In England and Wales in 2021, there were 824 983 conceptions for women of all ages, with women aged 30–34 having the highest incidence of conception and lowest termination rate of any of the age groups. Conception rates were highest in women outside of marriage and civil partnership for the first time, and this group also had a higher termination rate (Office for National Statistics (ONS), 2023). Over the last decade, the conception rate for women aged 15–44 years has decreased from 80.4 conceptions per 1000 women in 2011 to 71.5 per 1000 in 2021 (ONS, 2023).
There are 15 forms of contraception available in the UK, some of which are non-hormonal. Contraception works by one of the following methods:
- Stopping egg production
- Stopping spermatozoa reaching the egg
- Stopping a fertilised egg from attaching to the wall of the uterus.
The only form of contraception that will protect against both pregnancy and sexually transmitted infection (STI) is the condom, and its use should always be encouraged alongside other methods, particularly when starting new sexual relationships (Clinical Knowledge Summaries (CKS), 2024a).
Assessment for contraception
Assessment for contraception should include the following as a minimum:
- Consent and confidentiality
- Risk assessment for abuse, particularly:
- Age of sexual partner (consider abuse if the sexual partner is a person of trust in those under 18)
- Vulnerable young people, sexual exploitation, female genital mutilation and LGBTQ+ abuse (Brook, 2024)
- Family medical history and personal co-morbidity
- Date of last menstrual period, normal pattern
- Previous pregnancy and contraceptive use/failure
- Menstrual irregularities
- Transgender patients
- Religious beliefs or issues around using specific forms of contraception
- Pregnancy risk (CKS, 2024a)
- STI risk (Flavell et al, 2020; CKS, 2024a):
- Advise STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse (Faculty of Sexual and Reproductive Healthcare (FRSH), 2019a)
- Condom use
- Emergency contraception if needed/how to access
- Why contraception is required and preferred method
- Which contraceptive method may be most appropriate for age/adherence
- Form of contraception that may affect fertility in the short term if pregnancy is being considered in near future
- Lifestyle management advice, such as smoking, alcohol intake, obesity, exercise (CKS, 2024a; FSRH, 2019a; Brook, 2024).
Guidance is available to support discussion and inform clinical decisions about the need or preference for contraception in transgender patients (International Planned Parenthood Federation (IPPF), 2024). Transgender men may still require contraception even if they are taking testosterone (which reduces ovulation risk) and transgender women may require contraception to help prevent conception by their partner (IPPF, 2024).
There are 15 types of contraceptive available in the UK (Table 1) (CKS, 2024a; NHS, 2024a). When determining an appropriate form of contraception, eligibility screening should be undertaken using the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) (FSRH, 2019b) with recognition of additional advice given by the WHO (2015). The UKMEC reviews risks for specific contraceptive forms based on issues such as co-morbidity and family history, and rates risk as low–high (FSRH, 2019b).
| Method | Type | Contains hormones? Yes/No |
|---|---|---|
| Combined hormonal contraception (COC) | Oral pill (combined) Transdermal patch Vaginal ring | Yes |
| Progestogen-only contraception (POP) | Oral pill Implant Injectable | Yes |
| Intrauterine contraception (IUD) | Copper intrauterine device (Cu-IUD) Levonorgestrel intrauterine device (LNG-IUD) | No Yes |
| Barrier methods | Condom (male/female) Diaphragm Cap | No |
| Sterilisation methods | Tubal occlusion (female) Vasectomy (male) | No |
| Natural family planning methods | Lactational amenorrhea method Fertility awareness | No |
Source: CKS, 2024a; NHS, 2024a
Which form and type of contraceptive should I advise?
The decision about which form of contraceptive to advocate should be based on a multifactorial assessment and guided by UKMEC (FSRH, 2019b). While oral contraceptives remain the most popular choice overall, patients are less likely to adhere to taking them consistently, and long-acting reversible contraceptive methods (LARCs) are recommended to be promoted as first-line contraceptive choice in women (FSRH 2019a; 2022; NHS Digital, 2021; CKS, 2024a).
LARCs are defined as requiring administration less than once per cycle. They include IUDs, the combined transdermal patch, the progestogen-only injection and progestogen-only sub-dermal implant (Box 1). LARCs are the most effective form of contraceptive in terms of reducing pregnancy risk (CKS, 2024a). They are now considered for use on nulliparous patients (Royal College of Nursing, 2021). Some forms of LARC, such as IUDs, may be extended to provide contraceptive cover for up to 10 years in specific clinical situations, which can help to maintain concordance. Interestingly, the choice of LARCs as a form of contraception is lowest in younger age groups (NHS Digital, 2021). IUDs and the implant can only be inserted by appropriately trained staff (CKS, 2023a).
Box 1.
Long-acting reversible contraceptive methods
- Intrauterine device (IUD)
- Copper IUD (non-hormonal)
- Levonorgestrel intrauterine device/system (progestogen only) (IUDs are more likely to be expelled by women who have not given birth)
- Progestogen-only injectable
- Depot medroxyprogesterone acetate (DMPA) – most widely used. Ideally administer every 12 weeks
- Depot medroxyprogesterone acetate 104 mg (Sayana Press®)
- Norethisterone enantate 200 mg (Noristerat®) – rarely used
- Progestogen-only implant
- Etonogestrel 68 mg (Nexplanon®) is the only implant licenced in the UK (3-year duration, implanted on the inside of the under-arm area)
- Progestogen-only contraceptive pill (POP). Taken once daily, ideally at the same time, without a pill free break. It is an alternative where a pill formulation is preferred, but COCs are not tolerated or are contraindicated
- Combined hormonal contraceptives (CHC)
- Combined oral contraceptive pill (COC). First-line preferred options are monophasic preparations which contain 30–35 micrograms of oestrogen (plus either norethisterone or levonorgestrel)
- Vaginal ring – can stay in situ for 3 weeks
- Transdermal patch – worn for 7 days and then replaced
Source: FPA, 2019a; 2022; CKS, 2023a; 2023b; 2024b
It has long been recognised that there are still potential barriers to accessing contraception and contraceptive advice, such as locality, travel, fear of side effects, and cultural and/or social restrictions
For women wishing to conceive in future, it is important to discuss that, on stopping the progestogen-only injection, fertility may be delayed for up to a year, which may be an important factor in patient decision-making (FRSH, 2019a).
Hormone containing contraceptives may be the most useful option when treating concurrent common menstrual issues, such as acne, pain, heavy or irregular menstrual bleeding and iron deficiency anemia. It should also be noted that altered bleeding patterns may occur with some hormonal methods and with the copper IUD. Mood changes may be noted with the use of hormonal contraceptive methods, but evidence does not indicate that it is a cause of depression (FSRH, 2019a).
The commencement of contraception should be based on a full assessment of the individual's circumstances; as such, it can be a complicated process depending on a myriad of factors, including where the patient is in their cycle, if they are a new mother, if they are having gynaecological issues, or recently been pregnant or had a recent termination. Due to specific patient circumstances, product administration/insertion or duration of use may differ – please review the summary product characteristics of each product for definitive guidance on use.
Advice on chosen contraceptive method
The following information should be discussed once the method has been chosen:
- How to use
- Potential side effects and managing emergency situations (Table 2) Table 2.Common risks and benefits of contraception
Source: FSRH 2015; 2019a; CKS, 2023b; 2023c; 2024bSide effects Risk Benefit Weight gain The use of depot medroxyprogesterone acetate (DMPA) has been associated with some slight weight gain There is no evidence of weight gain with combined oral contraceptives (COC) and little evidence with progestogen-only pill (POP) use Acne The progestogen-only implant may improve this (or make it worse) The use of COC products can help to reduce acne Co-cyprindiol should not be prescribed for contraception alone. It contains an anti-androgen licensed for use in moderate-to-severe acne vulgaris and is advocated for severe acne where other methods have failed. It should be monitored and discontinued 3 months after the acne has been controlled Irregular bleeding/pain Intrauterine devices (IUD) and the implant may cause irregular bleedingThe copper IUD may cause altered bleeding patterns for up to 3–6 months The levonorgestrel-releasing (LNG)-IUD, COC and progestogen-only injectable may be useful in treating heavy menstrual bleeding Primary dysmenorrhoea may improve with the use of CHCs DMPA may cause amenorrhoea The transdermal patch may cause lighter periods Fertility Fertility delays of up to 1 year have been noted with DMPA use No delays to fertility have been noted with other contraceptive forms Bone mineral density DMPA users may experience a small loss of bone mineral density, which usually returns to normal after stopping use 2-yearly review is recommended during use. No loss of bone mineral density in other contraceptive products noted Cancer risk Small increased risk of breast cancer with CHC use (reduces when the CHC is stopped) and a small increased risk of cervical cancer with prolonged COC use The use of COC not only reduces ovarian cancer risk, but this protection continues after the product is stopped (provides approximately 15 years additional protection) Venous thromboembolis thromboembolism (VTE) occurring with CHCs Co-cyprindiol (Dianette®) also confers a slightly higher risk profile Little or no increase in the risk of VTE with progestogen-only methods - Drug interactions; for example, antibiotics, herbal remedies, liver enzyme-inducing medications
- Contraceptive failure and management
- Reducing the risk of STIs – use of barrier methods alongside other forms of contraception
- Emergency contraception – use, access, failure
- Who to contact for further information/advice (including out of hours)
- Follow-up and repeat prescriptions
- Concerns about use, such as weight gain, cancer risk, return to fertility (FSRH, 2019a; CKS, 2024a).
Contraception is freely available in the UK via the NHS through GP practices, genitourinary medicine (GUM) and sexual health clinics, family planning clinics and pharmacies, as well as online (NHS, 2024a). It can also be obtained through private providers, such as Brook clinics (Crossman, 2022). Further support can be accessed through the NHS sexual health helpline: 0300 123 7123 (NHS, 2024a). All information provided during the consultation should be supplied in the most appropriate format for the person, such as written information or website links. Remember that some patients may not want to be given paper information, which could be found by partners (see Box 2 for useful resources).
Box 2.
Resources
- Brook: www.brook.org.uk
- Family Planning Association: www.fpa.org.uk
- Faculty of Sexual and Reproductive Healthcare: www.fsrh.org
- National Institute for Health and Care Excellence Clinical Knowledge Summaries: https://cks.nice.org.uk
- NHS Sexual Health: www.nhs.uk/live-well/sexual-health
Emergency contraception
There are three methods of emergency contraception (EC) available in the UK and it is important to discuss that EC is not considered as a form of abortion (Table 3) (CKS, 2023d). Evidence shows that younger people require more access to emergency contraception than older groups (FPA, 2022). The emergency contraceptive pill may be provided free of charge in most areas of the UK, and can also be bought from most pharmacies (FSRH, 2019a). It can be inserted/taken from 3–5 days following sexual intercourse.
| Type | When it can be taken |
|---|---|
| Ulipristal acetate 30 mg single dose tablet | Licensed be taken up to 120 hours (5 days) after unprotected sex |
| Levonorgestrel 1.5 mg single dose tablet | Licensed be taken up to 72 hours (3 days) after unprotected sex |
| Copper intrauterine device | Licensed to be inserted up to 5 days after unprotected sexual intercourse, or up to 5 days after earliest ovulation date |
Source: CKS, 2023d
The copper IUD is the most effective method of emergency contraception and should ideally be the first-line option, even for those presenting at less than 5 days post-sexual intercourse, as it may remain in situ to provide continued contraception cover (FSRH, 2019a). Advance prescribing of oral emergency contraception is a debated topic, but evidence does not support the premise that it is more effective in reducing unwanted pregnancy than standard methods of access.
However, it may be a useful consideration in promoting the use and understanding of its role of in preventing pregnancy (American College of Obstetricians and Gynecologists, 2017). Consider ‘quick starting’ of other contraceptives at the consultation, provided there are no contraindications and where the person is not pregnant or at risk of pregnancy (FSRH, 2017).
Barriers to accessing contraception
It has long been recognised that there are still potential barriers to accessing contraception, and contraceptive advice such as locality, travel, fear of side effects, and cultural and/or social restrictions. A situation which was further exacerbated by the recent Covid-19 pandemic due to a reduction in access to services (Lewis et al, 2021; WHO, 2024).
Conclusion
Providing contraceptive provision is complex, and ongoing training and access to up-to-date resources for health professionals is vital in continuing to ensure patient safety. Plans for future conception must be considered, and recognition and more in-depth assessment of at-risk groups is needed to uncover evidence of abuse. Ensuring that patients are well informed, have appropriate choices provided and have the widest access to contraception via a variety of locations, will help to support a continued reduction in unwanted pregnancy.
Key Points
- Despite wider societal acceptance of contraception, there are still practical, psychological, and social barriers
- Consider age, religion, personal preferences, and future pregnancy plans
- Advise contraception with the highest likelihood of concordance and ease of use
- Consider pregnancy and sexually transmitted infection risk
CPD reflective questions
- How many types of contraception are available in the UK?
- Which form of LARC contraception may delay a return to fertility?
- Which groups of people are more vulnerable to sexual abuse?
- Which type of pill needs to be taken every day, COC or POP?