Key Facts

Contraception counselling is a core primary care skill. The UK has a wide range of available methods. Effective counselling involves a non-judgemental discussion of all options, assessment of eligibility using UKMEC criteria, and support for the patient's informed choice.

Epidemiology

• Approximately 75% of women of reproductive age use some form of contraception
• Combined oral contraceptive pill remains the most commonly used method in the UK
• LARC uptake has increased significantly following NICE CG30 recommendations
• Unintended pregnancy rate in the UK remains approximately 16% of all pregnancies

Methods Overview

• LARC: subdermal implant (Nexplanon), intrauterine system (Mirena, Levosert, Kyleena), intrauterine device (copper), depot injection (Depo-Provera)
• Combined hormonal: combined oral contraceptive pill (COCP), transdermal patch (Evra), vaginal ring (NuvaRing)
• Progestogen-only: progestogen-only pill (POP), including desogestrel (Cerazette)
• Barrier: male/female condoms, diaphragm
• Natural family planning: fertility awareness methods
• Permanent: female sterilisation, vasectomy

Key Principles

• Shared decision-making based on efficacy, side effects, convenience, STI protection, and patient preference
• UKMEC assessment for safety of combined hormonal methods
• Consider quick-start initiation at any time in cycle with appropriate pregnancy exclusion
• Dual protection: condoms for STI prevention alongside other contraception for pregnancy prevention
• Fraser guidelines for under-16s: assess competence and confidentiality

Assessment Before Prescribing

• Medical history: VTE, CVD, migraine (with/without aura), breast cancer, liver disease
• Medications: enzyme-inducing drugs (carbamazepine, phenytoin, rifampicin) reduce CHC and POP efficacy
• Smoking status and quantity
• BMI and blood pressure
• Menstrual history
• Pregnancy risk assessment (if starting mid-cycle)

Counselling Points by Method

• COCP: take daily for 21 days, 7-day break (or continuous/tailored regimen); missed pill rules
• POP (desogestrel): take daily within 12-hour window; no pill-free interval
• Implant: may cause irregular bleeding; discuss before insertion
• IUS/IUD: fitting involves cervical instrumentation; discuss risks (perforation 0.1%, expulsion 5%)
• Depot injection: potential for delayed return to fertility (up to 12 months); BMD concerns with prolonged use

Red Flags

• New migraine with aura while on CHC — stop immediately (stroke risk)
• Calf pain/swelling on CHC — exclude VTE
• Severe abdominal pain with IUD/IUS — exclude perforation, ectopic pregnancy
• Heavy or prolonged bleeding post-LARC insertion persisting >6 months — investigate
• Amenorrhoea — exclude pregnancy

Bedside

• Blood pressure: mandatory before prescribing CHC
• BMI: required for UKMEC assessment
• Pregnancy test: if starting mid-cycle or amenorrhoea

Bloods

• Not routinely required for starting contraception
• Consider lipids if strong family history of CVD
• Thrombophilia screen: only if personal/strong family history of VTE

Screening

• STI screening (chlamydia/gonorrhoea NAAT): offer at time of IUD/IUS fitting or routinely for at-risk individuals
• Cervical screening: as per national programme (not required before contraception)

Imaging

• USS: if IUD/IUS threads not visible or suspected perforation

Special Tests

• None routinely required
• LH, FSH, testosterone, pelvic USS: if PCOS suspected concurrent with contraception review

Non-pharmacological

• Provide comprehensive information on all methods
• Discuss efficacy: typical use vs perfect use failure rates
• Discuss side effects honestly (bleeding patterns, mood, weight)
• Natural family planning instruction if desired (use apps, basal body temperature, cervical mucus monitoring)
• Barrier methods for STI protection

Pharmacological

Combined hormonal contraception:

• COCP: first-line — monophasic levonorgestrel 150mcg + ethinylestradiol 30mcg (Microgynon 30, Rigevidon)
• Lower VTE risk with levonorgestrel-containing pills vs desogestrel/gestodene
• Consider tailored regimen (extended or continuous use) to reduce hormone-withdrawal symptoms

Progestogen-only pill:

• Desogestrel 75mcg OD (Cerazette): first-line POP; 12-hour missed-pill window; inhibits ovulation
• Traditional POP (norethisterone 350mcg): 3-hour missed-pill window (less commonly used)

LARC methods:

• Nexplanon (etonogestrel 68mg subdermal implant): effective for 3 years; most common side effect is irregular bleeding
• Mirena IUS (levonorgestrel 52mg): effective for 5 years contraception; also licensed for menorrhagia and HRT
• Copper IUD (TCu380A): effective for 5-10 years; may increase menstrual bleeding; non-hormonal
• Depo-Provera (medroxyprogesterone acetate 150mg IM): every 12-13 weeks; BMD monitoring if >2 years use

Emergency contraception:

• Levonorgestrel 1.5mg PO: within 72 hours of UPSI
• Ulipristal acetate (EllaOne) 30mg: within 120 hours of UPSI
• Copper IUD: within 120 hours (most effective emergency contraception, >99%)

Surgical

• Female sterilisation (laparoscopic): failure rate 1 in 200; difficult to reverse
• Vasectomy: failure rate 1 in 2000; simpler procedure; offer semen analysis at 12 weeks

Referral Criteria

• IUD/IUS fitting: to trained fitter (GP, sexual health clinic, or hospital)
• Implant fitting: to trained provider
• Complex UKMEC assessment: sexual health or gynaecology specialist
• Failed LARC insertion: alternative provider or USS-guided fitting
• Sterilisation request: gynaecology or urology referral

• Typical use failure rates: COCP 9%, POP 9%, condom 18%, implant 0.05%, IUS 0.2%, IUD 0.6%, injectable 6%
• Return to fertility: immediate for most methods; Depo-Provera may delay return by 6-12 months
• VTE risk on CHC: approximately 5-12 per 10,000 women-years (vs 2 per 10,000 in non-users; 29 per 10,000 in pregnancy)
• LARC continuation rates: implant 84% at 1 year, IUS 80% at 1 year (highest of all methods)
• Bone density on Depo-Provera: reversible decrease in BMD; most recovery within 2 years of stopping

UKMEC Category 4 (Absolute Contraindications) for Combined Hormonal Contraception

Contraceptive Efficacy Comparison