Methods of Contraception

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Contraceptives (or birth control) are methods for preventing pregnancy by stopping one or more of ovulation, fertilisation and implantation. There are many types of contraceptives, each with their own benefits and limitations. As a doctor, it is important to have an understanding of this to adequately inform your patients about the most suitable contraceptives based on their preferences, lifestyle and medical history. The below information should be considered a very brief summary and should not be used for clinical decision-making.


Types

There are several categories of contraceptives:

  • Barrier methods
  • Combined contraceptives
  • Progestogen-only contraceptives
  • Long-acting reversible contraceptives (LARCs)
  • Sterilisation
  • Natural family planning
  • Emergency contraception

Contraceptive choice

A contraceptive choices consultation should encompass exploring the patient’s ideas, concerns and expectations; information-giving about different available methods; and assessing the patient’s risk profile for these methods. A shared decision should be made.

Patients will make their choice based on an array of criteria:

  • Most effective: Some patients simply prefer the contraceptive method least likely to result in pregnancy.
  • Ease of use
  • Reversibility: This is particularly relevant in women who may be trying to become pregnant in the future.
  • Low side effect profile
  • Effect on menstruation: Patients may wish to continue to have regular periods, or prefer lighter periods, or no periods at all.
  • Non-hormonal
  • Previous experience
  • Experience of friends or family
  • Practicality: Some patients may not be physically able to eg insert cervical cap; or attend clinic for repeat injections.

Not all contraceptives will be suitable for all patients. The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) guideline, available online on the Faculty for Sexual and Reproductive Health (FSRH) website, sets out the risk profiles of different patient characteristics and medical conditions with regards to a contraceptive choice. These guidelines cover hormonal contraceptives in all forms, emergency contraception, and the copper IUD. Risks are graded from UKMEC 1 (no restriction) to UKMEC 4 (contra-indication). For example,  combined hormonal contraceptives are considered UKMEC 2 in women with insulin-dependent diabetes, i.e. benefit generally outweighs risk. If this patient also had a history of stroke, which is UKMEC 4, combined hormonal contraceptives would be contra-indicated.


Barrier methods

Barrier methods of contraception reduce the risk of pregnancy by acting as a barrier to stop the sperm and ovum meeting and so preventing fertilisation. These should be recommended to patients for all types of sexual contact to reduce sexually transmitted infection (STI) transmission. 

Male condoms

Male condoms are barriers made of latex, polyisoprene or polyurethane that cover the penis to prevent semen containing sperm from entering the vagina.

Benefits

  • Only used during intercourse
  • Reduces STI transmission
  • Side effects are rare

Limitations

  • Can break, split or tear during use
  • Can interrupt intercourse to put a male condom on
  • Need to know the correct technique for using condoms
  • Some patients are allergic to latex condoms (alternative materials are available)

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 18%

Female condoms

Female condoms are a barrier made of polyurethane that goes inside the vagina to prevent sperm from passing through the cervix and fertilising an ovum.

Benefits

  • Only used during intercourse
  • Reduces STI transmission
  • Side effects are rare

Limitations

  • Can break, split or tear during use
  • May interrupt intercourse to put the female condom in place
  • Need to know the correct technique for using condoms
  • Female condoms are not as widely available as male condoms

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 21%

Diaphragm/cervical cap

The diaphragm is a flat silicone cup which is placed over the cervix as a barrier to sperm. This is similar to a cervical cap, which is smaller and also placed over the cervix. Spermicide must be used with these methods.

Benefits

  • Only used during intercourse
  • Can be put in place in advance of intercourse
  • Side effects are rare

Limitations

  • Can break, split or tear during use
  • May interrupt intercourse to put the diaphragm/cap in
  • Patients need to know the correct technique for using a diaphragm/cap
  • Does not protect against STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 12%

Combined contraceptives

Combined contraceptives contain synthetic versions of both oestrogen and progesterone. They work by mimicking the luteal phase of the menstrual cycle, leading to inhibition of the hypothalamic-pituitary-gonadal axis. This prevents the release of LH and FSH needed for ovulation.

Combined contraceptives further reduce the risk of pregnancy by thickening the cervical mucus to prevent sperm passage and by thinning the endometrium to reduce the chance of implantation.

Medical contraindications

Certain patient groups are contraindicated from using combined contraceptives, including those with:

  • Migraine with aura
  • Current breast cancer
  • High VTE risk factors, such as:
    • Atrial fibrillation
    • SLE (positive for antiphospholipid antibodies)
    • Age over 35 years old and smoking at least 15 cigarettes daily
    • History of stroke
    • History of VTE
    • Major surgery with prolonged immobilisation
    • Known thrombogenic mutations
    • Complicated valvular or congenital heart disease
  • Other cardiovascular risk factors such as:
    • Hypertension: >160mmHg systolic BP or >100mmHg diastolic BP
    • History of ischaemic heart disease
  • Severe liver disease

These contraindications are listed in full in the UKMEC guidelines.

The oestrogen in combined contraceptives increases the risk of VTE in patients taking them. Any risk factors for VTE should be considered before the prescription of combined contraceptives.

There is some evidence to suggest that the risk of breast cancer is increased in individuals using combined contraceptives. However, this risk reduces to normal levels 10 years after stopping the contraceptive. Patients with a history of breast cancer may be allowed to use combined contraceptives but this should only be prescribed with the guidance of their oncology team. 

Combined oral contraceptive pills (COCP)

These are pills containing oestrogen and progestogen (synthetic progesterone) that inhibit ovulation. Traditionally, patients take the pill on a 21/7 cycle i.e. 21 days of taking the pill at the same time each day, then a 7-day break where they will have a period-like withdrawal bleed. Depending on patient preference and suitability, other regimens can be used such as 21/4, 63/7, or continuous use with no hormone-free interval. Commonly prescribed examples of the COCP are Microgynon 30® and Rigevidon®.

This type of contraception is most suited to women who are good at remembering to take pills daily and who tolerate hormonal contraceptives.

Benefits

  • No interruption to intercourse
  • Can be stopped at short notice if not tolerated
  • Less strict “missed pill rules” than the progestogen-only pill
  • May make periods more regular, lighter and less painful
  • May reduce the risk of ovarian, endometrial and bowel cancer
  • May have therapeutic benefits in gynaecological disorders including endometriosis and menorrhagia

Limitations

  • Effectiveness reduced if a pill is forgotten
  • Side effects may include headaches, nausea, breast tenderness and mood swings
  • Vomiting and diarrhoea may affect the effectiveness
  • Certain drugs including anti-epileptic drugs may affect the effectiveness
  • Increases the risk of VTE and stroke
  • Potentially increases the risk of breast cancer while using the COCP
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 9%

Contraceptive patches

Contraceptive patches deliver their oestrogen and progestogen through the skin and inhibit ovulation as above. They are approximately 4x4cm in size and can be applied to any skin except the breast, where the tissue is oestrogen sensitive. Common sites to apply them are on the back, abdomen and buttocks. One patch is applied for 7 days and then immediately changed for a new patch. Traditionally, 3 patches are worn for 21 days in total and then a 7-day patch-free interval is taken, where a patient may have a period-like withdrawal bleed. As with the COCP tailored regimens can be used.

This type of contraceptive might be well suited to someone who does not mind wearing the patch but tends to forget pills.

Benefits

  • Do not need to remember daily like the pill
  • No interruption to intercourse
  • Can be stopped at short notice if not tolerated
  • May make periods more regular, lighter and less painful
  • May reduce the risk of ovarian, endometrial and bowel cancer
  • Vomiting and diarrhoea do not affect effectiveness unlike the pill

Limitations

  • Protection from pregnancy may be affected if they forget to change the patch or if it falls off
  • Side effects may include headaches, nausea, breast tenderness and mood swings
  • Certain drugs may affect effectiveness including some anti-epileptic drugs
  • Increases the risk of VTE and stroke
  • Potentially increases the risk of breast cancer while using the patch
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 9%

Vaginal rings

The contraceptive vaginal ring (also known as the NuvaRing®) is a small plastic ring that is placed high in the vagina and secretes oestrogen and progestogen to prevent ovulation. The ring is inserted into the vagina for 21 days and then removed for 7 days before the next ring is put in. Again as with the COCP, tailored regimens can be used e.g. wearing 3 rings in a row for 63 days, then taking a 7-day break.

Benefits

  • Do not need to remember daily like the pill
  • No interruption to intercourse
  • Can be stopped at short notice if not tolerated
  • May make periods more regular, lighter and less painful
  • May reduce the risk of ovarian, endometrial and bowel cancer
  • Vomiting and diarrhoea do not affect effectiveness unlike the pill

Limitations

  • Side effects may include headaches, nausea, breast tenderness and mood swings
  • Certain drugs may affect protection including some anti-epileptic drugs
  • Increases the risk of VTE and stroke
  • Potentially increases the risk of breast cancer while using the ring
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 9%

Progestogen-only contraceptives

Progestogen-only pill (POP)

The progestogen-only pill is taken every day without any breaks. These pills do not contain any oestrogen. There are a couple of types of POP used currently:

  • Desogestrel POP works mainly by inhibiting ovulation. It also works by thickening cervical mucus and thinning the endometrium. This POP should be taken within the same 12 hours every day to be effective. A commonly prescribed example of this type is Cerazette®.
  • Norethisterone and levonorgestrel POPs work mainly by thickening cervical mucus and thinning the endometrium. These POPs are taken much less commonly as they should be taken within the same 3 hours every day to be effective.

Benefits

  • Suitable for patients where oestrogen is contraindicated or those who are intolerant to oestrogen
  • Taken without breaks so don’t have to remember to start and stop pills
  • No interruption to intercourse
  • Can be stopped at short notice if not tolerated

Limitations

  • Protection from pregnancy affected if a pill is forgotten
  • More strict “missed pill rules” than COCP
  • May cause irregular bleeding, amenorrhoea or more frequent bleeding
  • Vomiting and diarrhoea may affect protection
  • Certain drugs including some enzyme-inducers may affect the effectiveness
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 9%

Contraceptive injection

The injection contains progestogen only and is carried out every 12 weeks. It is typically administered intramuscularly into the buttocks. The systemic progestogen inhibits ovulation, thickens the cervical mucus and thins the endometrium. The Depo-Provera® is one of the most commonly administered contraceptive injections.

Benefits

  • Suitable for patients where oestrogen is contraindicated or those who are intolerant to oestrogen
  • Do not need to remember to take a pill daily
  • No interruption to intercourse

Limitations

  • May cause irregular bleeding, amenorrhoea or more frequent bleeding
  • The patient needs to tolerate injections
  • Can affect bone mineral density if used long-term
  • Does not protect from STIs
  • Irreversible for the duration of the drug’s effect
  • Fertility can take months to return after ceasing use

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 6%

Long-acting reversible contraceptives (LARCs)

LARCs are methods of contraception that are inserted into the patient and provide ongoing protection against pregnancy. They are effective for several years before they need replacing, are highly convenient once inserted, and are better at preventing pregnancy than other available methods.

Implant

The contraceptive implant is a small plastic rod approximately 4cm in length inserted under the skin in the upper arm. It slowly releases progestogen to prevent pregnancy by inhibiting ovulation as well as thickening the cervical mucus and thinning the endometrium. A commonly used type is Nexplanon®.

Benefits

  • Once inserted, it lasts for 3 years
  • Suitable for those who cannot use oestrogen
  • The most effective form of contraception available, including sterilization
  • No interruption to intercourse

Limitations

  • May cause irregular bleeding, amenorrhoea or more frequent bleeding
  • Qualified practitioner required to insert implant
  • Can cause or worsen acne
  • Procedure to fit and remove it which has a risk of bruising and infection
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of unintended pregnancies within 1 year with typical use of contraception method = 0.05% (i.e. 1 in 2000)

Hormonal coil

Hormonal coils, also known as intrauterine systems (IUS), are T-shaped plastic rods inserted into the uterus that release progestogen locally. They prevent pregnancy by thinning the endometrium to prevent implantation and by thickening cervical mucus to prevent sperm passage.

The Mirena® or is a hormonal coil licensed for use for 5 years for contraception and for treating menorrhagia.

The Kyleena® is a slightly smaller hormonal coil which contains less progestogen and is also licensed for 5 years.

The Jaydess® is a similar size to the Kyleena® and is licensed for 3 years.

The above coils are all suitable for nulliparous women.

Benefits

  • Lasts for 3 or 5 years
  • Suitable for those who cannot take oestrogen
  • Very effective in preventing pregnancy
  • No interruption to intercourse
  • More likely than the implant to reduce heavy menstruation (particularly the Mirena®)
  • Some women report less systemic side-effects as compared to the implant

Limitations

  • Can make menstruation irregular especially in the first 6 months from fitting and can cause amenorrhoea
  • Can cause acne, headaches and breast tenderness
  • Qualified practitioner required to insert coil
  • Involves a procedure with speculum exam to fit and remove the coil; some women prefer other options due to this
  • Small risk of uterine perforation and infection with insertion
  • If pregnancy occurs, more likely to be an ectopic pregnancy
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 0.2% (i.e. 1 in 500)

Copper coil

Copper coils, also known as intrauterine devices (IUD), are T-shaped plastic and copper rods inserted into the uterus. They prevent pregnancy by creating an inhospitable environment for the sperm and ovum to survive in the uterus. Various different coils are available in different shapes and sizes. Copper coils generally last for either 5 years or 10 years.

Benefits

  • Lasts 5-10 years
  • Suitable for women who cannot use hormonal contraceptives
  • Very effective in preventing pregnancy
  • No interruption to intercourse
  • Effectiveness unaffected by other medications
  • Can be used as emergency contraception

Limitations

  • Can cause heavier, longer and more painful menstruation
  • Qualified practitioner required to insert coil
  • Involves a procedure with speculum exam to fit and remove the coil; some women prefer other options due to this
  • Small risk of uterine perforation and infection with insertion
  • If pregnancy occurs, more likely to be an ectopic pregnancy
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 0.8% (i.e. 1 in 125)

Sterilisation 

Female sterilisation

Female sterilisation is a procedure usually done under general anaesthetic or sometimes at the time of Caesarian section. It is considered irreversible when counselling patients, though it is possible in a small number of cases to surgically reverse. Hence, it is only suitable for women who are certain they do not want to become pregnant in the future.

Methods of female sterilisation

  • Tubal occlusion with surgical clips
  • Hysteroscopic sterilisation using fallopian implants
  • Salpingectomy

Benefits

  • Permanent contraception
  • No interruption to intercourse
  • Does not affect their hormonal levels
  • Effectiveness unaffected by other medications

Limitations

  • Carries risks of surgery including bleeding and infection
  • Many women experience pain after their surgery
  • Very difficult to reverse
  • Women need to be informed that in rare cases they can still become pregnant
  • If pregnancy occurs, more likely to be an ectopic pregnancy
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 0.5% (i.e. 1 in 200)

Male sterilisation

Male sterilisation, or vasectomy, involves a procedure under a local anaesthetic to the scrotum and testicles to remove a section of each vas deferens. This prevents pregnancy by stopping the sperm from entering the semen to prevent fertilisation. Because vasectomy is considered irreversible, this procedure is only suitable for men who do not intend to have children in the future.

Benefits

  • Permanent contraception
  • Does not interrupt intercourse
  • Less invasive and lower risk procedure than female sterilisation

Limitations

  • Carries risks of surgery including bleeding and infection
  • Some men experience pain after their surgery
  • Very difficult to reverse
  • Contraception should be used afterwards until semen confirmed to be sperm-free
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 0.15% (i.e. 1 in 667)

Natural family planning

Natural family planning, or fertility awareness, is where intercourse is timed to coincide with the times during the menstrual cycle when ovulation is least likely. Fertility signs such as body temperature and cervical secretions may be monitored by the individual. This aims to prevent pregnancy by reducing the risk of the ovum being available for fertilisation by the sperm. This method is unsuitable for women with irregular menstrual cycles.

Benefits

  • There are no side effects from this type of contraception
  • It is acceptable to most faiths and cultures

Limitations

  • Much less effective form of contraception
  • Must avoid sex or use other contraception around the time of ovulation
  • Requires significant patient commitment to record daily fertility signs
  • Fertility signs are unreliable when breastfeeding
  • Fertility signs can be affected by illness and stress
  • Does not protect from STIs

Unintended pregnancy rate

  • Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 24%

Emergency contraception

Emergency contraception is used by women who have had unprotected sexual intercourse (UPSI) or contraceptive failure, and wish to minimise their resulting risk of pregnancy. There are three methods of emergency contraception discussed below. Levonelle® and ellaOne® are forms of emergency contraceptive pills or morning-after pills. The copper coil can also be used as emergency contraception and is by far the most effective form. All are more effective the earlier they are used following unprotected intercourse. 

Levonelle®

This contains a high dose of the synthetic progestogen levonorgestrel. It is thought to prevent pregnancy by delaying ovulation, by which time any sperm in the reproductive tract would be non-viable. Levonelle® must be taken within 72 hours of the unprotected intercourse to be effective. If taken after the start of the LH surge, there is no evidence of any benefit to this method of emergency contraception.

Benefits

  • Can be taken if the patient has recently taken a progestogen-containing contraceptive
  • Can start ongoing hormonal contraception on the same day
  • Can be taken more than once in a menstrual cycle
  • Unlike the copper coil, no insertion procedure is required
  • Easily accessible for patients
  • Fewer contra-indications than ellaOne®

Limitations

  • No evidence of any benefit if taken after ovulation has occurred
  • More effective at the start of the 72-hour window than at the end
  • Efficacy affected by enzyme-inducing medications and by patient weight
  • The least effective form of emergency contraception
  • Does not provide any ongoing contraception

Unintended pregnancy rate

  • Effectiveness is difficult to quantify but around 1.7-2.2% of women who took this pill within 72 hours of UPSI became pregnant in the same cycle

ellaOne®

EllaOne®, which contains ulipristal acetate, prevents pregnancy by delaying or stopping ovulation. It must be taken within 120 hours to be effective, and unlike Levonelle® evidence suggests that some effectiveness remains even after the start of the LH surge (although not after ovulation itself).

Benefits

  • More effective than Levonelle®, particularly if close to ovulation date
  • Unlike the copper coil, no insertion procedure is required
  • Easily accessible for patients
  • Effective up to 120 hours after UPSI, as compared to 72 hours for Levonelle®
  • Effectiveness remains the same throughout the 120-hour window
  • Can be used more than once in the same cycle

Limitations

  • No evidence of any benefit if taken after ovulation has occurred
  • Efficacy affected by enzyme-inducing medications and by patient weight
  • Must wait 5 days after taking ellaOne® before starting other hormonal contraceptives; efficacy in theory reduced if hormonal contraceptives taken within the preceding 7 days
  • Not recommended in patients with severe asthma, hepatic dysfunction, or taking PPIs/antacids
  • Does not provide any ongoing contraception

Unintended pregnancy rate

  • Effectiveness is difficult to quantify but around 1.3-1.6% of women who took this pill within 120 hours of UPSI became pregnant in the same cycle

Copper coil

The copper coil, or IUD, prevents pregnancy as discussed in the section above. It is the most effective form of emergency contraception and should be offered to all patients for consideration. The coil must be inserted either within 5 days of UPSI or within 5 days of ovulation (whichever date falls latest in the menstrual cycle). As such the coil is effective even if there have been multiple episodes of UPSI earlier on in a cycle, so long as it is inserted within the window after ovulation. It can then be left in place to give long-term contraception if desired. Contra-indications for insertion are the same as if inserting for contraceptive benefit.

Benefits

  • The most effective form of emergency contraception
  • Provides ongoing contraception for up to 10 years
  • The only form of emergency contraception which is effective if fitted after ovulation
  • Is not affected by patient weight or other medications

Limitations

  • As explored above, a qualified practitioner is required to insert the coil, which some women may find uncomfortable. The procedure itself carries small risks of perforation and infection.
  • Less convenient than oral emergency contraception
  • Absolutely contra-indicated to insert >5 days after ovulation

Unintended pregnancy rate

  • Effectiveness is difficult to quantify but <0.1% of women who had the coil inserted during the appropriate window became pregnant in the same cycle

Reviewer

Dr Grace Farrington

GP Trainee


References

  • Percy, L., & Mansour, D. (2016). Contraception Made Easy Revised Edition. Banbury: Scion Publishing Ltd.
  • Your contraception guide – NHS.uk. 2018 [cited 14 February 2018]. Available from: [LINK]
  • Collins S, Arulkumaran S, Hayes K, Jackson S, Impey L. Oxford Handbook of Obstetrics and Gynaecology. 3rd ed. Oxford: Oxford University Press; 2013.
  • Faculty of Sexual and Reproductive Health [FSRH] (2019) FSRH Guideline Combined Hormonal Contraception. Available at: [LINK]
  • FSRH (2019) Faculty of Sexual and Reproductive Healthcare Clinical Guidance, Progestogen-Only Pills. Available at: [LINK]
  • FSRH (2016) UK Medical Eligibility Criteria for Contraceptive Use UKMEC 2016. Available at: [LINK]
  • FSRH (2019) Faculty of Sexual and Reproductive Healthcare Clinical Guidance, Intrauterine Contraception. Available at: [LINK]
  • FSRH (2017) FSRH Guideline: Emergency Contraception. Available at: [LINK]

 

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