UK Medical Eligibility Criteria (UKMEC) is a classification system of risk factors and contraindications for all contraceptive methods. It is available as a summary sheet. The four UKMEC levels are:

• UKMEC 1: No restriction
• UKMEC 2: Advantages generally outweigh the risks e.g. CHC in smoker aged 20
• UKMEC 3: Theoretical or proven risks usually outweigh advantages of using method. Provision of a method to a woman with UKMEC 3 requires expert clinical judgement and/or referral to a specialist contraceptive provider since the use of the method is not usually recommended unless other methods are not available or not acceptable.
• UKMEC 4: A condition which represents an unacceptable health risk if the contraceptive method is used e.g. migraine with aura

Consider in general that, where more than one condition applies, the situation is moved up one category, e.g. two category 2 conditions, move the situation to category 3. The addition of a category 2 or 3 condition to another category condition moves the situation to category 4.

Assess risk factors for VTE and arterial disease carefully and separately.

User-failure rates at one year per 100 women for different methods of contraception.

Range in world literature (excludes atypical studies and all extended-use studies)

Percentage of women experiencing an unintended pregnancy during the first year of typical use of contraception (modified from Trussell et al. Contraceptive efficacy, 2011)

If a health professional is reasonably sure that a woman is not pregnant or at risk of pregnancy from recent unprotected sexual intercourse (UPSI):

• contraception can be started immediately unless the woman prefers to wait until her next period (such practice may be outside the product licence/device instructions)
• if a woman's preferred contraceptive method is not available, combined hormonal contraception (CHC) (excluding co-cyprindiol 2000/35), the progestogen-only pill (POP) or progestogen-only injectable can be used as a bridging method
• women requesting the progestogen-only injectable should ideally be offered a bridging method if pregnancy cannot be excluded, but immediate start is acceptable if other methods are not appropriate or acceptable
• the progestogen-only injectable should only be considered as a bridging method if other methods are not appropriate or acceptable

If pregnancy cannot be excluded (e.g. following administration of emergency contraception) but a woman is likely to continue to be at risk of pregnancy, or has expressed a preference to start contraception without delay, immediate 'quick starting' of CHC (except co-cyprindiol 2000/35), the POP, or progestogen-only implant may be considered. The woman should be informed of the potential risks and the need to have a pregnancy test no later than 3 weeks after the last episode of UPSI (see Emergency Contraception for further information on quick-starting contraception after EC).

If pregnancy is diagnosed after starting contraception and the woman wishes to continue with the pregnancy, the method should usually be stopped or removed. Intrauterine contraceptives should not be removed if pregnancy is diagnosed after 12 weeks' gestation.

Assessment of risk factors

The majority of women can use CHCs without harm from menarche to age 50, when no other risk factors are present. However, it is necessary to have an overview of the health status of the individual woman before first prescription of a CHC in order to establish the safety of combined oral contraception.

History should include enquiry about:

• Medical conditions (past and present)
• Drug use (prescription, non-prescription and herbal remedies)
• Family history
• Specific enquiry about migraine and cardiovascular risk factors (smoking, obesity, hypertension, thrombophilia, previous VTE and hyperlipidaemia)

Examinations:

• Blood pressure and BMI should be documented prior to a first prescription of CHC
• A thrombophilia screen is not recommended routinely before prescribing CHC
• Breast and pelvic examinations are unnecessary in asymptomatic women

Potential harms associated with CHC use should be discussed:

• All CHCs increase the risk of VTE, MI and ischaemic stroke but the absolute risk is small.
• Any increase in the risk of breast cancer associated with CHC use is likely to be small, is in addition to the background risk and is reduced to no increased risk 10 years after stopping.
• There may be a very small increase in the risk of cervical cancer with CHC use, which increases with increasing duration of use.

Use of CHC is not recommended for women in the following circumstances:

• Smokers aged 35 years or older
• Migraine with aura at any age
• Personal history of cardiovascular disease or stroke
• When using long-term liver enzyme-inducing drugs
• Migraine without aura when aged 35 years or older
• BMI 35 kg/m² or over
• Blood pressure consistently greater than140–159 mmHg systolic or 90–94 mmHg diastolic
• Personal history of VTE or a thrombogenic mutation

Venous thromboembolism (VTE) risk

All risk factors for VTE should be considered when selecting which CHC to prescribe.

Current use of CHC is associated with increased risk of VTE; some CHC formulations are associated with a greater risk of VTE than others, dependent on progestogen type and oestrogen dose. It is important to note that despite this increased risk, the number of VTE events in women using CHC remains very small.

The benefits of any CHC far outweigh the risk of serious side effects but prescribers and women should be aware of the major risk factors for thromboembolism, and of the key signs and symptoms.

All hormonal contraceptives are highly effective and safe, and have important health benefits, in addition to avoiding unplanned pregnancy.

The number of VTEs per year is fewer than the number expected in women during pregnancy or in the postpartum period.

Risk of VTE is highest in the months immediately after initiation of CHC or when restarting after a break of at least 1 month. The risk then reduces over the first year of use and remains stable thereafter. Frequent stopping and starting of CHC is therefore discouraged.

BMI is the most important risk factor for a VTE; use CHCs with caution for women with a BMI greater than 30kg/m2.

MHRA Drug Safety Update (February 2014): Combined hormonal contraceptives and venous thromboembolism: review confirms risk is small

European Medicines Agency estimated risk of developing a venous thromboembolism (VTE) in a year according to type of combined hormonal contraception (CHC) used (2014):

Features of CHCs to discuss with women

How it works

• primarily by preventing ovulation

Duration of use

• from menarche to age 50 if there are no other risk factors

Failure rate

• "perfect" use: 0.3%
• "typical" use (actual use including inconsistent or incorrect use) is 9%

Effects on periods

• menstrual pain and blood loss may be reduced with CHC use

Other risks

• VTE risk: see notes above
• Ischaemic stroke: two fold increase in risk with CHCs but annual incidence in women less than 35 years of age is low (3 cases per 100,000),
• Coronary artery disease: see notes above
• Breast cancer: any risk of breast cancer associated with CHC use is likely to be small, and will reduce with time after stopping
  • A family history of breast cancer is a UKMEC score of 1. Among CHC users with a family history of breast cancer, there was no increased risk of breast cancer compared with non-CHC users with a family history of breast cancer. Among women with BRCA1 mutations, CHC users may have a small increased risk of breast cancer compared with nonusers.
• Cervical cancer: (11 cases per 100 000 in non-CHC users), small increase with CHC use after 5 years and two fold increase after 10 years
• Risk of ovarian and endometrial cancer halved with CHC use and effect lasts for 15 years after stopping
• CHC use is associated with a reduction in the risk of colorectal cancer
• No evidence of effect on weight gain

Return to fertility

• No delay

Initial choice on prescribing of CHC

All combined oral contraceptives should be prescribed by brand name to minimise patient confusion and reduce the risk of dispensing error. Where two brands exist for the same formulation the cheaper option should be prescribed. Generally a preparation with the lowest oestrogen and progestogen content that gives good cycle control and minimal side effects in the individual woman should be chosen.

There is no reason to choose one pill over another in the majority of women, the product of lowest acquisition cost should be chosen in the first instance.

Woman has never used CHC:

• Start with Rigevidon

Woman has used CHC in past and there are no new contraindications:

• Return to previously tolerated CHC, if unknown follow 'never used CHC' above

Progestogenic side effects (e.g. depression, sustained weight gain, loss of libido with mood change, acne, hirsutism, vaginal dryness, breast tenderness):

• Try an oestrogen dominant CHC e.g. Gedarel, Marvelon, Femodene, Yasmin

Oestrogenic excess (e.g. nausea, bloating, breast tenderness, cyclical weight gain, vaginal discharge with no infection, loss of libido with no mood change, benign breast disease, fibroids, endometriosis):

• Try a progestogen dominant COC e.g. Rigevidon or a low-dose oestrogen COC, e.g. Gedarel 20/150

Breakthrough bleeding:

• exclude other causes then try Millinette 30/75 or Femodene or a phasic CHC Logynon

Women wanting combined hormonal contraception who decline Long-Acting Reversible Contraceptive (LARC) and where oral CHC are not tolerated or not suitable:

• Try EVRA combined transdermal patch

Women wanting combined hormonal contraception who decline Long-Acting Reversible Contraceptive (LARC) and where oral or transdermal CHC are not tolerated or not suitable:

• Try SyreniRing combined vaginal ring

Women should be encouraged to use a CHC for at least 3 months before considering an alternative.

Arrange follow up no longer than 3 months after the first prescription of a CHC, and annually thereafter.

Check blood pressure, BMI, and assess for any new risk factors which may mean the CHC is no longer suitable

In the absence of special problems, a 12-month supply of CHC can be given. Women should be encouraged to return if any problems arise.

Potential non-contraceptive benefits associated with CHC use can be considered:

• Menstrual pain and blood loss may be reduced.
• The incidence of functional ovarian cysts and benign ovarian tumours is reduced.
• The risk of colorectal cancer is reduced.
• The risk of ovarian and endometrial cancer is reduced by at least 50% during use and for at least 15 years after stopping.
• Improvement in symptoms of acne vulgaris.

Women having menstrual cycles:

• Start CHC up to and including day 5, no additional protection required
• At any other time if it is reasonably certain there is no pregnancy, additional protection required for 7 days

Women who are amenorrhoeic:

• CHC can be started at any time, if it is reasonably certain there is no pregnancy, additional protection required for 7 days

Following abortion:

• Can start CHCs within 7 days of surgical or medical abortion at gestations less than 24 weeks, no additional protection required

Postpartum (not breastfeeding):

• Start CHC on day 21 postpartum if vaginal delivery and no additional risk factors for VTE, no additional protection required
• If more than 21 days postpartum and menstrual cycles have returned, start CHC as for other women having menstrual cycles. (See above for additional protection advice)
• If more than 21 days postpartum and menstrual cycles have not returned treat as amenorrhoeic. (See above for additional protection advice)

Postpartum (breastfeeding):

• If more than 6 months postpartum and menstrual cycles have returned start CHC as for other women having menstrual cycles. (Women breastfeeding less than 6 weeks postpartum should not use CHCs and between 6 weeks and 6 months. CHC can be started as for those who are postpartum and not breastfeeding (see above)

Switching from other hormonal methods (other than LNG-IUD):

• CHC can be started immediately if using the hormonal method consistently and correctly, or if it is reasonably certain there is no pregnancy. There is no need to wait for next menstrual period. No additional protection required
• If previous method was an injectable or an implant (which inhibit ovulation), CHC can be started any time up to when the repeat injection is due or the implant is removed. No additional protection required

Switching from other non-hormonal methods (other than LNG-IUD):

• As for women having menstrual cycles (see above)

Switching from Cu-IUD or LNG-IUD:

• CHC can be started up to and including day 5 after the start of menstrual bleeding. Cu-IUD / LNG-IUD can be removed at that time, no additional protection required
• CHC can be started at any other time, if it is reasonably certain there is no pregnancy. Ideally Cu-IUD / LNG-IUD can provide contraceptive protection until seven or more pills have been taken. The Cu-IUD / LNG-IUD can then be removed. If the Cu-IUD / LNG-IUD removed at the time of starting CHC then additional contraception is required for 7 days as ovulation still occurs for women using intrauterine methods

Combined oral contraceptives (and HRT) should be stopped pending investigation in the following circumstances:

• Sudden severe chest pain (even if not radiating to left arm).
• Sudden breathlessness (or cough with blood-stained sputum).
• Severe pain in calf of one leg.
• Severe stomach pain.
• Serious neurological effects including unusual severe, prolonged headache especially if first time or getting progressively worse or sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders or dysphasia or bad fainting attack or collapse or first unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body.
• Hepatitis, jaundice, liver enlargement.
• Blood pressure above systolic 160mmHg and diastolic 95mmHg.
• Detection of a risk factor

Caution should be taken for prescription, non-prescription, and recreational drugs, herbal preparations, and dietary supplements that have the potential to interact with hormonal contraception

Important drug interactions that should be considered include:

• drugs that induce hepatic cytochrome P450 enzymes (CYP450) (also known as enzyme-inducing drugs) which could increase clearance of contraceptive hormones, resulting in loss of contraceptive efficacy
• drugs that inhibit CYP450 which could increase exposure of contraceptive hormones

Contraceptive methods that are considered to be affected include:

• combined hormonal methods (CHC) (i.e. combined oral contraceptive pills, vaginal ring, and patch)
• progestogen-only pills (POP)
• contraceptive progestogen implants
• oral emergency contraception

Contraceptive methods that are considered to be unaffected include:

• Depot medroxyprogesterone acetate progestogen-only injectable (achieves very high serum progestogen levels)
• levonorgestrel-releasing intrauterine device (LNG-IUD) (the local progestogen effect on endometrium is unaffected)
• copper intrauterine device (Cu-IUD) (non-hormonal method)
• barrier methods such as condoms

Individuals using teratogenic (or potentially teratogenic) drugs require special consideration. Some teratogenic drugs are also enzyme-inducers. Some patients may also be taking other enzyme-inducing drugs. For further advice on contraception in these circumstances, see:

• FSRH (Faculty of Sexual and Reproductive Healthcare) Drug Interactions Guidance
• MHRA: Pregnancy testing and contraception for pregnancy prevention during treatment with medicines of teratogenic potential
• Detailed information on teratogenic drugs available on the UKTIS website
• See also: Resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation

Women who are HIV positive have special contraception and preconception needs, seek expert advice from Contraception/GUM services

Specialist advice can be obtained from the Contraception Service (01392 284982 or 284931)

For more information see:

• FSRH (Faculty of Sexual and Reproductive Healthcare) Drug Interactions Guidance
• Using contraception with enzyme-inducing medicines (Specialist Pharmacy Service)
• BNF contraceptives interactions treatment summary
• BNF drug interaction pages; combined hormonal contraceptives, desogestrel, levonorgestrel, medroxyprogesterone, norethisterone, ulipristal

Antibiotics

Drugs with the potential to interact include (but are not limited to) rifabutin and rifampicin

Recommended contraceptive:

• Depot medroxyprogesterone OR
• intrauterine device (Cu-IUD or LNG-IUD)

Recommended emergency contraceptive:

• Cu-IUD OR
• 3mg (double dose) of levonorgestrel or 30mg (single dose) of ulipristal acetate, with advice that effectiveness is unknown

Additional contraceptive precautions are not required when antibiotics that do not induce enzymes are used by women taking CHCs. If the antibiotics (and/or the illness) cause vomiting or diarrhoea, then the usual additional precautions relating to these conditions should be observed

Useful links:

• FSRH CEU Response to study: Analysis of reports of unintended pregnancies associated with the combined use of non-enzyme inducing antibiotics and hormonal contraceptives

Antiepileptic drugs

Drugs with the potential to interact include (but are not limited to) carbamazepine, eslicarbazepine acetate, lamotrigine (see below), oxcarbazepine, perampanel, phenobarbital, phenytoin, primidone, rufinamide, and topiramate (see here for resources on contraception for drugs with teratogenic potential)

Recommended contraceptive:

• Depot medroxyprogesterone (PLUS condoms if taking a drug with teratogenic potential) OR
• intrauterine device (Cu-IUD or LNG-IUD)

Recommended emergency contraceptive:

• Cu-IUD OR
• 3mg (double dose) of levonorgestrel or 30mg (single dose) of ulipristal acetate, with advice that effectiveness is unknown

Lamotrigine

It is possible that contraceptive effectiveness of CHC, all progesterone-only pills, and the etonogestrel implant could be reduced during use of lamotrigine, although there is no study data to inform this. The following good practice points are recommended:

• Depot medroxyprogesterone or an intrauterine device (Cu-IUD or LNG-IUD) is the recommended effective choice of contraception
• local specialists do not recommend the use of CHC and lamotrigine without specialist input
• if patients want to remain on POP or implant, seek specialist input
• individuals commencing POP/implant/injectable contraception should be vigilant for signs of lamotrigine toxicity (dizziness, ataxia, diplopia)
• review patients starting and stopping hormonal contraception so any dose adjustments can be made

Useful links:

• Management of epilepsy for further information on epilepsy and pregnancy

Anti-retrovirals

Drugs with the potential to interact include (but are not limited to) cobicistat, efavirenz, etravirine, fostemsavir, nevirapine, and ritonavir (see FSRH guidance for combined products)

Recommended contraceptive:

• Depot medroxyprogesterone OR
• intrauterine device (Cu-IUD or LNG-IUD)

Recommended emergency contraceptive:

• Cu-IUD OR
• 3mg (double dose) of levonorgestrel or 30mg (single dose) of ulipristal acetate, with advice that effectiveness is unknown

Useful links:

• FSRH CEU Guidance: Drug Interactions Between HIV Antiretroviral Therapy (ART) and Contraception
• University of Liverpool HIV Drug Interaction Checker

St John’s Wort

Women should avoid taking St John’s Wort with contraceptives. If they wish to continue using St John’s Wort, recommended contraceptives are:

• Depot medroxyprogesterone OR
• intrauterine device (Cu-IUD or LNG-IUD)

Recommended emergency contraceptive:

• Cu-IUD OR
• 3mg (double dose) of levonorgestrel with advice that effectiveness is unknown

Useful links:

• FSRH CEU Statement: St John’s Wort and Hormonal Contraception

Drugs that cause vomiting or severe diarrhoea

If an individual has persistent vomiting or diarrhoea, consider:

• Depot medroxyprogesterone OR
• intrauterine device (Cu-IUD or LNG-IUD) OR
• progestogen-only implant OR
• CHC patch OR
• CHC vaginal ring

Recommended emergency contraceptive:

• Cu-IUD

Women already using CHC: Continue next packet without a break. Omit dummy tablets if using an Every Day pack.

Women not taking an oral contraceptive: Start a progestogen, e.g. norethisterone 5-10mg three times a day, about 3-5 days before next expected period. Continue until a withdrawal bleed is desired

See section 7.3 Contraceptives

Progestogen-only contraceptives POPs are suitable when oestrogens are contra-indicated (e.g. VTE or a past history or predisposition to venous thrombosis). If used consistently and correctly, POPs are more than 99% effective. They are suitable for older women, for heavy smokers, and for those with hypertension, valvular heart disease, diabetes mellitus, and migraine.

Changes in bleeding patterns associated with the POP are common and women should be informed about such changes. If a woman experiences bleeding problems or "minor" side-effects such as breast discomfort and acne an alternative progestogen may be tried as side-effects appear to depend on target-organ sensitivity.

Available evidence has not shown an increased risk of pregnancy in POP users with a heavier body weight or a higher body mass index. There is insufficient evidence to support a dose of more than one pill per day for women who are heavy or overweight.

POP users taking enzyme-inducing drugs should be advised to switch to the progestogen-only injectable or intrauterine contraception. For short durations of enzyme-inducing treatment (under 2 months) women can continue the POP providing they use additional precautions during treatment and for 28 days afterwards. Women wishing to start the POP after stopping enzyme-inducing drugs should be advised to use condoms until 28 days after the last dose of enzyme-inducing drug. Progestogen-only contraceptives (POPs) are not affected by broad spectrum antibiotics.

In the absence of any other clinical reason, the product of lowest acquisition cost should be chosen.

How it works

• Traditional POPs work by altering cervical mucus to prevent sperm penetration. Ovulation is inhibited in some women
• Desogestrel-only pill works primarily through inhibition of ovulation

Duration of use

• From menarche until age 55 years (when natural loss of fertility assumed)

Failure rate

• Failure rates for traditional POPs vary (0.3 and 8.0 per 100 woman years) but are lower in women aged over 40 years (0.3 per 100 woman years) than younger women

Effects on periods

• Changes are common: 2 in 10 women have no bleeding, 4 in 10 women have a regular bleeding pattern, 4 in 10 women have irregular bleeding

Other risks

• Data suggests there is little or no increase in risk of VTE, stroke or myocardial infarction associated with POP use.
• Breast cancer: any risk of breast cancer associated with COC use is likely to be small, and will reduce with time after stopping

Return to fertility

• No delay

Combined hormonal contraceptive pill (CHC)

Advice for women missing oral combined hormonal contraceptive pills (adapted from FSRH).

N.B. Refer to manufacturer's guidance for women taking Qlaira.

A CHC pill is classed as being "missed" if 24 hours have elapsed since it should have been taken.

Advice to women if one pill has been missed from anywhere in the pack (including the first day):

• Take the last pill you missed now even if it means taking two pills in one day
• Continue taking the rest of the pack as usual
• No additional contraception needed but see notes below
• Take your 7-day break as normal.

Advice to women if two or more pills have been missed from anywhere in the pack:

• Take the last pill you missed now even if it means taking two pills in one day
• Leave any earlier missed pills
• Continue taking the rest of the pack as usual and use an extra method of contraception, or avoid intercourse, for the next 7 days
• Emergency contraception (EC) may be needed (see below)
• You may need to start the next pack of pills without a break (see below).

If missed pills are from the first week of the pack:

• EC may be needed if UPSI has occurred in the pill-free interval or the first week of pill taking.

If missed pills from the second week of the pack where UPSI has occurred in the previous seven days and the pills in the first week had been taken consistently and correctly (assuming the pills thereafter are taken correctly and additional contraception is used):

• EC is not needed

If missed pills from the third week:

• EC should not be needed provided the woman omits the pill-free interval after finishing the pills in the current pack (discarding any placebo tablets from an ED pack) by starting a new pack the next day.

Progestogen only contraception (POP)

The Faculty of Sexual and Reproductive Healthcare recommends emergency contraception if one or more progestogen-only contraceptive tablets are missed or taken more than 3 hours (12 hours for desogestrel) late and unprotected intercourse has occurred before 2 further tablets have been correctly taken

See Emergency contraception below

Vomiting up to 2 hours after taking a CHC may render it ineffective. Very severe diarrhoea can reduce the absorption of the active ingredients. Use additional methods until 7 pills have been correctly taken after recovery. If the diarrhoea or vomiting occurs during the last 7 tablets of a packet, omit the pill free interval and commence the next packet the following day.

If a woman vomits within 2 hours of taking a POP, another pill should be taken as soon as possible. If the subsequent pill is missed, additional precautions are required until 48 hours after pill taking has been resumed.

VTE risk is increased by oestrogens. The BNF advises that they are stopped 4 weeks before major elective surgery or any surgery of the legs or which involves prolonged immobilisation of a lower limb. They may be recommenced at the first menses occurring at least 2 weeks after full mobilisation. Use thromboprophylaxis if it has not been possible to stop the oestrogen. Progestogen-only methods can be continued during major surgery.

The risk of DVT may be increased if any mode of travel involves immobility for more than 5 hours. The risk may be reduced by exercise, adequate hydration, avoidance of alcohol and the use of compression hosiery.

For further details refer to FSRH Guidance (December 2014): Progestogen-only Injectables

Medroxyprogesterone acetate

• See section 7.3.2 Progestogen-only contraceptives

How it works

• Primarily by inhibiting ovulation

General prescribing notes

• Frequency of administration:
  
  • every 12 weeks for Depo-Provera - intramuscular injection of DMPA
  • every 13 weeks for Sayana Press – subcutaneous injection of DMPA
• Women using DMPA who wish to continue use should be reviewed every 2 years to assess individual situations, and to discuss the benefits and potential risks.
• Women are generally advised to switch to another method at age 50 years.
• In women aged under 18 years DMPA may be used as first-line contraception after all options have been discussed and considered unsuitable or unacceptable.
• For women with significant lifestyle and/or medical risk factors for osteoporosis other methods of contraception should be considered.
• The efficacy of DMPA contraception is not reduced with concurrent use of enzyme inducing drugs.

Failure rate

• When administered at the recommended dosing interval (used consistently and correctly) the failure rate of progestogen-only injectable contraception is approximately 0.2% in the first year of use, but with typical use (includes incorrect/inconsistent use) the failure rate is approximately 6%.

Effects on periods

• Altered bleeding patterns are commonly experienced by women using DMPA but there is a trend towards less bleeding and amenorrhoea with increased duration of use
• DMPA use may reduce pain associated with endometriosis.

Other risks

• The side-effect profiles for subcutaneous DMPA are broadly similar to those of intramuscular DMPA.
• Whilst there is little evidence available to demonstrate causation, a number of possible side effects such as acne, decreased libido, mood swings, headache, hot flushes and vaginitis have been reported with use of DMPA.
• Use of DMPA appears to be associated with weight gain, particularly in women under 18 years of age with a body mass index (BMI) ≥30 kg/m2. Women who gain more than 5% of their baseline body weight in the first 6 months of DMPA use are likely to experience continued weight gain.
• Progestogen-only injectable use is associated with a small loss of bone mineral density, which is usually recovered after discontinuation.
• The clinical significance of changes in BMD with use of DMPA is unclear and it is not known whether this translates to an increased risk of fracture.
• Use of DMPA is not associated with an increased risk of ovarian or endometrial cancer and may offer some protection.
• There is possibly a weak association between current use of DMPA and breast cancer
• There is a weak association between cervical cancer and use of DMPA for 5 years or longer.
• A causal association between DMPA and venous thrombosis has not been demonstrated
• Health professionals should ensure that women requesting DMPA are up-to-date with cervical cytology screening and, if relevant, have completed the human papillomavirus vaccination programme.

Return to fertility

• There can be a delay of up to 1 year in the return of fertility after discontinuation of IM or SC DMPA
• Women who do not want to get pregnant should be advised to start another contraceptive method before or at the time of their next scheduled injection even if amenorrhoeic.

Etonogestrel (Nexplanon implant)

• See section 7.3.2 Progestogen-only contraceptives

How it works

• Preventing ovulation

Duration of action

• 3 years

Failure rate

• Very low: fewer than 1 in 1000 over 3 years

Effects on periods

• Irregular bleeding is common. 20% of women have no periods, and almost 50% have infrequent or prolonged bleeding; bleeding patterns likely to remain irregular but dysmenorrhoea may improve. It is important that the patient is made aware of this before the implant is fitted. Women who have had gynaecological pathology excluded and for whom oestrogen is not contra-indicated may be offered a COC for treatment (unlicensed). This may be used for up to three months and can be given in the usual cyclic manner or continuously. Data to support this treatment option is limited

Other risks

• Up to 43% of women stop using Nexplanon® within 3 years; 33% because of irregular bleeding, and less than 10% for other reasons including hormonal (non-bleeding) problems
• 'Minor' progestogenic side effects, e.g. acne, breast pain
• No evidence of effect on: weight, mood, libido, headaches or bone mineral density

Return to fertility

• No evidence of delay

Advice at time of administration

• Insertion and removal may cause discomfort and bruising but technical problems occur in fewer than 1 in 100 procedures
• Local adverse effects at site of insertion. Difficulty with removal and scarring are very infrequent
• MHRA Drug Safety Update (February 2020): Etonogestrel (Nexplanon ) contraceptive implants: new insertion site to reduce rare risk of neurovascular injury and implant migration
  • An implant should be inserted subdermally by a healthcare professional who has been appropriately trained and accredited
  • New insertion site and guidance on how to correctly insert the implant – see Safety Update for links to guidance
  • Show the woman how to locate the implant and advise her to do this occasionally; if she has any concerns, she should return promptly to the clinic for advice
  • Localise any implant that cannot be palpitated (for example, by imaging the arm) and remove it at the earliest opportunity – perform chest imaging if it cannot be located in the arm
  • Implants inserted at the previous site that can be palpated should not pose a risk and do not need to be moved to the new site; only replace implants if you have concerns regarding their location or if routine replacement is due
• No routine follow-up but return at any time if problems or to change/ discontinue method

See section 7.3.2 Progestogen-only contraceptives

MHRA Drug Safety Update (January 2016): Levonorgestrel-releasing intrauterine systems should always be prescribed by brand name because products have different indications, durations of use, and introducers

For information on heavy and/or painful periods please refer to: NICE NG88 Heavy menstrual bleeding: assessment and management (March 2018)

For information on long-acting reversible contraception (LARC) please refer to: NICE CG30 long-acting reversible contraception (September 2014)

Progestogen-only intrauterine devices (IUD) are contraceptive devices that release levonorgestrel directly into the uterine cavity, preventing endometrial proliferation, thickening of cervical mucus, and suppressing ovulation in some women.

Four levonorgestrel-containing intrauterine devices (LNG-IUD) are available: Jaydess, Levosert, Mirena, and Kyleena. Their licensed indications, duration of action, and associated bleeding patterns differ. See section 7.3.2.3 Intrauterine progestogen-only devices

Failure rate

Fewer than 1 in 100 women will get pregnant over five years when using an LNG-IUD.

Adverse effects

Irregular bleeding and spotting common in first 6 months, oligomenorrhoea or amenorrhoea likely by end of first year

Other risks

• Ectopic pregnancy
• Pelvic inflammatory disease
• Uterine perforation
• Change in mood or libido
• Acne

Advice at time of fitting

• There may be pain and discomfort for a few hours and light bleeding for a few days
• Watch for symptoms of uterine perforation
• Follow-up visit after first menses or 3–6 weeks after insertion
• Return at any time if problems or to change method
• Check for threads regularly

MHRA Drug Safety Update (June 2015): Before inserting an intrauterine system (IUS) or intrauterine device (IUD), inform women that perforation occurs in less than 1 in 1,000 women and that the symptoms include:

• severe pelvic pain after insertion (worse than period cramps)
• pain or heavy bleeding after insertion which continues for more than a few weeks
• sudden changes in periods
• pain during sex
• not being able to feel the threads

Explain to women how to check their threads and tell them to return for a check-up if they cannot feel them (especially if they also have significant pain). Partial perforation may have occurred even if the threads can still be seen; consider this if there is severe pain following insertion.

For further information

For further clinical guidance regarding specific methods of contraception, please refer to The Faculty of Sexual & Reproductive Healthcare Website.

See section 7.3.4 Contraceptive devices

How it works

• Preventing fertilisation and inhibiting implantation

Duration of action

• Women under 40 years: 5-10years for IUDs with 380mm² copper, depending on type
• Until contraception no longer needed if woman 40 years or older at time of insertion

Failure rate

• Fewer than 2 in 100 women over 5 years for IUDs with at least 380mm² copper.
• Expulsion occurs in fewer than 1 in 20 women in 5 years

Effects on periods

• Heavier bleeding and/or dysmenorrhoea likely

Other risks

• Up to 50% of women stop using IUDs within 5 years; most common reasons are unacceptable vaginal bleeding and pain.
• Ectopic pregnancy: overall rates lower than with no contraception but if a woman becomes pregnant with IUD in situ, risk is about 1 in 20 so she should seek advice to exclude it
• Pelvic inflammatory disease: less than 1% for women at low risk of STI
• Uterine perforation: less than 1 in 1000
• Change in mood or libido: may be a small effect
• No evidence of effect on weight gain

Return to fertility

• No evidence of delay

Advice at time of fitting

• There may be pain and discomfort for a few hours and light bleeding for a few days
• Watch for symptoms of uterine perforation
• Follow-up visit after first menses or 3–6 weeks after insertion
• Return at any time if problems or to change method
• Check for threads regularly

Intrauterine device (IUD)

A copper IUD is more effective than hormonal methods of emergency contraception (98% effective, regardless of delay). It can be inserted up to 5 days after unprotected sexual intercourse (USI) or up to 5 days after the earliest likely day of ovulation (i.e. before implantation). The IUD can then be removed with the next period or left in situ for long-term contraception. Please see section 7.3 Contraceptives

The effectiveness of Levonorgestrel and possibly Ulipristal Acetate is reduced in women taking enzyme inducing drugs (and possibly for 4 weeks after stopping). A copper IUD may be the preferred option in this circumstance.

If a surgery is unable to provide an IUD insertion, patients can arrange a fitting by contacting:

• Devon Sexual Health (Barnstaple, Exeter, and Torbay) (electronic referral system available)
  • A patient can self-refer by phoning 0300 303 3989 for a consultation within 24 hours. Please give relevant treatment information to the patient to bring to clinics, i.e. results of previous cultures and any treatments.
• SHiP (Sexual Health in Plymouth)

Patient or GP must mention the appointment is for an emergency fitting.

Emergency hormonal contraception (EHC)

Ulipristal Acetate (UPA) and Levonorgestrel work by delaying ovulation. UPA 30mg single dose can be given up to 120 hours after USI and Levonorgestrel 1.5mg single dose can be given up to 96 hours after USI (licensed for 72 hours only).

The earlier the treatment is commenced the more reliable it is. Therefore, women should be advised to take the dose as soon as possible after USI, and be advised that treatment failure may occur.

Weight and EHC

If a woman is over 70kg or has a BMI > 26kg/m², the efficacy of Levonorgestrel 1.5mg single dose may be impaired and she could have UPA single dose or Levonorgestrel double dose (unlicensed use).

If a woman has a BMI > 30kg/m² or weight > 85kg, consider emergency contraception if IUD not appropriate, but understand the efficacy of UPA may be reduced.

Progestogens and UPA

UPA is the most effective method mid-cycle, but it cannot be given if any progestogen (including Hormone Replacement Therapy and Levonorgestrel EHC) has been taken in the preceding 7 days.

Delay quick starting any progestogens for 5 days after UPA as this may interfere with the action of this method.

Other considerations

At the request of EHC by a patient consider sexually transmitted infection (STI) screening. In all patients less than 18 years of age and vulnerable adults consider safeguarding issues.

Patients should be advised that if a period is lighter than usual or more than 7 days late, they should return to clinic for pregnancy testing 3 weeks after taking oral EHC or IUD fitting.

After taking UPA and Levonorgestrel EHC, condoms or avoidance of sex should be advised for 7 days after starting Combined Hormonal Contraceptive (CHC), 9 days for Qlaira (non-formulary) CHC or 2 days after Progesterone only pill.

For further information

For further clinical guidance regarding specific methods of contraception, please refer to The Faculty of Sexual & Reproductive Healthcare Website.

See FSRH Decision-making Algorithms for Emergency Contraception to help with deciding the best method of emergency contraception.