Contraception

Current contraceptive usage in the UK¹²

It is difficult to get full data on contraception use in the UK, as the surveys done (for example by NHS Digital in 2024-25) only cover provision from sexual and reproductive healthcare clinics and not provision in primary care (where about 50% of women get their contraception from). Given that caveat, the most recent data shows the following:

• 51% of women accessing contraception choose a long-acting reversible contraceptive (LARC), compared to 49% using a method with user dependency (eg, the pill or patch).

• The implant is the most popular LARC, used by 20% of women, compared to 14% who use a levonorgestrel intrauterine device (LNG-IUD) and 10% who use a copper intrauterine device (Cu-IUD). Implants are more popular in the younger age group and intrauterine devices in the older age group.

• Younger women are more likely to choose a LARC (55% of those aged <16, compared to 38% of those aged >45).

• There is a steady drop in the provision of emergency contraception (EC), possibly related to the fact that it can be accessed over the counter.

• There is a long-term downward trend in female sterilisation, with the 2024-25 total being 22% lower than 10 years earlier. Conversely, the number of vasectomies grew by 16% between 2023-24 and 2024-25.

Failure rates of contraception

Two types of contraceptive failure:

• User failure: when the contraceptive method was not being used properly.

• Method failure: pregnancy results even though the contraceptive method was used properly.

User failure rates are much higher than method failure rates, especially in first year of use.

Published failure rates are usually based on the 'Trussell table',³ based on failure rates in the USA; the figures below are from the National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (CKS) and take other UK-based guidelines and reviews into account.

Issues to consider when discussing contraceptive choice

• The individual woman's preferences and choice. A woman who comes in asking for 'the pill' may indeed have done her research and decided that the pill is the right thing for her. It is also however possible that she is using the phrase 'the pill' to mean 'any form of contraception' and would benefit from having other options, including LARC, explained to her.

• Education. Make sure that she is aware of all appropriate options and fully informed. Address any misconceptions.

• Comorbidity. Consider conditions which may rule out certain options as choices.

• Medication. Consider concurrent medication which may affect choice - in particular, the use of enzyme-inducing medication significantly narrows options to only the injection and intrauterine device.

• Age and parity.

• Smoking history and weight.

• Family plans. The need for short-term or long-term contraception will affect choice.

• Protection from sexually transmitted infection. Encourage use of condoms in addition to the contraceptive method chosen, where appropriate.

• Exclude pregnancy.

• Ethical issues: consider consent and safeguarding when prescribing for girls aged under 16 or women with learning difficulties.

Contraception and special groups

Several groups of women have special requirements. Extra attention, for example, may be needed when considering:

• Women aged over 40.

• Women who are breastfeeding.

• Smokers.

• Younger women.

• Women who have diabetes.

• Women with obesity.

See also the separate Contraception and special groups, Emergency contraceptives and Ethnocultural issues in contraception articles. The small increased risks of meningioma and breast cancer are now discussed; other risks are given in the sections on specific methods.

Contraception and meningioma⁴

• In 2024 and 2025, papers were published linking various progestogen containing contraceptives with a risk of intracranial meningioma requiring surgery.

• Meningioma is a rare and benign tumour, with an incidence or 19 per 100,000 over the age of 40 and 0.16 per 100,000 under the age of 20. The main risk factors are age and being female.

• The odds ratios and numbers needed to harm are given in the table below where available. The absolute risk is low, due to the low background incidence of meningioma.

• The CoSHR advises that specialist advice should be sought before starting or continuing any hormonal contraception in individuals with a current or past history of meningioma.

• For those without such a history, they should be counselled about the increased risk before starting any method containing cyproterone acetate, nomegestrol acetate, desogestrel or medroxyprogesterone acetate.

• There is no data for etonogestrel (used in the contraceptive implant) but it is the active metabolite of desogestrel, so it would be sensible to seek advice for patients with a current or past history of meningioma who have an implant in situ.

Contraception and breast cancer

• There is a small increased risk of breast cancer in women who use hormonal contraception - previously this has been thought to only affect CHC, but a 2023 study found that the magnitude is similar in women using progestogen only contraception.

• The absolute risks are low and estimated at an extra 8 cases per 100,000 women aged 16 -20 and 265 cases per 100,000 women aged 35 - 39.

• This should be considered against the significant reduction in ovarian cancer for women using CHC (50% after 10 years of use) and women should be counselled accordingly.

Brief summaries of reversible contraceptive methods are shown below. Sterilisation for men and women, although technically reversible, should be viewed as permanent. Reversal is not always successful and not usually available on the NHS. They are covered in the separate Sterilisation (vasectomy and female sterilisation) article.

Combined hormonal contraception (CHC)^{5 6}

For more comprehensive information, see the separate articles Combined oral contraceptive pill (first prescription), and Combined oral contraceptive pill (follow-up and common problems).

The combined pill (COC) is a highly effective form of contraception and is the most commonly used method of contraception in the UK.⁷

The COC contains a combination of synthetic oestrogen and a progestogen. They have been classified into first-, second- and third-generation preparations reflecting their hormonal content and period of development. All current brands contain 20-35 micrograms of oestrogen. The hormonal combination is also available as a transdermal patch, Evra®, and a contraceptive vaginal ring, NuvaRing®. Both have approximately similar efficacy to the COC. Collectively, these methods are known as CHC.

Combined hormonal contraception (CHC) action

The COC pill prevents conception by acting on:

• The hypothalamic-pituitary-ovarian axis, to suppress synthesis and secretion of follicle-stimulating hormone and the mid-cycle surge of luteinising hormone, thus inhibiting the development of ovarian follicles and ovulation. (Primary method of action).

• Cervical mucus to prevent penetration of sperm. (Thickens cervical mucus).

• The endometrium to inhibit blastocyst implantation. (Reduces endometrial receptivity).

Combined hormonal contraception (CHC) benefits

• Highly effective, easy to reverse and convenient to use.

• Useful to treat abnormal uterine bleeding, pre-menstrual syndrome, and endometriosis.

• Reduces incidence of benign breast disease, ovarian cysts, ovarian cancer (50% reduction if the combined pill is used for 10 years), and endometrial cancer.

Combined hormonal contraception (CHC) adverse effects

• Side-effects - eg, breakthrough bleeding, breast tenderness, mood swings.

• Increased risk of venous thromboembolism (VTE) - this varies with the type of progestogen, as per the table below.⁶

• Increased risk of myocardial infarction and stroke; the absolute risks of both of these is small, given the very low background risk in young women. For women with risk factors the baseline risk and absolute increased risk will be greater. Stroke risk is increased significantly by the presence of migraine with aura, which is an absolute contraindication to the use of CHC.

• Possible small increased risk of cervical cancer; however, this may be related to other factors - eg, the number of sexual partners, non-barrier use during intercourse, human papillomavirus (HPV) exposure.

• CHC containing certain progestogens is linked to a small increased incidence of meningioma requiring surgery - see the section on this below.

Progestogen-only contraceptive pill (POP)⁸

For more comprehensive information, see the separate article Progestogen-only contraceptive pill.

The contraceptive progestogen-only pill (POP) is particularly used when combined hormonal contraception is contra-indicated, for example for women who have a history of VTE, or have migraine with aura, although for some women it may be a first choice.

There are three types of POP. The 'traditional' pills are rarely used now and will not be discussed further. They generally contain norethisterone or levonorgestrel, do not reliably inhibit ovulation and have to be taken within 3 hours of the same time each day. The most commonly used POP contains desogestrel, but a relatively recent addition to the market contains drospirenone - the rest of this leaflet will discuss just these two options.

Progestogen-only contraceptive pill action

• Ovulation is inhibited in the majority of cycles for desogestrel and drospirenone.

• Transport of the ovum is delayed.

• The cervical mucus becomes more viscous and impenetrable to sperm.

• The endometrium becomes unsuitable for implantation.

Progestogen-only contraceptive pill benefits

• It is reliable if taken correctly, is easily reversible and convenient to use.

• Avoids the cardiovascular risks of oestrogen.

• It can often be used by many women with contra-indications to the COC pill. Few medical conditions restrict use of the POP.

• It can be used during breastfeeding at any point, whereas CHC has restrictions on use in breastfeeding in the first six weeks post-partum.

• It can be used up to the age of 55.

Progestogen-only contraceptive pill side-effects

• Menstrual problems such as amenorrhoea and breakthrough bleeding. These are less common in drospirenone pills than in desogestrel pills.

• A desogestrel pill is considered missed if it has not been taken within 12 hours of the time when it would usually be taken; this is less than the missed pill window for combined and drospirenone pills, which is 24 hours.

• There is increased risk of functional ovarian cysts.

• It has previously been considered that if pregnancy occurs on the POP, it has a slightly higher risk of being ectopic. The overall risk of ectopics is much lower than background, as the overall number of pregnancies is lower. The majority of data underpinning this comes from the traditional pills which do not reliably inhibit ovulation and so it may be less of an issue with desogestrel and drospirenone pills.

Levonelle® is also used as a progestogen-only emergency contraception.

Progestogen-only injectable contraceptives⁹

For more comprehensive information, see the separate article Progestogen-only injectable contraceptives.

A progestogen-only injection is a long-acting, reversible contraceptive. A synthetic progesterone, or progestogen, is slowly released into the systemic circulation following intramuscular or subcutaneous injection.

There are three forms of depot injection currently available on the UK market:

• Depo-Provera® is depot medroxyprogesterone acetate (DMPA) aqueous suspension 150 mg in 1 ml for deep intramuscular injection.

• Sayana Press® is DMPA 104 mg MPA in 0.65 ml for subcutaneous injection.

• Noristerat® is norethisterone enantate (oenanthate) 200 mg in 1 ml in an oily liquid. This is only licensed for short-term use - eg, for women whose partners have undergone vasectomy, until the vasectomy is effective. It is rarely used in the UK.

Progestogen-only injectable contraceptive action

• Its main mechanism of action is to suppress ovulation.

• It also makes the endometrium unsuitable for implantation if fertilisation occurs.

• It also increases the viscosity of cervical mucus, making the mucus less easily penetrable to sperm.

Progestogen-only injectable contraceptive benefits

• Very effective and convenient. Provided that the injections are given on a regular basis (every 13 weeks for Depo-Provera® and Sayana Press®, every 8 weeks for Noristerat®), there is a very low failure rate.

• Can be used during breastfeeding.

• Amenorrhoea is common, which may be an advantage for women with menorrhagia or dysmenorrhoea.

• Self-administration can be used for Sayana Press®; women can be taught to inject by a practice nurse when they have the first injection, or via a video on the manufacturer's website.

Progestogen-only injectable contraceptive side-effects

• It is not quickly reversible.

• There is an associated small loss of bone mineral density and possibly a subsequent increased fracture risk, which recovers after stopping. The Medicines and Healthcare products Regulatory Agency (MHRA) and the Faculty for Sexual and Reproductive Healthcare (FSRH) advice is therefore:

  • Contraceptive injections should not be used for women aged under 18 unless no other option is suitable.

  • Risks and benefits should be reviewed every two years.

  • Consider other contraceptive options in women with other risk factors for osteoporosis.

• Menstrual irregularities common in women using this method, with irregular bleeding being a common reason for stopping. Amenorrhoea commonly develops with time, however, and women should be counselled before use about the possibility of early bleeding and encouraged to persevere. It is sensible not to start the depot injection in women for whom irregular bleeding in the first three months would be particularly problematic.

• Weight gain year may occur. A higher initial BMI (≥30 kg/m²) makes this more likely, particularly in women aged less than 18.

• Delayed return of fertility of up to one year after stopping.

Progestogen-only subdermal implant¹⁰

For more comprehensive information, see the separate article Progestogen-only subdermal implants.

The progestogen-only subdermal implant (SDI) is a long-acting reversible contraceptive. Etonogestrel (a progestogen) contained in a rod is released slowly into the systemic circulation following subdermal insertion in the upper arm.

Nexplanon® is now the only contraceptive implant on the UK market. It is a 4 cm flexible rod containing 68 mg etonogestrel. Nexplanon® must be removed after five years when it can then be replaced.

Progestogen-only subdermal implant action

The main mechanism of action of Nexplanon® is to inhibit ovulation. It also thickens the cervical mucus, inhibiting the passage of sperm to the uterus, as well as thinning the endometrium, preventing implantation were an egg to be fertilised.

Progestogen-only subdermal implant benefits

• Highly effective with very few pregnancies reported. The main reason for 'failure' is incorrect timing of insertion, conception prior to insertion and failure of insertion.

• Long duration of action.

• Reversible. There is no evidence of delay in return to fertility on removal of Nexplanon®.

• It is very convenient, only needing replacement every five years.

• Reduction in menstrual problems such as dysmenorrhoea.

Progestogen-only subdermal implant side-effects

• Irregular bleeding; common in the first year but declines thereafter.

• Changes in weight, mood and libido have been reported; however, no causal association has been found..

Intrauterine contraceptive device (IUD)¹¹

For more comprehensive information, see the separate articles Intrauterine contraceptive device and Levonorgestrel intrauterine device.

The IUD is a safe and effective method of contraception with a very low failure rate. There are two types of IUD - the copper IUD (Cu-IUD) and the levonorgestrel IUD (LNG-IUD). The latter was previously known as the intrauterine system (IUS) and some educational materials may still use this terminology.

IUDs have a monofilament thread to permit checking of presence and to allow removal. Women should be counselled to check for their threads at least monthly and to attend for a check (and use alternative contraception) if they cannot feel them. If the healthcare professional cannot see or feel the threads then a pelvic ultrasound should be done - if the device is present, the woman can be reassured, but she may need a hysteroscopy to remove the device. If the ultrasound does not show the device, an abdominal x-ray should be done to check that it has not perforated the uterus. If no device is present in the abdominal cavity then it has fallen out and alternative long-term contraception should be arranged.

IUD contraceptive action

Cu-IUD:

• Fertilisation is prevented by the effect of copper on ova and sperm.

• Reduced penetration by sperm due to the effect of copper on cervical mucus.

• Endometrial inflammatory reaction giving an anti-implantation effect.

LNG-IUD:

• This is mainly by reducing endometrial growth and preventing implantation. There is endometrial atrophy within one month of insertion.

• Progestogenic effects on cervical mucus reduce penetration by sperm.

• Ovulation is usually not inhibited.

Intrauterine contraceptive benefits

All IUDs:

• Highly effective, reversible and convenient.

• No demonstrable effect on bone density.

• No significant interaction with other drugs - can be used in women taking enzyme-inducers.

Cu-IUD only:

• Effective directly following fitting.

• Can be used for emergency contraception.

• No hormones involved, reducing potential for risks and adverse effects.

• Effective for up to 10 years.

LNG-IUD only:

• It reduces blood loss and dysmenorrhoea.

• It may reduce the risk of PID compared with normal IUDs, because of thickening of cervical mucus.

• 52 mg devices can be used for 8 years for contraception; see below for individual brand lengths of use.

• 52 mg devices an also act as the progestogen component of hormone replacement therapy, making it a useful method for women aged over 40 - for this indication it must be changed at 5 years.

Intrauterine contraceptive side-effects

All IUDs:

• Insertion may be uncomfortable, but local anaesthetic can be used.

• Displacement or expulsion: 1 in 20 women, most commonly in the first three months after insertion.

• Increased risk of PID - around 1% in the first three weeks after insertion.

• Uterine perforation: approximately 1-2/1,000 insertions (higher in breastfeeding women).

• Ectopic pregnancy: absolute risk very low; however, in pregnancies which occur with an ID in place, up to half of them may be ectopic.

Mainly affect Cu-IUD:

• Increased blood loss and longer and more painful periods are common.

Mainly affect LNG-IUD:

• Spotting and bleeding between periods is common in the first six months.

Considerations when choosing a brand of IUD

There are a large number of brands of Cu-IUD - a full list can be found in the CoSRH guidance.¹¹ A brand with at least 300 mm² of copper should be used to allow a 10 year lifespan - if fitted after the age of 40, such an IUD can stay until the menopause. IUDs with less copper can be slightly smaller and therefore easier to fit (particularly in a nulliparous woman) but will have a shorter lifespan.

There are five brands of LNG-IUD available in the UK, shown in the table below with their licenses and with CoSRH guidance on their use.

Diaphragms and caps¹²

For more comprehensive information, see the separate Female barrier methods of contraception article.

Popularity of diaphragms and caps as forms of contraception has declined with the availability of more effective methods and with awareness of the need to protect against sexually transmitted infections.

Diaphragms are thin, dome-shaped devices made of latex or silicone. They come in a range in sizes and types of spring. Diaphragms should lie diagonally between the posterior fornix and behind the pubic bone. Caps are smaller than diaphragms, fitting closely over the cervix. Both should be used with spermicides.

Mode of action

Diaphragms and caps form a physical barrier, preventing entrance of sperm to the cervix.

Benefits

• Compared with the timing of use required by condoms, insertion of diaphragms or caps before intercourse can allow more spontaneity.

• No serious side-effects and no hormonal effects.

Problems with diaphragms and caps

• Women need to be well motivated and careful in its use.

• Not as effective as some of the methods above.

• Spermicides can cause a local reaction.

• Little evidence of protection from sexually transmitted infections, unlike other barrier methods.

• Urinary tract infection incidence may be increased with diaphragms.

• It can be difficult to find a practitioner who is trained to fit one, even within sexual and reproductive health services.

Female condoms¹²

The female condom (Femidom®) has been available in Great Britain since 1992. It is made of soft pliable polyurethane, pre-lubricated and with two flexible rings.

Female condom action

This is a barrier method.

Female condom benefits

• There are no known side-effects.

• Helps to prevent sexually transmitted infection and possibly reduces risk of cervical carcinoma.

• Can be inserted prior to intercourse.

• No fitting required.

Female condom problems

• Needs careful insertion.

• Can be pushed into the vagina or bypassed.

• May be uncomfortable or noisy, or interfere with sensation.

• Not as effective as some of the other methods of contraception above.

Male condoms¹²

The only contra-indication to the use of latex condoms is for people with sensitivity or allergy to latex proteins, as risks generally outweigh benefits. Men and women with sensitivity to latex may use male or female polyurethane condoms or deproteinised latex male condoms.

Male condom action

This is a barrier method.

Male condom benefits

• Ready availability.

• Protects against sexually transmitted infection and may protect women against cervical cancer.

Male condom problems

• They are relatively expensive if purchased, but are usually available for free at sexual and reproductive health clinics.

• There is the need for prior planning.

• Lacks spontaneity.

• Requires co-operation of both partners.

• May reduce sensitivity.

• Can break or slip off, although research shows failures due to breakage or slippage decrease with increasing experience of use.

• Relatively low efficacy.

Natural family planning¹³

Several methods are available, including calendar, temperature, observation of cervical mucus, and palpating the cervix. Mobile phone apps and dipsticks to measure hormone levels in urine can be used. Failure rate however remains high.

The lactational amenorrhoea method (LAM) is also an effective natural family planning option for breastfeeding mothers. For LAM to be effective, a woman must be fully breastfeeding, have amenorrhoea and a baby who is less than 6 months old. The failure rate for LAM is around 2%, higher than many other methods, so it is perfectly reasonable for a woman who fits the LAM criteria to also use another method.

Benefits

• There are no side-effects.

Problems

• Considerable commitment from both partners is required.

• Unreliable with unpredictable cycles.

• Less effective than some other methods described above.