30% of pregnancies in the UK are unplanned. Therefore methods of contraception should be offered to all women of child bearing age.


Combined Pill

This pill contains both oestrogen and progesterone. It works primarily by stopping ovulation, but also by thickening the cervical mucus and thinning the lining of the uterus.

The pill is taken around the same time for 21 days followed by a 7 day break in which there is a withdrawal bleed. If taken every day, this pill is 99% effective. If a pill is missed at the start or middle of the packet, take when remembered, preferably within 12 hours. If during the last 7 days of the packet, the next packet should be started without a break.


Microgynon 30 - one of the commonly used COCP's


  • Very effective
  • Reduced menstrual bleeding and pain



  • Breakthrough bleeding, although not as much as the progesterone only pill
  • Slightly increased risk of breast and cervical cancer



    • Previous or family history of breast cancer
    • Hypertension
    • History of DVT / CHD / IHD
    • BMI >40kg/m2
    • Over 35 and a smoker
    • Migraine with aura
    • Over 35 and migraine without aura


      Progesterone Only Pill


      This pill contains only progesterone and works by thickening the cervical mucus and thinning the lining of the uterus. Pills such as Cerazette that contain a higher dose of progesterone may also work by inhibiting ovulation in some women. 


      Women should take this pill at the same time (within 3 hours) everyday. Newer pills can be taken within 12 hours. There is no break in the cycle, each packet is taken continuously. When taken correctly this pill is 99% effective.



      • No main contraindications unlike the combined pill



        • Dysfunctional bleeding- irregular/heavy/intermenstrual


          Transdermal Patch


          This patch is applied to the arm, torso, buttock or lower abdomen. It releases a constant dose of oestrogen and progesterone into the circulation. The patch is applied on the first day of menstruation and then replaced every 3 weeks, with a patch free week inbetween. 


          Failure rates for the patch are around 98%.


          Barrier Methods


          Male condoms are the most commonly used method of contraception. They work by creating a barrier, therefore preventing sperm from entering the vagina. They should be put on an erect penis before intercourse and removed whilst the penis is still erect.


          True failure rates for condoms are 98% but typically this can be as low as 85%, due to user error and other factors. Condoms have the added benefit of protecting individuals from sexually transmitted diseases (STI's).


          Male Condoms

          Female barrier methods are less commonly used than male condoms. Femaie condoms provide a barrier against sperm, whereas diaphragms and caps provide a physical and chemical barrier due to the simultaneous use of spermicide.A diaphragm or cap should be left in place 6 hours after intercourse.


          Diaphragms and caps, together with use of spermicide are 94% effective and female condoms are 95% effective in preventing pregnancy.


          LARC Methods


          This stands for long acting reversible contraceptive methods. These methods do not reply on daily compliance and therefore have lower failure rates than those methods above.

          These include:

          • IUD
          • IUS
          • Implanon
          • Depo-Provera


          Copper Intrauterine Devices (IUD)


          This is a copper T-shaped device that is inserted into the uterus. It works by inhibiting fertilisation, as copper it toxic to the sperm. It also induces at inflammatory response in the endometrium, therefore preventing implantation.


          Failure rates are low: less than 1%. Once inserted they can remain in place for up to 10 years, after which it will need to be replaced. If inserted after 40 years old, the IUD can remain in place until the menopause has been confirmed. This is 1 year after the last menstrual period if over 50 and 2 years if under 50.



          • Doesn't use any hormone
          • Fertility returns to normal once removed



          • Increased menstrual blood loss, although some women stop altogether.
          • Increased dysmenorrhoea
          • If method fails there is a small risk of ectopic pregnancy.
          • Risk of expulsion (1 in 20 women)- women are advised to feel for their threads, especially in the first few months and after their first period.


            Intrauterine System (IUS) e.g. Mirena

            This is a T-shaped system coated in progesterone and works primarily by preventing implantation. It also has a local effect on cervical mucus and the endometrium.


            This system is licensed for 5 years of use, after which it will have to be replaced. Failure rates for this are less than 1%.



            • Progesterone only acts locally so no systemic effects.
            • Once removed fertility returns to normal
            • Reduction in menstrual loss- most women stop menstruating altogether.



            • Possibility of spotting and irregular bleeding in the first six months
            • If method were to fail small risk of ectopic pregnancy
            • Risk of expulsion- check threads

            Implant (Implanon)


            This is a small, flexible rod containing progesterone that is inserted under the skin in the medial aspect of the upper arm. Women should be able to feel it, but it won't be seen. It's mode of action is to prevent ovulation as well as thickening cervical mucus and thinning the endometrium.


            Implanon lasts for 3 years, but can be removed at any time. Failure rates are less than 1%. Nearly half of women have the implant removed before 3 years due to altered bleeding. Some women have no bleeding, whilst others have very frequent and prolonged bleeding. Once removed fertility returns to normal. Women should be counselled about the possibility of implanon leaving a scar.

            Depo Injection


            The injection (Depo-Provera) contains progesterone only. It works primarily inhibiting ovulation as well as thickening the cervical mucus, preventing sperm from entering the upper reproductive tract.


            Injections, usually into the buttock, are given every 12 weeks. They can be given up to 2 weeks late with the same contraceptive effect but this is not advised. Failure rates if given every 12 weeks are <1%.



            • Reduces risk of endometrial cancer
            • Reduces pelvic inflammatory disease



            • Delay in return to fertility. Therefore this needs to be considered in women wishing to become pregnant in the future. The effect usually lasts 6 months, but as this varies between women, other methods of contraception should be used until pregnancy is wanted.
            • Irregular bleeding pattern
            • Weight gain- on average women put on 3kg over 2 years of use.
            • Not advised in younger women as causes a reduction in bone mineral density. Recovered after stopping.


            Permanent Methods- Sterilisation


            This is the most common method of contraception for older women.


            Female sterilisation involves fallopian tube occlusion using Filshie clips, done through a laparoscopic procedure. The overall failure rate it 1 in 200 women.


            Male sterilisation (vasectomy) involves both division of the vas deferens, as well as diathermy. After there needs to be 2 sperm counts to confirm azoospermia. The failure rate is 1 in 2000.  It should be presented as an option to all women or couples considering female sterilization as it is a far simpler and less risky proceedure that may not have been considered.


            Before each of these methods are chosen, the patient/couple need to be counselled as it is a permanent method and cannot be reversed easily or on the NHS.


            Emergency Contraception


            This allows women to prevent pregnancy after unprotected sexual intercourse (UPSI) or contraceptive failure. There are two methods:


            Oral progesterone-only emergency contraception containing levonorgesterel (Levonelle).

            • Licensed to be given up to 72 hours after. Efficacy rates fall the more hours between the UPSI and when  it is taken.
            • Given as a single dose and works by preventing ovulation.
            • After women may find disturbances to their cycle and experience bleeding within the next 7 days. Bleeding shows that it has been effective. If no bleeding, advise woman to do a pregnancy test.


              Copper intrauterine device (IUD)

              • Can be inserted within 120 hours (5 days) of UPSI or contraceptive failure.
              • Direct toxic effect on fertilisation 
              • Can be left in place as a LARC method or removed after 3 weeks once no pregnancy has been confirmed.


                Post-Partum Contraception


                Post-partum all women should be advised on contraception.


                For women breastfeeding the only method contraindicated is the combined oral contraceptive pill as it contains oestrogen, and this will supress lactation. Any other method is suitable. Breastfeeding it itself may also be a form of contraception, but should not be relied on.


                Women wanting to go on a pill should wait 3 weeks, until they have had their first period, before they start.


                Women wishing to have an IUS/IUD inserted should wait 6 weeks in order for the uterus to return to normal size.



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