and address safeguarding, sexual assault and reproductive coercion.1
UKMEC categories and classic examinations2
| Scenario | Key UKMEC categories | Interpretation |
|---|---|---|
| Current migraine with aura | CHC 4 | Unacceptable stroke risk; use a suitable non-CHC method |
| Migraine with aura 5 or more years ago | CHC 3 | Remote aura is not category 4, but risks usually outweigh benefits |
| Migraine without aura | CHC initiation 2, continuation 3 | Do not quote a single category without distinguishing starting from continuing |
| Current or previous VTE | Cu-IUD 1; LNG-IUD, implant and POP 2; DMPA 3; CHC 4 | UKMEC 2025 specifically separates DMPA from other progestogen-only methods |
| Smoking below age 35 | CHC 2 | Usually usable, with smoking-cessation advice |
| Smoking age 35 or older | CHC 3 below 15 cigarettes/day; CHC 4 at 15 or more/day | Choose a safer non-CHC option |
| Former smoker age 35 or older | CHC 3 if stopped under 1 year ago; CHC 2 if stopped at least 1 year ago | Record when smoking stopped |
| Controlled hypertension, clinic BP 140-159/90-99 or home BP 135-149/85-94 | CHC 3 | Risks usually outweigh benefits |
| Clinic BP at least 160/100 or home BP at least 150/95 | CHC 4 | Do not use CHC |
| BMI 35 kg/m2 or above | CHC 3 | Discuss safer alternatives and other cardiovascular risks |
| Current breast cancer | Cu-IUD 1; all hormonal methods 4 | Non-hormonal contraception is preferred; involve the specialist team |
| Breast cancer after completed treatment | Cu-IUD 1; hormonal methods 3 | UKMEC 2025 has no 5-year waiting threshold; specialist judgement remains necessary |
Starting, switching and quick-starting
Use reasonable-certainty criteria
Pregnancy is reasonably excluded 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. Start any medically eligible method without waiting for the next period.7
Quick-start hormonal contraception when appropriate
If pregnancy cannot be excluded, CHC, POP or an implant can usually be started after a negative test and individual assessment, with a repeat high-sensitivity test at least 21 days after the last unprotected intercourse. Use DMPA only when 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. If the preferred method is unavailable, offer an acceptable bridging method rather than leaving a gap.7,6,5
Bridge gaps in cover
When immediate cover does not apply, advise condoms or abstinence for 7 days after standard CHC, implant, DMPA, drospirenone POP or LNG-IUD, and 2 days after traditional or desogestrel POP. The copper IUD is effective immediately. Switching rules can remove or alter these intervals, so check the exact source and product.7,4,3,5
Emergency contraception management
Offer the copper IUD
It is the most effective EC and provides immediate ongoing contraception. Insert within 5 days after the first UPSI in a natural cycle or within 5 days after the earliest likely ovulation, whichever is later. If insertion is delayed, give oral EC at referral in case fitting does not occur. Weight and enzyme induction do not reduce efficacy while the device is correctly positioned, but higher BMI is associated with increased IUC expulsion; explain expulsion signs.6,5
Choose oral EC if needed
UPA 30 mg is effective up to 120 hours and is generally more effective than LNG across this interval, especially close to ovulation before ovulation has occurred. LNG 1.5 mg is licensed up to 72 hours and can be considered off-label from 72 to 96 hours. Neither is effective after ovulation.6
Modify for weight and medicines
At weight over 70 kg or BMI over 26 kg/m2, consider UPA or off-label LNG 3 mg and explain uncertainty about the double dose. During enzyme-inducer use and for 28 days after, prefer copper IUD; if unavailable or declined, LNG 3 mg is an uncertain off-label alternative and UPA is not recommended. Avoid UPA with severe asthma controlled by oral glucocorticoids, and consider recent progestogen exposure before selecting it.6,8
Start ongoing contraception
After UPA, wait 5 days before hormonal contraception in the usual pathway, then use method-specific extra precautions. After LNG, start hormonal contraception immediately with extra precautions until effective. Oral EC does not protect later intercourse.6
Manage repeat EC in the same cycle
The same oral EC agent may be used again when indicated. Do not give LNG within 5 days after UPA because it may reduce UPA's effect; offer a copper IUD or repeat UPA. UPA may be less effective within 7 days after LNG, so offer a copper IUD or consider repeat LNG.6
Incorrect use algorithms
Standard monophasic COC
For a standard 21/7 monophasic COC after correct preceding use, one missed active pill is usually insufficient to reverse ovarian suppression: take it and continue without EC or extra precautions. A late restart leaving at least 9 completed days since the last active pill, or 2 or more missed pills, requires the exact FSRH pathway: take the most recent missed pill, continue, use condoms for 7 days and assess EC when week 1 or the hormone-free interval is compromised. Omit the next interval after misses in the final active week; manage more than 7 missed pills as a new start and use product-specific rules for other regimens.10,6
Traditional and desogestrel POP
Traditional levonorgestrel or norethisterone POP is missed when over 3 hours late; desogestrel POP when over 12 hours late. Take the most recent missed pill, continue and use condoms until correct use has been re-established for 48 hours. Assess EC for UPSI after the pill became missed and before those 48 hours have elapsed.4,6
Drospirenone POP
An active drospirenone pill is missed when over 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 and vaginal ring
Risk depends on how long use was interrupted and whether the hormone-free interval was extended. Follow the specific FSRH chart, restore the method promptly, use additional precautions for the stated interval and assess EC rather than applying COC rules by analogy.10
Late injection
Confirm the product and date of the last injection. 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. Also assess EC for UPSI during those 7 days after a late injection.11,6
Drug interactions
- Enzyme inducers reduce CHC, traditional, desogestrel and drospirenone POPs, the implant and oral EC. Examples include carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, rifampicin, rifabutin, some antiretrovirals and St John's wort. Effects persist for 28 days after stopping.8,4
- Copper IUD, LNG-IUD and DMPA effectiveness is not reduced by enzyme induction when the method is medically eligible.8
- 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, every POP and the implant, whereas DMPA and IUDs are unaffected. Seek specialist advice; if CHC is unavoidable, monitoring and continuous use may reduce fluctuation.8
- Tirzepatide reduces oral-contraceptive reliability: add a barrier method or use a non-oral contraceptive for 4 weeks after initiation and each dose increase. With any medicine causing vomiting or diarrhoea, apply missed-pill or absorption advice.9
- Broad-spectrum antibiotics that are not enzyme inducers do not by themselves require additional precautions.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
Using combined hormonal contraception safely
Initial formulation and regimen
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. Offer tailored, extended or continuous use when preferred; monthly withdrawal bleeding has no health benefit.3
Surgery, mobility and review
Special situations
After childbirth
POP and implant can start immediately. For breastfeeding, CHC is category 4 under 6 weeks, 2 from 6 weeks to under 6 months and 1 thereafter. If not breastfeeding, CHC under 3 weeks is 4 with VTE factors and 3 without; from 3 to under 6 weeks it is 3 with factors and 2 without; from 6 weeks it is 1. Early DMPA is category 2 without additional VTE factors and 3 with them; while breastfeeding under 6 weeks it is 2. IUC is category 1 up to 48 hours or from 4 weeks, 3 between those windows and 4 with postpartum sepsis. No EC is needed before day 21; thereafter assess it unless all LAM criteria apply.2,4,5,11,6
After abortion, miscarriage or ectopic pregnancy
Discuss and provide contraception immediately where possible because fertility can return quickly. Assess EC for UPSI from day 5 after abortion, miscarriage, ectopic pregnancy or gestational trophoblastic disease treatment. The exact timing of intrauterine insertion depends on the event and confirmation that the pregnancy has ended.4,5,6
Young people
Current or previous breast cancer
The copper IUD is category 1. Breast cancer that is currently being treated makes all hormonal methods category 4; after treatment is completed they are category 3. UKMEC 2025 has no 5-year waiting threshold. Coordinate decisions with the cancer and specialist contraception teams.2
Current or previous meningioma
A June 2026 CoSRH statement, explicitly not formal clinical guidance, advises avoiding cyproterone acetate, medroxyprogesterone acetate, nomegestrol acetate and desogestrel in current or previous meningioma, and says etonogestrel may also be inappropriate. Seek specialist advice before any hormonal method with current meningioma and specialist review after previous meningioma.20
Later reproductive life
Eligible users should switch from CHC at age 50. POP can usually continue to age 55, when contraception can stop. 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 age 55 for contraception, but replace it after 5 years when used for HRT endometrial protection.3,4,5
Bleeding, follow-up and return to fertility
- Before starting, explain the expected bleeding pattern. Irregular bleeding is common with POP, implant and early LNG-IUD use; amenorrhoea is not harmful once pregnancy and pathology are excluded. Copper IUD can make bleeding heavier and more painful.4,5,11
- New persistent or unacceptable bleeding warrants assessment of adherence, pregnancy, STI, medicine interactions and age-appropriate cervical or endometrial pathology before attributing it to contraception.4,5
- Review CHC and POP at least annually; include blood pressure and BMI for CHC, and remote POP review is often suitable. Repeat DMPA at the product interval and formally reassess benefits, bone health and alternatives at least every 2 years. Arrange a 4- to 6-week check after immediate postpartum IUC insertion. Interval implant and IUD users need access to review or removal but no routine visit solely to preserve effectiveness.3,4,11,1,5
- Return to fertility is rapid after pills, CHC, implant and intrauterine methods. Ovulation after DMPA can be delayed for many months, sometimes around a year; this is a delay, not permanent infertility.11,3,5
Red flags and escalation
Escalate suspected thrombosis or stroke immediately. Pregnancy with intrauterine contraception, device displacement and post-insertion infection require urgent assessment rather than routine contraceptive follow-up.
- CHC plus unilateral leg swelling, chest pain, breathlessness, haemoptysis, focal neurological deficit or new migraine aura: stop further doses pending urgent clinical assessment and follow the relevant emergency pathway.2,3
- Positive pregnancy test or symptoms with an IUD: urgently identify pregnancy location. 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 threads, suspected expulsion or a non-palpable implant: use additional contraception, assess EC and pregnancy, and arrange trained review and location imaging. Do not attempt blind removal.5,12,6
- Fever, increasing pelvic pain, purulent discharge, severe bleeding or collapse after IUD insertion requires urgent 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
- Sexual assault, exploitation, inability to consent or reproductive coercion: address immediate safety, STI testing, HIV or hepatitis post-exposure needs, emergency contraception and safeguarding through local pathways.1,6
Exam traps
The common errors are treating UKMEC as a treatment ranking, calling all progestogen-only methods risk-free, assuming a negative test excludes a recent conception, and using one missed-pill rule for every product.
- Oral EC delays ovulation and is ineffective after ovulation; do not claim that UPA works after ovulation.6
- One missed standard 21/7 COC pill usually needs no extra precautions only after correct preceding use; a late restart leaving at least 9 completed days since the last active pill is a high-risk extended hormone-free interval.10
- The implant is now licensed for 5 years, not 3 years, in the UK.12
- DMPA has about a 4% typical-use failure rate and is UKMEC 3 with current or previous VTE.2
- A 52 mg LNG-IUD used for HRT endometrial protection lasts 5 years even when its contraceptive licence or age-based duration is longer.5
- Current migraine with aura is CHC category 4, but aura that last occurred 5 or more years ago is category 3; migraine without aura is initiation 2 and continuation 3.2
- Screening an asymptomatic person at IUD insertion need not delay insertion, but this is not the same as inserting routinely when chlamydia or gonorrhoea is already known.5
- UKMEC 2025 uses currently being treated versus completed breast-cancer treatment; it no longer uses a 5-year disease-free threshold.2
Guidelines
- UK Medical Eligibility Criteria for Contraceptive Use 2025 (CoSRH, 2025)
- Long-acting reversible contraception (CG30) (NICE, 2005)
- Clinical Guideline: Emergency Contraception (FSRH, 2017)
- Clinical Guideline: Combined Hormonal Contraception (FSRH, 2019)
- Clinical Guideline: Progestogen-only Pills (FSRH, 2022)
- Clinical Guideline: Intrauterine Contraception (FSRH, 2023)
References
- NICE, Long-acting reversible contraception (CG30)Published 26 Oct 2005 | Updated 2 Jul 2019
- College of Sexual and Reproductive Healthcare, UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) 2025 (UKMEC 2025)Published 8 Dec 2025
- FSRH Clinical Guideline: Combined Hormonal Contraception, January 2019, amended October 2023
- FSRH Clinical Guideline: Progestogen-only Pills, August 2022, amended April 2026Updated 30 Apr 2026
- FSRH Clinical Guideline: Intrauterine Contraception, March 2023, amended January 2025
- FSRH Clinical Guideline: Emergency Contraception, March 2017, amended July 2023Updated 11 Jul 2023
- FSRH Clinical Guideline: Quick Starting Contraception, April 2017Published 1 Apr 2017
- FSRH Clinical Guidance: Drug Interactions with Hormonal Contraception, May 2022Published 5 May 2022
- MHRA, GLP-1 medicines for weight loss and diabetes: what you need to knowPublished 5 Jun 2025 | Updated 5 Feb 2026
- FSRH CEU: Recommended Actions after Incorrect Use of Combined Hormonal Contraception, March 2020, amended 6 July 2021Updated 6 Jul 2021
- FSRH Clinical Guideline: Progestogen-only Injectables, December 2014, amended July 2023Updated 11 Jul 2023
- CoSRH CEU statement: Extension of use of the etonogestrel implant (Nexplanon) to 5 yearsPublished 13 May 2026
- NICE, Contraception quality standard: contraceptive information and methods (QS129)Published 8 Sept 2016
- NHS, What is female sterilisation?Updated 14 Feb 2024
- Gloucestershire Hospitals NHS Foundation Trust, Female sterilisation
- NHS, What is a vasectomy?Updated 28 Feb 2024
- NHS, Recovering after a vasectomyUpdated 28 Feb 2024
- FSRH Statement: Ulipristal Acetate and Breastfeeding, January 2025Published 24 Jan 2025
- BASHH, United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease, 2019 interim update (BASHH PID 2019)Updated 26 Jan 2019
- CoSRH Statement: Meningioma and Progestogens, 4 June 2026Published 4 Jun 2026
Evidence checked: 2026-07-29
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.