QUICK REFERENCE GUIDE

TITLE
Contraception Management in General Practice
AUTHOR Dr Katie McElroy, MB BCh BAO DCH DRCOG MICGP

PUBLISHED March 2024

OVERVIEW AIMS OF THE DOUCUMENT

JUMP TO…
Access to safe, voluntary contraception is a human The aim of this Quick Reference Guide is to
summarise and simplify the key practice points of
Combined Hormonal Contraception
right and is central to gender equality and reducing
poverty.1 According to Census data, there are one each method of contraceptive for GPs. The evidence Progesterone-Only Pill
million women in Ireland aged 15–45.2 The current and recommendations in this Guide are based on
Contraceptive Injection
funded contraception scheme has begun to address several guidelines produced by the Faculty of Sexual
and Reproductive Healthcare. Contraceptive Implant
their sexual and reproductive healthcare needs and
reduce associated cost barriers in accessing care. Intrauterine Contraception
Choosing the correct contraception requires an SUMMARY Patient-Specific Considerations
individualised, person-centred approach to minimise • Each method of contraception has specific
risk and ensure tolerability. eligibility criteria, benefits, side effects and risks

Aside from their role in family planning, many • Patient-specific considerations are important in
contraceptives are vital in the management determining the most suitable contraception
of important and common gynaecological • Managing problems that arise on contraception
presentations in general practice. is key to patient satisfaction

Contents Proceed to full topic Evidence Updates >

Contraception Management in General Practice – EVIDENCE UPDATES
CITING QUICK REFERENCE GUIDE ICGP QUALITY & SAFETY IN PRACTICE COMMITTEE HCG Human Chorionic Gonadotrophin
Irish College of General Practitioners. [Contraception Dr Stella Burska Dr Ciara McCarthy HFI Hormone-Free Interval
Management in General Practice] ICGP Quick Reference Guide Dr Laoise Byrne Dr Helen McVeigh
HMB Heavy Menstrual Bleeding
(ICGP QRG) Dublin: ICGP; 2024 [cited mm/yyyy]. Available Dr Patricia Carmody Dr Emer O’Brien
from www.icgp.ie HPV Human Papilloma Virus
Dr Patrick Kelly Dr Aimee O’Farrell
HSPT High-Sensitivity Pregnancy Test
Users wishing to use, reproduce or republish ICGP material Dr Una Kennedy Dr Aoife O'Sullivan
IHD Ischaemic Heart Disease
for commercial purposes must seek prior approval for Dr Denise Lundon Dr Diarmuid Quinlan
IM Intramuscular
reproduction in any medium. Applicants for such permission
IMP Implant
should email [email protected]. CORRESPONDENCE
Please direct any queries by email to [email protected] IUC Intrauterine Contraceptive
DISCLAIMER AND WAIVER OF LIABILITY IUD Intrauterine Device
Whilst every effort has been made by the Quality and ACKNOWLEDGEMENTS IUS Intrauterine System
Safety in Practice Committee to ensure the accuracy of the We would like to thank the ICGP library for their assistance. LARC Long-Acting Reversible Contraception
information and material contained in this document, errors Special thanks to Dr Ciara McCarthy, ICGP/HSE Clinical Lead in LMP Last Menstrual Period
or omissions may occur in the content. This guide represents Women’s Health and Dr Noirin O’Herlihy.
LNG Levonorgestrel
the view of the ICGP, which was arrived at after careful
CONFLICTS OF INTEREST MOA Mechanism of Action
consideration of the evidence available at time of publication.
This quality of care may be dependent on the appropriate None declared at time of publication. MEC Medical Eligibility Criteria
allocation of resources to practices involved in its delivery. NSAID Non-Steroidal Anti-Inflammatory Drug
Resource allocation by the State is variable depending on
LIST OF ABBREVIATIONS OTC Over-The-Counter
geographical location and individual practice circumstances. ATE Arterial Thrombotic Event PCB Postcoital Bleeding
There are constraints in following the guide where the BMD Bone Mineral Density PCOS Polycystic Ovarian Syndrome
resources are not available to action certain aspects of the BMI Body Mass Index PID Pelvic Inflammatory Disease
guide. Therefore, individual healthcare professionals will BP Blood Pressure PMS Premenstrual Syndrome
have to decide what is achievable within their resources,
BTB Breakthrough Bleeding POP Progesterone-Only Pill
particularly for vulnerable patient groups. The guide does
CHC Combined Hormonal Contraception SI Sexual Intercourse
not, however, override the individual responsibility of
healthcare professionals to make decisions appropriate to CIN Cervical Intraepithelial Neoplasia SLE Systemic Lupus Erythematosus
the circumstances of individual patients in consultation with COCP Combined Oral Contraceptive Pill SPC Summary of Product Characteristics
the patient and/or guardian or carer. The Quick Reference Cu Copper STI Sexually Transmitted Infection
Guides are not policy documents. Feedback from local faculty CVD Cardiovascular Disease TB Tuberculosis
and individual members on ease of implementation of these DM Diabetes Mellitus TIA Transient Ischaemic Attack
guides is welcomed. DMPA Depot Medroxy Progesterone Actetate UPA Ulipristal Acetate
EC Emergency Contraception UPSI Unprotected Sexual Intercourse
EVIDENCE SUMMARY
EE Ethinyl Estradiol VTE Venous Thromboembolism
This is a review of the literature of the relevant topic area. This
is a summary of several guidelines produced by the Faculty of FSH Follicle Stimulating Hormone
Sexual and Reproductive Healthcare. In addition systematic FSRH Faculty of Sexual and Reproductive Healthcare
Published: March 2024 Next review date: TBC
review evidence is presented where possible. HCP Healthcare Professional

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ICGP QUICK REFERENCE GUIDE – Contraception Management in General Practice | iii

TABLE OF CONTENTS

TABLE OF CONTENTS

Overview i Factors Affecting Metabolism 8 Intrauterine Contraception 16

Prescribing 8 Hormonal Intrauterine System (IUS) 16
The Contraception Consultation 1 Managing Problems on POP 8 Copper IUD 16
Method-Specific Considerations 1 The Contraceptive Injection 9 UK Medical Eligibility Criteria 16
Contraception Injection Summary 9 Health Risks 17
UK Medical Eligibility Criteria (UKMEC) 1
UK Medical Eligibility Criteria 9 Non-Contraceptive Benefits 17
Combined Hormonal Health Risks 9 Drug Interactions and Other Factors
Contraception (CHC) 2 Affecting Absorption 17
Non-Contraceptive Benefits 10
Contraceptive Failure 17
CHC Counselling 2 Drug Interactions and Other Factors
Affecting Metabolism 10 Initiation 18
UK Medical Eligibility Criteria 2
Initiation 10 Pre-Insertion Checklist 18
Health Risks of CHC 3
Late Injection Rules 11 Complications of IUC 19
Non-Contraceptive Benefits 4
Managing Problems on DMPA 11 Managing Problems on IUC 19
Drug Interactions 4
Prescribing 11 Prescribing 20
Other Factors Affecting Absorption 4
Initiation 4 Progesterone-Only Implant 12 Patient-Specific Considerations 21
Missed-Pill Rules 5 Progesterone-Only Implant Summary 12 Contraception in Women >40 Years Old 21
Tailored Pill-Taking 5 UK Medical Eligibility Criteria 12 Overweight and Obesity 22
Prescribing 6 Health Risks 12 Drug Interactions 23
Managing Problems on CHC 6 Non-Contraceptive Benefits 12 Postpartum/Breastfeeding 25
Drug Interactions and Other Factors Contraception in Cancer Survivors 25
Progesterone-Only Contraception 7 Affecting Metabolism 13
Progesterone-Only Pill (POP) 7 Training Resources 26
Contraceptive Failure 13
UK Medical Eligibility Criteria 7 Initiation 13 Emergency Contraception 26
Health Risks 7 Pre-Insertion Checklist 14
Non-Contraceptive Benefits 7 Appendix 1: Example Tailored Pill-
Side Effects – Irregular Bleeding 14
Taking Patient Information Leaflet 27
Initiation 7 Other Side Effects 15
Missed-Pill Rules 7 Prescribing 15 References 28

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ICGP QUICK REFERENCE GUIDE – Contraception Management in General Practice | 1

The Contraception Consultation Method-Specific Considerations

The contraception consultation should include the following, in order to
adequately select the appropriate method for a patient (Tables 1 and 2): Table 2 – Method-specific considerations

• Obstetric history: mode of delivery,

Table 1 – Assessment for contraception previous ectopic pregnancy
INTRAUTERINE CONTRACEPTION: • Pelvic inflammatory disease (PID)
Current contraception, history of prior use and side effects • Fibroids
Last menstrual period (LMP) • Cervical Screening

Last sexual intercourse (SI) CONTRACEPTIVE IMPLANT: • Dominant arm

CONTRACEPTIVE INJECTION: • Osteoporosis risk factors

Menstrual history: menorrhagia, dysmenorrhoea

Medical history: NB migraine, liver disease, malabsorption

Medications
UK Medical Eligibility Criteria (UKMEC)6
The UKMEC offer evidence-based guidance on the safety of different
Cardiovascular risks: NB smoking contraceptive options depending on certain patient characteristics
and the presence of medical conditions. The UKMEC Guidelines can be
Venous thromboemolism (VTE) risk: personal history or family
history in a 1st degree relative <45 years accessed here.

Blood pressure (BP) • UKMEC 1 = no restriction for use.

• UKMEC 2 = benefits generally outweigh risks.
Body mass index (BMI)
• UKMEC 3 = risks usually outweigh benefits, not recommended unless
Undiagnosed vaginal bleeding other methods not available/acceptable.
• UKMEC 4 = unacceptable health risk if the method is used.
Undiagnosed breast symptoms or current/past breast cancer
• There is no agreed method for assessing multiple UKMEC categories,
Sexually transmitted infection (STI) risk assessment and clinical judgement should be used.

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Combined Hormonal Contraception (CHC) Table 3 – UKMEC for CHC

The contraceptive pill remains one of the most popular methods of CONDITION UK MEC 4 UK MEC 3
contraception in Ireland. A 2020 study of >1,000 sexually active Irish women
aged 17–45 has shown that 27% currently use “the pill” and 73% had used it at Breast disease Current breast cancer Past breast cancer OR
carrier of known gene
one time3. Yet with a known failure rate of 9% per year for typical use (perfect
mutations associated
use <1%) it is also the least effective prescription form of contraception. with breast cancer OR
undiagnosed breast
Key practice point: Women requesting CHC should be informed of mass/symptoms
the effectiveness of CHC (typical and perfect use) and the superior
Liver disease Decompensated cirrhosis Acute hepatitis
effectiveness of long-acting reversible contraception (LARC). OR Hepatocellular tumour OR previous CHC-
(adenoma/carcinoma) related cholestasis OR
CHC Counselling4, 5 symptomatic, current
gallbladder disease
• CHC = Combined oral contraceptive pill (COCP), patch, ring.
• Contains Estrogen and Progestogen (Table 4 – Generation of Migraine With aura, at any age History (>5 years ago)
Progestogens in CHC). of migraine with aura,
at any age OR migraine
• Mechanism of action (MOA): Inhibition of follicular development/
without aura, present at
ovulation after 7 days use. continuation of CHC
• Contraceptive effectiveness is similar across methods, although limited
evidence suggests a possible reduction in patch effectiveness in Smoking Aged >35 and smoking Aged >35 and smoking
women ≥90 kg. >15/day <15/day OR aged >35
and stopped smoking <1
UK Medical Eligibility Criteria6 year
Medical eligibility (see Table 3 – UKMEC for CHC)
Hypertension Systolic BP>160, Diastolic Systolic BP 140–159,
~ CHC can be used for medically eligible women from menstruation >100 OR vascular disease Diastolic 90–99 OR
until age 50 confirmed hypertension,
~ Assessment includes: personal and family history, drug history, even if adequately
lifestyle factors, BMI and BP recording controlled

~ Pelvic examinations are not required

~ Breast examinations and blood tests are not required routinely

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CONDITION UK MEC 4 UK MEC 3 Table 4 – Generation of Progestogens in CHC

Cardiovascular Historical/current Multiple risk factors for Progestogens can be grouped 1st : Norethisterone
disease (CVD) ischaemic heart disease CVD (smoking, increasing together by ‘generation’ according
2nd: Levonorgestrel (LNG)
(IHD) OR stroke OR age, DM, dyslipidaemia, to when they were first marketed
atrial fibrillation OR obesity) as constituents of CHC: 3rd: Desogestrel, gestodene, norgestimate
complicated valvular/
Newer/other: Drospirenone, dienogest,
congenital heart disease
nomegestrol acetate
OR cardiomyopathy with
impaired cardiac function
Health Risks of CHC
Venous History of VTE OR current Family history of VTE in VTE
thromboembolism VTE on anticoagulants a first-degree relative • 3–3.5-fold increase in the rates of VTE compared to a non-user but
(VTE) OR known thrombogenic <age 45 OR prolonged as background rates of VTE are so low, the absolute risk of VTE for an
mutation OR major immobility unrelated to
individual user remains very low (2/10,000 in non-users increases to
surgery with prolonged surgery eg wheelchair
5–12/10,000 in users). Risk is highest immediately after initiation or when
immobilisation use, debilitating illness
restarting after a break of 1 month and reduces over the course of the first
Obesity N/A BMI >35 year. Therefore, frequent starting/stopping of CHC is discouraged. Note,
3rd/4th generation COCP has a 2-fold higher risk than 2nd generation.
Postpartum 0–6 weeks in those In those not breast-
Arterial thromboembolism (ATE)
breast-feeding OR 0–3 feeding: 0–3 weeks,
• Linked to estrogen dose within CHC, lower doses (e.g., 20mcg) safer if
weeks in those not without other risks factors
breastfeeding with other for VTE OR 3–6 weeks with there are additional risks for ATE in someone who meets UKMEC criteria
risk factors for VTE other risk factors for VTE for safe use.
Breast cancer
Diabetes N/A With established
• Small increased risk with current use of CHC (relative risk 1.19) which
nephropathy, neuropathy,
retinopathy or vascular
reduces with time after stopping, with no significant increased risk 10
disease years after stopping.
Cervical cancer
Positive With OR without a N/A
• Use of CHC for more than 5 years is associated with a small increased
antiphospholipid diagnosis of Systemic
risk of cervical cancer (double background rate); risk reduces over time
antibodies Lupus Erythematosus
(SLE) after stopping CHC and is no longer increased by about 10 years after
stopping.

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Non-Contraceptive Benefits Ulipristal acetate

• Control of menstrual pain /heavy menstrual bleeding. Selective progesterone receptor modulator = need to wait 5 days before
• Control of acne. restarting CHC, or UPA may not be effective
• May be beneficial for premenstrual syndrome (PMS).
Other Factors Affecting Absorption
• Control of endometriosis.
• Women who have had bariatric surgery should be informed that the
• Treatment of menstrual irregularities/hyperandrogenism in polycystic effectiveness of COCP may be reduced.
ovarian syndrome (PCOS).
• Follow the advice for missed pills if vomiting occurs within 3 hours of
• 50% reduced risk of endometrial cancer after 10 years’ use – persists taking the pill or if severe diarrhoea occurs for >24 hours.
after stopping.
• Note: NO additional contraceptive precautions are required when
• 50% reduced risk of ovarian cancer after 10 years’ use – persists after antibiotics that are not enzyme-inducers are used with CHC.
stopping.
• Reduced risk of bowel cancer: ever-users have a 19% reduced risk in Initiation7
comparison to never-users. Figure 1 below outlines initiation of the CHC

Drug Interactions DURING • Day 0–5 of a normal menstrual cycle, without

Enzyme-inducing drugs MENSTRUATION additional precautions OR
Reduced contraceptive effectiveness during use and for 28 days after:
• At any time in the cycle, if reasonably certain the
• Anti-epileptics: carbamazepine, topiramate, phenytoin, phenobarbital. QUICK-START woman is not pregnant, with additional contraceptive
• Antibiotics: rifampicin, rifabutin. measures for 7 days

• Anti-retrovirals: efavirenz, nevirapine, ritonavir (always check here for HIV • No UPSI since LMP
drug interactions). • Using another method of contraception correctly and
consistently
• St John’s wort, modafinil. HOW TO BE
“REASONABLY • <5 days post abortion, miscarriage or ectopic
Lamotrigine CERTAIN” pregnancy
Possible reduced effect resulting in reduced seizure control and • Fully breastfeeding and amenorrhoeic and <6 months
post-partum
lamotrigine toxicity during any hormonal free interval
• No UPSI in last 21 days and a negative HSPT

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Tailored Pill-Taking
If pregnancy cannot reasonably be excluded:
• Women should be given information about both standard and tailored
• Do a high sensitivity pregnancy test (HSPT). regimes, to broaden contraceptive choice (See Figure 3 – Options in
• If negative, can quick start with additional contraception for Tailored Pill-Taking).
seven days as usual. • Tailored regimes are “off-license”, but supported by the FSRH.
• Evidence suggests no adverse impact of fetal exposure to • There is no health benefit from monthly withdrawal bleeds.
contraceptive hormones.
• Withdrawal bleeds may be painful, heavy, or simply unwanted, and may
• Follow up with another HSPT at 21 days post UPSI. be associated with other hormonal symptoms.
• Ovarian suppression is reduced and follicular development occurs during
Missed-Pill Rules 8 the HFI, particularly with COC containing lower estrogen doses, thus
In all situations, take the missed pill as soon as possible and continue “missed pill” events around the HFI could lead to pregnancy.
remaining pills at the usual time (See Figure 2 for more details).
Figure 3 – Options in Tailored Pill-Taking
For guidance on incorrect use of the patch or ring, see FSRH guide here.
Continuous • No HFI

Figure 2 – Missed-pill rules • Previously referred to as bicycling/tricycling

Extended
Note: The following applies when pills are being taken in a 21/7 or 21/4 regimen use • Timing of the HFI can be fixed (after 6, or 9 weeks) or flexible
(triggered by 3–4 days of Breakthrough Bleeding (BTB)

“Extended Hormone- • Sometimes referred to as 21/4

• Consider EC if UPSI during the HFI Shortened
Free Interval (HFI)” HFI • Shortened HFI can be incorporated into extended use
• Barrier method until 7 pills taken
>9 completed days regime also
since last pill • Consider pregnancy test

• Week 1: provided the first pill after the HFI was • To date, data too limited to recommend the use of one type of regimen
1 missed pill taken correctly, no additional precautions over another.
• Week 2 or 3: No additional precautions • Data has not demonstrated clear reduction in risk of pregnancy
although this is hypothesised.
• Week 1: consider EC if UPSI during HFI or week 1.
2 or more Additional precautions for 7 days • Multiphasic COCP cannot be tailored (e.g. Logynon or Qlaira).
missed pills • Week 2 or 3: No EC. Additional precautions for 7 • Bleeding patterns equivalent or improved in comparison to standard
days. If in the 7 days prior to a HFI, omit same regime, although more BTB in first few months.

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Prescribing • Consider extended/continuous CHC use.

• COCP containing estrogen ≤30 mcg with LNG/Norethisterone is a • Consider switching to the vaginal ring.
reasonable first line choice to minimise cardiovascular risks.
• Women should be aware of key indications for medical review. Mood
• No consistent evidence that CHC causes depression.
• 12 months prescription can be issued at initiation or continuation visits,
annual review advised. • If a woman experiences mood change on CHC but wants to continue
use, trial a formulation with a different progestogen empirically.
• Specific recommendations for:
• If mood change is related to the menstrual cycle or HFI, consider
~ Travel: avoid immobility.
continuous use.
~ Altitude: consider a safer method if trekking to >4500m for 1 week.
~ Surgery: switch to an alternative contraceptive method at least 4 Weight gain
weeks prior to major surgery or planned immobility. • No clear evidence that CHC causes weight gain.

Managing Problems on CHC Libido

Headache • No clear evidence that CHC causes reduced libido in pills containing
• Assess for features of migraine. Note, new migraine without aura, ≥20mcg estrogen.
which develops subsequent to commencement of CHC, is UKMEC3 at
the continuation visit. This is in contrast to the presence of migraine
without aura prior to commencement of CHC, which is UKMEC2.
• Consider extended/continuous CHC, if headaches occurring primarily
during the HFI.
• No evidence that switching progestogens, route of administration, or
reducing the dose of estrogen reduces headache.

Irregular bleeding
• A common side effect, improves with time.
• Exclude missed pills, pregnancy, STI or cervical pathology.
• Formulations with higher doses of estrogen (≥30mcg) are associated
with less irregular bleeding.
• 2nd generation progestogens may be favourable to 1st generation.

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Progesterone-Only Contraception Health Risks

• No association between POP and VTE/cardiovascular disease.
Progesterone-Only Pill (POP)9
• The available evidence suggests a possible association between current
• Traditional POP (Noriday) contains 350mcg norethisterone and MOA is or recent use of hormonal contraception (including POP) and a small
NOT ovarian suppression, but changes to cervical mucus that prevent increase in risk of breast cancer; absolute risk remains very small.
penetration by sperm.
• Ectopic pregnancy: overall risk is low, but 1:10 pregnancies arising on
~ This effect occurs rapidly, after just 2 days, but also wears off rapidly, traditional POP are ectopic.
hence the precise timing required; a pill taken >3 hours late is a
missed pill. Non-Contraceptive Benefits
• Desogesterol POP (Cerazette) causes anovulation in up to 97% of users, • May improve dysmenorrhoea.
hence the wider window of 12 hours.
Initiation7
• Other MOAs include endometrial changes and reduced ciliary function Figure 4 below outlines initiation of the POP
of fallopian tubes.
DURING • Day 0–5 of a normal menstrual cycle, without additional
MENSTRUATION precautions OR
Key practice point: Very few medical conditions restrict the use of POP.

• >Day 5 of menstrual cycle, if human chorionic gonado-

QUICK-START
UK Medical Eligibility Criteria6 trophin (HCG) test negative, with precautions for 48 hours

Table 5 – UKMEC for POP

Missed-Pill Rules
CONDITION UK MEC 4 UK MEC 3 • UPSI before a missed pill does not risk pregnancy, as cervical mucus
Cardiovascular N/A Current/history of changes prevent sperm entering the upper genital tract and sperm in
disease ischaemic heart disease at the lower genital tract can only survive for a few hours.
continuation OR Stroke/TIA
• Take the missed pill as soon as it is remembered, even if that means
at continuation
taking 2 pills in one day.
Breast disease Current breast cancer Past breast cancer
• If more than one pill has been missed, only one pill should be taken.
Liver disease NIA Decompensated cirrhosis • Additional contraceptive measures are required for 48 hours.
OR Liver tumour (adenoma/
carcinoma) • Consider emergency contraception (EC) if unprotected sexual
intercourse (UPSI) takes place during this window.

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Factors Affecting Metabolism

• No evidence to support increased pregnancy risk in users with a higher
BMI. No indication for more than one pill per day.
• If vomiting occurs within 2 hours, take another pill as soon as possible.

Prescribing
• 12 months can be issued at initiation/continuation.
• Can be safely continued until aged 55 when loss of fertility is assumed.

Managing Problems on POP

Change in bleeding pattern (DSG-POP)
• 20–30% become amenorrhoeic.
• Approx 40% continue with normal frequency of menstrual bleeds.
• Approx 30% have infrequent bleeding.
• Bleeds can be prolonged (>14 days) in 10%.
• <10% have frequent bleeding (2 or more episodes per month).
• No evidence that giving ‘double dose’ (150mcg) improves bleeding
pattern, although this strategy is used in clinical practice.

Mood
• Evidence does not support a causal link between POP and depression.

Other
• No clear evidence as to a causal link between POP and acne, weight
gain, headaches, or change in libido.

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The Contraceptive Injection10 Health Risks

Reduced bone mineral density
Contraception Injection Summary
• Use of DMPA results in a small loss of bone mineral density (BMD)
• Depot medroxyprogesterone acetate (DMPA) is given by deep which is largely recovered back to baseline levels on discontinuation.
intramuscular (IM) injection, preferably into the gluteal region (deltoid The clinical significance of this, and whether it translates to an
also acceptable). increased fracture risk, is unknown.
• MOA: inhibits ovulation, thickens cervical mucus and causes changes • DMPA may be used in women <18 and >45 if other options are
to endometrium that can reduce implantation. unacceptable.
• Failure rates: 0.6% (perfect use) – 6% (typical use). • At age 50, it is advised to switch to another method due to the
• Summary of product characteristics (SPC) recommends dosing interval theoretical risk to skeletal health. If a woman does not wish to switch,
of 12 weeks, Faculty of Sexual and Reproductive Healthcare (FSRH) consideration can be given to continuation after risk-benefit analysis.
supports 13 week interval. • A risk-benefit analysis should be carried out for all users every 2 years.
• If additional risks for osteoporosis are present, other methods should be
Key practice point: Women who gain more than 5% of their baseline
considered.
body weight in the first 6 months of use are likely to experience
• The use of routine bone density scan monitoring in DMPA users has not
continued weight gain.
been established.

UK Medical Eligibility Criteria6 Breast cancer

• Possible, weak association between current DMPA use and breast cancer.
Table 6 – UKMEC for Contraceptive Injection
Any increased risk is small, and decreases with time after stopping.
CONDITION UK MEC 4 UK MEC 3
Cervical Cancer
Cardiovascular NIA Current/history of ischaemic heart disease
disease OR Stroke/TIA OR Hypertension with • Weak association between DMPA use for >5 years and cervical cancer.
vascular disease OR multiple CVD risks This increased risk may be due to confounding factors. Any increased
risk reduces with time after stopping.
Breast disease Current Past breast cancer
breast cancer • Healthcare professionals (HCP) should check that users are up to date
with their cervical screening.
Liver disease NIA Decompensated cirrhosis OR Liver tumour
(adenoma/carcinoma) Cardiovascular disease
Gynaecology N/A Unexplained vaginal bleeding (serious • No causal relationship between DMPA use and VTE.
cause suspected)
• Impossible to confirm/deny a relationship between DMPA use and ATE.

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Weight gain Initiation7

• DMPA use can be associated with weight gain, and this is often cited as Figure 5 below outlines initiation of the DMPA
the reason for discontinuation.
• This occurs particularly in women <18 with a BMI >30 at initiation, but DURING
this association has not been observed in adult women. MENSTRUATION • Day 0–5 of a normal menstrual cycle, or <21 days
• As mentioned above, women who gain more than 5% of their baseline OR <21 DAYS postpartum without additional precautions OR
POSTPARTUM
body weight in the first 6 months of use are likely to experience
continued weight gain.
• At any time in the cycle, if reasonably certain the
Return to fertility QUICK-START woman is not pregnant, with additional contraceptive
• Women should be informed that there can be a delay in return to measures for 7 days
fertility of up to 1 year after stopping DMPA. • No UPSI since LMP
• However, this varies greatly between individuals, and if a woman • Using another method of contraception correctly and
does not wish to conceive she should immediately commence consistently
contraception on stopping DMPA, even if she is amenorrhoeic. HOW TO BE
• <5 days post abortion, miscarriage or ectopic
“REASONABLY
CERTAIN” pregnancy
Non-Contraceptive Benefits
• Fully breastfeeding and amenorrhoeic and <6 months
• The majority of users become amenorrhoeic with time, which may post-partum
be of benefit in heavy menstrual bleeding, dysmenorrhoea, or
• No UPSI in last 21 days and a negative HSPT
endometriosis.
• Use is not associated with an increased risk of ovarian or endometrial
cancer and may offer some protection. If pregnancy cannot be excluded, ideally use a bridging method
• DMPA may reduce the severity of pain in sickle cell disease crisis. until negative HCG 3 weeks after last UPSI.
Drug Interactions and Other Factors Affecting Metabolism No evidence of harm to the fetus if pregnancy occurs while using
• The efficacy of DMPA is not reduced by concurrent use of enzyme- DMPA, so can consider quick-starting if a delay in contraception/
inducing drugs. other methods as bridging are unacceptable, with a follow-up
HCG 21 days after last UPSI.
• No decreased effect has been noted in women who are overweight or
obese, although there is little evidence in users with a BMI >40.
• In women with deep adipose tissue in the gluteal area, standard-length
needles (as supplied) may not reach the muscle layer and deltoid
administration should be considered.

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Late Injection Rules Managing Problems on DMPA

• Women should be advised to return every 13 weeks for repeat Altered bleeding pattern:
injection. • Common, improves with trends towards less bleeding and
• DMPA can be administered up to 7 days late (14 weeks) without the amenorrhoea with increased use.
need for additional precautions (off licence but supported by FSRH) • Exclude other causes (infection, pregnancy, cervical pathology).
(see Figure 6 below).
• If medically eligible, can trial CHC for 3 months.
• SI that occurs up to week 14 is protected.
• No long-term evidence on the benefit/risks of combined CHC and
• If necessary, the injection can be given early, from 10 weeks after last DMPA use beyond this, clinical judgement required.
injection.
• An alternative is mefenamic acid 500mg 3 times daily for 5 days.
Figure 6 – Late DMPA rules • If bleeding is occurring towards the end of the injection interval,
intervals can be shortened to 10 weeks, although the evidence for this
>14 weeks and UPSI in last 5 days is limited.
>14 weeks and no UPSI = give
= consider EC, then DMPA and
DMPA, barrier method for 7 days, Other side effects
barrier for 7 days. HCG 3/52 after
no need for HCG
last UPSI • Other reported side effects include acne, mood change, reduced
libido, headache, hot flushes and vaginitis although there is insufficient
evidence to determine causation.
>14 weeks and UPSI >5 days ago
but <3 weeks ago = no role for >14 weeks and UPSI >3 weeks ago Prescribing
EC, HCG now, give DMPA, barrier = HCG now, if negative can give • A 12-month prescription can be issued.
method for 7 days, HCG again DMPA, barrier method for 7 days • At each visit the health professional administering the injection should
3/52 after last UPSI assess the time since last injection, bleeding pattern, any changed
to medical eligibility criteria and assess risk of sexually transmitted
infections.
Remember! Ulipristal acetate
• Long-term users should be reviewed by their prescriber every 2 years
effectiveness may be reduced by
for a risk-benefit assessment.
circulating progestogen, and if UPA is
given delay DMPA for 5 days

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Progesterone-Only Implant11 Health Risks

Reduced bone mineral density
Progesterone-Only Implant Summary
• Available evidence is too limited to confirm or exclude an association
• Etonogestrel implant licensed for 3 years of use. Limited evidence between implant use and reduction in BMD.
available suggests that risk of pregnancy in the 4th year of use is likely to
be very low and EC is unlikely to be required in this situation. As evidence Breast cancer
is limited, routine use beyond 3 years cannot be recommended. • The available evidence suggests a possible association between
• Failure rate 0.05% in first year. current or recent use of hormonal contraception (including the
• MOA: Suppression of ovulation, with additional effects on contraceptive implant) and a small increase in risk of breast cancer;
endometrium and cervical mucus. absolute risk remains very small.

Gynaecological cancer
Key practice point: The contraceptive implant is the most effective • Available evidence is too limited to inform whether there is any
form of LARC, but bleeding problems are a common reason for increased risk in cervical, ovarian or endometrial cancer.
discontinuation, and users should be counselled carefully about this.
Cardiovascular disease
• No increased risk of VTE or ATE, although evidence is limited.
UK Medical Eligibility Criteria6
Non-Contraceptive Benefits
Table 7 – UKMEC for Progesterone-Only Implant • Dysmenorrhoea: Most individuals with dysmenorrhea report an
improvement with implant (IMP) use. Approximately 5% of users report
CONDITION UK MEC 4 UK MEC 3 new-onset or worsening of dysmenorrhea.
Cardiovascular N/A Current/history of ischaemic heart disease • Available evidence is too limited to draw conclusions about the effect
disease at continuation assessment (MEC 2 for
of IMP on HMB.
initiation) OR Stroke/TIA at continuation
assessment (MEC 2 for initiation) • Very limited evidence suggests that IMP may reduce endometriosis
Breast disease Current Past breast cancer
symptoms.
breast cancer
Liver disease N/A Decompensated cirrhosis OR Liver tumour
(adenoma/carcinoma)
Gynaecology N/A Unexplained vaginal bleeding (before
evaluation)

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Drug Interactions and Other Factors Affecting Metabolism Initiation7

• Enzyme-inducing drugs can reduce the contraceptive effectiveness of Figure 7 below outlines initiation of the Progesterone-Only Implant
IMP during use, and for 28 days after.
• Individuals using enzyme-inducing drugs should be offered a reliable DURING
contraceptive method that is unaffected by these medications. MENSTRUATION • Day 0–5 of a normal menstrual cycle, or <21 days
OR <21 DAYS postpartum without additional precautions OR
• The effectiveness of UPA-EC can be reduced if an IMP is in situ, or is POSTPARTUM
inserted within 5 days of use.
• Contraceptive effectiveness of IMP is not affected by body weight • At any time in the cycle, if reasonably certain the
or BMI, and early replacement on the basis of weight or BMI is not QUICK-START woman is not pregnant, with additional contraceptive
recommended. measures for 7 days
• No UPSI since LMP
Contraceptive Failure
• Using another method of contraception correctly and
• The risk of any pregnancy (ectopic or intrauterine) during use of the consistently
implant is very low. HOW TO BE
• <5 days post abortion, miscarriage or ectopic
“REASONABLY
• Prior ectopic pregnancy is not a contra-indication to use. pregnancy
CERTAIN”
• Most pregnancies that occur on the implant are conceived prior to • Fully breastfeeding and amenorrhoeic and <6 months
insertion, or prior to the device becoming effective, OR due to the use postpartum
of enzyme-inducing drugs. • No UPSI in last 21 days and a negative HSPT
• There is no evidence to suggest a teratogenic effect of IMP.
• In the case of a continuing pregnancy with IMP in situ, it is standard No evidence of teratogenicity of Implanon (limited data), so can
practice to remove the device. be quick-started if patient prefers not to delay contraception, with
• In the case of an abortion, the device can be retained to provide a follow up HCG 21 days after last UPSI.
ongoing contraception.
• In cases of true contraceptive failure in an established user, the user
may wish to consider an alternative method.

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Pre-Insertion Checklist • 1 in 5 users report prolonged bleeding episodes, lasting 14 days or more.
• Meets medical eligibility criteria. • Users with an ‘unfavourable’ bleeding pattern in the first few months of
• No medication interactions. use have a 50% chance that bleeding will improve over time.
• No drug allergies. • Users with a ‘favourable’ bleeding pattern in the first few months after
insertion are more likely to continue in that pattern.
• Suitable time to insert/requirement for additional contraception or
follow-up pregnancy testing. • Discontinuation rates due to bleeding problems range from 10–20%.
• Patient has been informed of: Managing Irregular Bleeding on IMP
~ Contraceptive effectiveness. Assessment of unfavourable bleeding on IMP:
~ Duration of use.
• Document bleeding pattern before use and since device was inserted.
~ Medication interactions.
• Cervical screening history and HPV vaccination status +/– physical
~ Potential bleeding problems. examination.
~ Risks of insertion including infection, haematoma, scarring, deep • STI risk assessment +/– testing.
insertion, intravascular insertion, migration and neurovascular damage.
• Rule out pregnancy.
~ Removal procedure.
• Medication history, including OTC medications (interactions).
Side Effects – Irregular Bleeding • Assess for symptoms suggestive of another underlying cause: PCB,
• Irregular, unpredictable bleeding is common during IMP use and may dyspareunia, menorrhagia, abdominal/pelvic pain.
occur at any time following insertion.
Irregular bleeding treatment options:
• On average, the number of bleeding days per month with IMP is lower
than/comparable to a natural menstrual cycle, or CHC use, but the • Trial of CHC for 3 months, unless medically contraindicated. This is off
pattern is less predictable. license use of CHC and safety of long-term use of CHC and IMP beyond
3 months has not been studied. Longer-term use could be considered
• 1 in 3 users report irregular bleeding with an average of 1 bleeding on a case-by-case basis, using the provider’s clinical judgement.
episode per month.
• If CHC is contraindicated, oral mefenamic acid 500mg three times daily
• 1 in 3 users report irregular bleeding with an average of <1 bleeding for 5 days may be considered. The aim of this is to shorten or lighten
episode per month. an individual episode of bleeding, but will not have any impact on the
• A small number of users report irregular bleeding that occurs at a longer-term bleeding pattern.
frequency of >1 episode per month. • There is currently inadequate evidence to recommend the use of
• 1 in 4 users report amenorrhoea. progestogens, including the POP, although this is often done in practice.

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Other Side Effects

Headache
• Commonly reported but evidence cannot confirm/exclude a causative
effect.

Acne
• A minority of users experience new-onset/worsening of acne, while
some report an improvement.

Mood disorder
• Available evidence is too limited to confirm/exclude a causative effect.

Weight gain
• Available evidence is too limited to confirm/exclude a causative effect.

Prescribing
• Can safely be used until age 55 when loss of fertility is assumed.

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Intrauterine Contraception12 UK Medical Eligibility Criteria6

Hormonal Intrauterine System (IUS) Table 8 – UKMEC for Intrauterine Contraception

• Levonorgestrel intrauterine systems: Mirena 52mg (8 years)13, Kyleena
19.5mg (5 years), Jaydess 13.5mg (3 years). CONDITION UK MEC 4 UK MEC 3

• MOA: Prevention of implantation via progestogenic effect on the Postpartum Postpartum Sepsis >48 hours but <4 weeks
endometrium. In devices with higher dose (Mirena), ovulation may be postpartum
prevented (in approx. 25% of users). Changes to the cervical mucus also Cardiac N/A Known Long QT Syndrome
occur. arrhythmia at Initiation (MEC 1 for
Continuation)
• Failure rate/year: 0.2% (Mirena)–0.3% (Kyleena/Jaydess).
• Cannot be used for emergency contraception. Cardiovascular N/A Current/history of IHD/
disease Stroke (at Continuation,
Copper IUD MEC 2 for Initiation,
Hormonal coils only, CU
• Non-hormonal, vary in size, shape and duration of use. IUD MEC 1)
• MOA: Changes to cervical mucus inhibiting penetration of sperm,
Breast disease Current breast cancer Past breast cancer
effects on the ovum and sperm cells to reduce fertilisation, (Hormonal coils only, CU (Hormonal Coils only, CU
inflammatory change in endometrium preventing implantation. IUD is MEC 1) IUD is MEC 1)
• Failure rate/year: T-shaped devices 0.1–1% (lower failure rate with Liver disease N/A Decompensated
devices containing 380mm2 and additional copper on the transverse cirrhosis OR Liver tumour
arms), Ballerine 0.5%14. (adenoma/carcinoma)
• Can be used for emergency contraception, with the exception of (Hormonal Coils only, CU
Ballerine. |UD is MEC 1)

• A device containing >300mm2 of copper inserted after the age of 40

can remain in situ until menopause15.

Key practice point: the hormonal IUS is a first-line treatment for the
management of heavy menstrual bleeding (HMB), as well as being a
highly effective form of LARC. The copper intrauterine device (IUD) is
the only form of entirely non-hormonal prescription contraception.

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CONDITION UK MEC 4 UK MEC 3 hormonal IUS) and a small increase in risk of breast cancer; absolute risk
remains very small.
Gynaecology • Gestational trophoblastic • Gestational trophoblastic
disease with malignancy disease with decreasing Cardiovascular disease
or persistently elevated levels
• Little or no increased risk of VTE or ATE with hormonal coils, although
HCG levels • Radical trachelectomy for evidence is limited.
• Cervical Cancer awaiting cervical cancer
treatment (at Initiation) • Uterine fibroids or other Non-Contraceptive Benefits
• Endometrial Cancer anatomical variant
(Initiation) causing distortion of the
• Mirena IUS may reduce pain associated with primary dysmenorrhea,
uterine cavity endometriosis or adenomyosis.
• Unexplained vaginal
bleeding with suspected • Mirena IUS is very effective in reducing menstrual blood loss, and can
serious cause, before be used in the management of HMB.
evaluation (Initiation)
• Mirena IUS can be used to prevent endometrial hyperplasia, in
Infection • Current Pelvic • HIV infection with CD4 conjunction with estrogen therapy (HRT) for 5 years.
Inflammatory disease (at count < 200 (at Initiation)
Initiation) • Use of a Cu IUD may be associated with a reduced risk of endometrial
• Asymptomatic Chlamydia
• Current symptomatic (at Initiation)
and cervical cancer.
STI-Chlamydia/ • Pelvic TB (continuation)
gonorrhoea/purulent Drug Interactions and Other Factors Affecting Absorption
cervicitis (at Initiation) • Nil.
• Pelvic TB (initiation)
Contraceptive Failure
Organ N/A Complicated (graft failure,
Ectopic pregnancy
transplantation rejection, vasculopathy)
• Overall, as the risk of pregnancy is so low, the risk of ectopic pregnancy
is also low (1/1000 over 5 years).
Health Risks
• However, if a pregnancy does occur, it is more likely to be ectopic,
Bone mineral density with some studies reporting up to 50% of pregnancies that occur on
• No effect on BMD has been observed. intrauterine contraception (IUC) are ectopic.

Breast cancer • Users should be informed of this risk, the signs of ectopic pregnancy,
and the requirement for an urgent scan in the event of pregnancy.
• The available evidence suggests a possible association between
current or recent use of hormonal contraception (including the

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Intrauterine pregnancy
A negative HCG adds weight to the exclusion of pregnancy, if >3
• Increased risk of adverse pregnancy outcomes such as miscarriage, weeks post UPSI.
preterm delivery or chorioamnionitis.
Hormonal coils should not be quick-started unless pregnancy can
• If the pregnancy is continuing, removal of the IUC early (<12 weeks) is
be excluded.
recommended, to reduce these risks.
• No known associated teratogenicity from IUS.
• In the case of medical termination of pregnancy, IUS should be As the Cu IUD is effective immediately, it can be inserted at any
removed before administration of mifepristone. point without additional measures once pregnancy is excluded.

Initiation7
Figure 8 below outlines initiation of hormonal IUS Pre-Insertion Checklist
• Meets medical eligibility criteria.
• STI risk assessment:
DURING • Day 0–5 of a normal menstrual cycle, without
~ STI testing is recommended for all women with risk factors for STI
MENSTRUATION additional precautions OR
including: age <25 years, new sexual partner in the last 3 months, >1
sexual partner in the last year, history of STIs or alcohol/substance
• At any time in the cycle, if reasonably certain the abuse.
QUICK-START woman is not pregnant, with additional contraceptive ~ A vulvovaginal or endocervical swab for chlamydia/gonorrhoea is
measures for 7 days recommended. Urine testing is not recommended.
• No UPSI since LMP ~ In asymptomatic women, screening can be carried out prior to
• Using another method of contraception correctly and insertion, or at insertion.
HOW TO BE consistently
“REASONABLY ~ If any symptoms of STI, insertion should be delayed where possible,
• <7 days post abortion, miscarriage or ectopic and bridging contraception offered.
CERTAIN”
pregnancy
~ Consider antibiotic prophylaxis for chlamydia (+/– gonorrhoea) in
• Fully breastfeeding and amenorrhoeic and <6 months
postpartum line with national guidelines (www.antibioticprescribing.ie) if an
emergency IUD is being inserted in a woman with symptoms or who
is high risk.

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• Patient has been informed of: Managing Problems on IUC

~ Contraceptive effectiveness. Irregular bleeding
~ Duration of device. • This is common in the initial months of use, and generally improves
with time. There is no evidence as to the most appropriate treatment
~ Risks of procedure and device including: failure of insertion, failure for irregular bleeding on IUS. Once infection has been excluded, CHC
of device (with an increased risk of ectopic pregnancy), expulsion, can be trialled for 3 months if medically eligible.
perforation, change to bleeding pattern, infection, hormonal side
effects (in the case of IUS) and pelvic pain. • Consider NSAIDS in the management of bleeding problems on Cu IUD.

Complications of IUC Missing threads

• Exclude pregnancy.
Expulsion
• Risk of expulsion is 1 in 20, and is more common in the first year of use, • Consider need for emergency contraception.
particularly the first 3 months. • Start bridging contraception.

Hormonal side effects • Arrange an ultrasound.

• Acne, mastalgia and headaches are all commonly reported after • If device not located on ultrasound: arrange X-ray of abdomen and pelvis.
hormonal IUS insertion but these symptoms settle with time, and rates • If device not located on X-rays, can confirm expulsion.
of discontinuation due to side effects do not differ between hormonal
• If device located in abdomen/pelvis, can confirm perforation and refer
and copper coils.
to Gynaecology for laparoscopy.
Weight gain
Non-fundally placed IUC
• There is no evidence to support a causal association between IUC and
• Limited evidence on how to manage.
weight gain.
• Overall, contraceptive effectiveness of non-fundally placed IUC cannot
Ovarian cysts be guaranteed, especially if >2cm from the fundus on ultrasound
• These can occur on the hormonal IUS, but are usually asymptomatic measurement.
and resolve spontaneously. Note, a history of ovarian cysts is not a • Decision to remove/replace a device is a matter of clinical judgement
contra-indication to IUS. following discussion with the woman and review of her risk factors for
pregnancy (age, type of device, history of expulsion).
Perforation
• Rate of perforation is 2/1000, although this is 6 times higher in
breastfeeding women.

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Pelvic infection
• Asymptomatic infection (detected on screening) should be treated
promptly, but does not require removal of an IUC.
• IUC removal is not routinely required in women with PID. However, the
device should be removed if there is no response to treatment after 72
hours.
• Recurrent bacterial vaginosis or vulvovaginal candida has been
observed in Cu IUD users, and alternative contraception may be
advisable.

Prescribing
• Can safely be used until age 55 when loss of fertility is assumed.
• Mirena IUS now licensed for 8 years for contraception at all ages.
• FSRH supports extended duration use in women aged 45+: in this
setting the Mirena should be removed when it is no longer effective (at
controlling bleeding) or required (for contraception).
• Note, for endometrial protection in the setting of HRT the duration of
use remains 5 years.

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Patient-Specific Considerations and the woman wishes to continue, consider continuation after careful
risk-benefit analysis and with regular review). DMPA use is associated
Contraception in Women >40 Years Old15 with a small loss of bone mineral density which is usually recovered after
What are the general considerations for contraception in women discontinuation. This does not appear to be repeated or worsened by
aged >40? menopause. However, women with additional risk factors for osteoporosis
As there is an age-related increased background risk of cardiovascular (smoking, inactivity, family history) are advised to consider other methods
disease, obesity and breast cancer, women ≥40 require special consideration at age 40. The value of routine bone density scans or estrogen levels in
when it comes to contraception. While there is natural decline in fertility DMPA users has not been established.
with age, effective contraception is recommended until menopause to
prevent unintended pregnancy and it should be noted that pregnancy Implant
and childbirth at age ≥40 has increased adverse maternal and neonatal The progesterone-only implant is not associated with risk of VTE, stroke/MI
outcomes. Women ≥40 may also need assessment and management of or change in BMD. The available evidence suggests a possible association
symptoms of the perimenopause, alongside contraceptive care. between current or recent use of hormonal contraception (including
progestogen-only implants) and a small increase in risk of breast cancer;
CHC absolute risk remains very small. There is no evidence to suggest that
CHC is licensed until age 50. Women aged 50 and older are advised to bleeding patterns are more predictable in women ≥40 than <40.
switch to a safer alternative method. In women ≥40, the first line option
for the COC should be a preparation containing a 1st or 2nd generation Cu-IUD
progestogen (Levonorgesterol or norethisterone), as these are safer from The FSRH supports extended use of Cu-IUDs when inserted at aged 40 or
a VTE perspective. The dose of estrogen should be 20mcg or 30mcg, greater. A device containing ≥300mm2 can be considered contraceptive
as these preparations have less cardiovascular risk. Note that age ≥40 is until menopause and should be retained for 1 year after the LMP in a
UKMEC 2. woman >50 and 2 years after the LMP in a woman <50. The main concern
with Cu-IUDs is potential for worsening of heavy menstrual bleeding in the
POP peri-menopause.
The POP is not associated with increased risk of VTE, stroke/MI, and has
not been shown to affect BMD. The available evidence suggests a possible LNG-IUS
association between current or recent use of hormonal contraception FSRH supports extended use of Mirena for contraception until age 55 if
(including POP) and a small increase in risk of breast cancer; although inserted at 45 or older, provided it is not being used as the progestogen
absolute risk remains very small. component of HRT for endometrial protection (5 years maximum). Both
FSRH and the HPRA of Ireland have extended the duration of use for
DMPA Mirena in contraception and HMB (providing it is still effective) to 8 years.
After age 45, DMPA use moves from UKMEC 1 to UKMEC 2, and ongoing The main non-contraceptive benefit of Mirena is reduction in painful/
use ≥50 is not usually recommended (if no other method is suitable problematic bleeding, with some studies showing similar results between

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Mirena and hysterectomy in terms of quality of life. There is little or no Overweight and Obesity5
increased risk of VTE/stroke/MI. The available evidence suggests a possible Obesity is an important consideration due to the increased risk of VTE and
association between current or recent use of hormonal contraception ATE.
(including hormonal IUS) and a small increase in risk of breast cancer;
absolute risk remains very small (current breast cancer UKMEC 4, history of CHC
breast cancer remains UKMEC 3). • CHC use is UKMEC 2 for women with a BMI 30–34, and UKMEC 3 >35.
• Limited evidence suggests the transdermal patch may be less effective
Can contraception be used alongside HRT? in women >90kg.
Yes. HRT (other than Mirena IUS) is non-contraceptive and peri- • Note ‘multiple cardiovascular risk factors’ constitutes a UKMEC 3, even at
menopausal women should be advised to use an appropriate method lower BMI threshold.
to prevent pregnancy. All methods of progesterone only HRT (POP,
DMPA, implant) can be used alongside HRT, but these are not licensed POP
for and cannot be recommended as the endometrial protection aspect • Effectiveness of POP is not affected by body weight.
of HRT. CHC can be used as an alternative to HRT for relief of menopausal • No requirement for double dosing for contraceptive effect.
symptoms and prevention of loss of BMD in women under 50.
DMPA
Postmenopausal women do not need to start contraception when they
• No evidence to suggest Depo-Provera (DMPA) is affected by body
commence HRT as it does not restore fertility.
weight.
When can I stop contraception? • Obesity alone is UKMEC 1, however it becomes UKMEC 3 in the setting
Contraception can be stopped: of multiple cardiovascular risk factors.
• DMPA use does have an association with weight gain, particularly in
• At age 55 women aged <18 with a BMI >30. Note: women who experience >5%
OR weight gain in the first 6 months after DMPA initiation are more likely to
• Once menopause diagnosed: 1 year of amenorrhoea if >50, 2 years of continue to gain weight.
amenorrhoea if <50 • DMPA should be administered intramuscularly; consider a longer
OR needle or deltoid administration if you are concerned you will not
reach the muscle layer in a woman with obesity.
• In a woman over 50 years, who is amenorrhoeic using a progesterone
only method (IMP/POP/LNG-IUS), follicle stimulating hormone (FSH) Implant
can be measured. If the FSH level is >30, contraception should be • Evidence to date suggests no impact of weight on safety or
continued for 1 further year, and can then be stopped. If FSH is <30, effectiveness of progestogen-only implants.
continue contraception and repeat the FSH in 1 year.

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IUS/IUD • POP: use NOT advised as contraceptive effectiveness could be

• Evidence to date suggests no impact of weight on safety or reduced during use of an enzyme-inducing drug and for 28 days after.
effectiveness of intrauterine contraception. Alternative contraception recommended.
Weight-loss treatments and contraception • Implant: use NOT advised as contraceptive effectiveness could be
• Bariatric surgery may affect the absorption of COC and POP. Patients reduced during use of an enzyme-inducing drug and for 28 days after.
should be counselled about this prior to surgery. Alternative contraception recommended.
• DMPA: no effect on contraception. No additional precautions required.
Drug Interactions16
• Hormonal IUS: no effect on contraception. No additional precautions
Drug interactions can reduce the effectiveness of both the contraceptive
required.
hormones and the drug in question. A medication history is an important
element of the contraception consultation. • Copper IUD: no effect on contraception. No additional precautions
required.
Enzyme inducing drugs
Lamotrigine
Enzyme-inducing drugs increase hepatic clearance of contraceptive
• CHC: estrogen causes increased metabolism of lamotrigine, which
hormones. These include: anti-epileptics (carbamazepine, topiramate, can result in reduced serum levels and increased risk of seizure, and/
phenytoin, phenobarbital), antibiotics (rifampicin, rifabutin), anti-retrovirals or lamotrigine toxicity in the hormone-free interval. It is also possible
and others (St. John’s wort, modafinil). that the lamotrigine could reduce the effectiveness of contraceptive
• CHC: use NOT advised as contraceptive effectiveness could be hormones, and additional reliable use of condoms is recommended. If
reduced during use of an enzyme-inducing drug and for 28 days after. use of combined hormonal contraception is unavoidable, lamotrigine
Alternative contraception recommended. dose may need to be increased (potentially as much as two-fold) and
serum lamotrigine levels monitored to avoid reduction in effectiveness
If alternative effective contraception is not acceptable (except in of lamotrigine. It is suggested that a continuous combined hormonal
the case of the potent enzyme inducers rifampicin/rifabutin), and in contraceptive regimen (with no hormone-free interval) is used to avoid
exceptional circumstances, consider use of two ethinylestradiol (EE) cyclical changes in lamotrigine levels.
monophasic combined oral contraceptive pills together containing
a total of 50μg of EE (30μg + 20μg). These should be used in a • POP/Implant: contraceptive effectiveness may be reduced, and additional
continuous regimen (or tricycled with a shortened hormone-free reliable use of condoms is recommended. Desogestrel might increase
interval of 4 days). The user should be aware that contraceptive exposure to lamotrigine in some individuals. Evidence relating to effect
effectiveness is not guaranteed and that there could be increased risk of other progestogen-only contraceptives on serum lamotrigine levels
of thrombosis if exposure to EE is increased. Use of two combined is extremely limited. Individuals using lamotrigine who commence
contraceptive patches or two combined contraceptive rings together is a progestogen-only contraceptive should be vigilant for signs of
not recommended.

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lamotrigine toxicity (dizziness, ataxia, diplopia). Consider monitoring • CHC: do not quick-start for 5 days. Use condoms reliably during this
serum lamotrigine levels when the progestogen is stopped. time, and until this method becomes effective.
• DMPA: no expected effect on contraceptive effectiveness. No additional • POP: do not quick-start for 5 days. Use condoms reliably during this
precautions required. time, and until this method becomes effective.
• Hormonal IUS: no expected effect on contraceptive effectiveness. No • Implant: do not quick-start for 5 days. Use condoms reliably during this
additional precautions required. time, and until this method becomes effective.
• Copper IUD: no expected effect on contraceptive effectiveness. No • DMPA: do not quick-start for 5 days. Use condoms reliably during this
additional precautions required. time, and until this method becomes effective.
• Hormonal IUS: do not insert until pregnancy can be excluded.
Griseofulvin
The mechanism by which griseofulvin may affect contraceptive • Copper IUD: no interaction. See FSRH decision making algorithm for
emergency contraception.
effectiveness is unknown, but there are case reports which describe
change in bleeding patterns and/or pregnancy in users of CHC who are Thyroxine
exposed. Risk is uncertain but as griseofulvin may be teratogenic, caution Oral contraception may increase thyroxine requirement in hypothyroid
is recommended. individuals, by increasing thyroid-binding globulin. In individuals taking
• CHC: additional reliable use of condoms recommended. thyroxine, consider checking thyroid function 6 weeks after initiation of CHC.
• POP/implant: additional reliable use of condoms recommended. No additional measures are required in patients taking POP or using non-
• DMPA: contraceptive effectiveness unlikely to be affected, no additional oral forms of contraception.
precautions advised.
• Hormonal IUS: contraceptive effectiveness unlikely to be affected, no Teratogens
additional precautions advised. A pregnancy prevention plan should be in place for all patients exposed to
• Copper IUD: contraceptive effectiveness unlikely to be affected, no teratogens, to ensure there is no risk of conception.
additional precautions advised.
During use of a teratogen that is NOT an enzyme inducer (and no
Ulipristal acetate other enzyme-inducing drug being taken):
Ulipristal acetate can compete with contraceptive hormones for binding • CHC: use not recommended. If used, additional reliable use of condoms
at progesterone receptors, making them less effective. The ulipristal recommended.
acetate may also be reduced in effectiveness, if a progestogen has been • POP: use not recommended. If used, additional reliable use of condoms
administered in the 7 days prior. recommended.

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• Implant: recommended. No additional precautions required. • POP: can start immediately post-partum. No impact on breastfeeding.
• DMPA: use not recommended. If used, additional reliable use of • Implant: can start immediately post-partum. No impact on
condoms recommended. breastfeeding.
• Hormonal IUS: recommended. No additional precautions required. • DMPA: can start immediately post-partum. No impact on breastfeeding.
• Copper IUD: recommended. No additional precautions required. • Hormonal IUS: can insert 0–48 hours post-delivery (in the hospital
During use of a teratogen that is an enzyme inducer or a potential setting). After 48 hours, insertion is contraindicated (UKMEC 3) until 4
weeks postpartum. Note: risk of perforation is significantly increased
enzyme inducer (or if an enzyme-inducing drug is also being taken) :
in breastfeeding women. Contraindicated (UKMEC 4) in the setting of
• CHC: contra-indicated. postpartum sepsis.
• POP: contra-indicated. • Copper IUD: can insert 0–48 hours post-delivery (in the hospital
setting). After 48 hours, insertion is contraindicated (UKMEC 3) until 4
• Implant: contra-indicated.
weeks postpartum. Note: risk of perforation is significantly increased
• DMPA: recommended, but additional reliable use of condoms required. in breastfeeding women. Contraindicated (UKMEC 4) in the setting of
• Hormonal IUS: recommended. No additional precautions required. postpartum sepsis.
• Copper IUD: recommended. No additional precautions required. Contraception in Cancer Survivors6
Postpartum/Breastfeeding17 Breast cancer
Effective contraception should be initiated as soon as possible after • Family history of breast cancer is not a contra-indication to any form of
childbirth in both breastfeeding and non-breastfeeding women, as sexual contraception.
activity and fertility may return quickly. Although contraception is not • Genetic mutations associated with breast cancer: if the patient
required in the first 21 days postpartum, many methods can be started themselves is a known carrier of a genetic mutation associated with
safely in this time period. breast cancer (BRCA 1/BRCA 2), CHC is contra-indicated, all other
methods are acceptable.
• CHC: in breastfeeding women, or non-breastfeeding women with • Current breast cancer: copper IUD recommended. All other methods
additional risk factors for VTE (immobility, transfusion at delivery, body are UKMEC 4.
mass index ≥30 kg/m2, postpartum haemorrhage, post-caesarean
delivery, pre-eclampsia or smoking) contraindicated until 6 weeks • Past breast cancer: copper IUD recommended. All other methods are
postpartum (UKMEC 4). UKMEC 3.
In non-breastfeeding women with no additional risk factors for VTE, can Ovarian cancer
initiate at 3 weeks postpartum. • All methods of contraception are acceptable.

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ICGP QUICK REFERENCE GUIDE – Contraception Management in General Practice | 26

Endometrial cancer Training Resources

• Hormonal IUS and copper IUD contraindicated to initiate (UKMEC 4), ICGP Certificate in Contraception Theory
continuation is UKMEC 2. All other methods are acceptable.
Advanced Certificate in LARC
Cervical cancer
• Hormonal IUS and copper IUD contraindicated to initiate if awaiting Community Gynaecology course
treatment, continuation is UKMEC 2.
ICGP resources and useful links
• Hormonal IUS and copper IUD not advised (UKMEC 3) after radical
trachelectomy.
• All other methods acceptable. Emergency Contraception
• In the case of cervical intraepithelial neoplasia (CIN), all methods are For full guideline see FSRH Emergency Contraception Guide
acceptable.

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ICGP QUICK REFERENCE GUIDE – Contraception Management in General Practice | 27

Appendix 1: Example Tailored Pill-Taking Patient Information Leaflet

TAILORED PILL-TAKING

Your doctor has prescribed the combined breakthrough bleeding or spotting. You can
hormonal pill. In the instructions in the packet, it continue to take your pill and this bleeding will
will say ‘take this for 21 days, followed by a 7 day eventually stop. However how long it lasts and
when it comes can be unpredictable.
break, then repeat’.
• Option 3 – Extended pill-taking: Extended
Taking the pill like this is not the current
pill-taking means you take your pill for 6 or 9
recommendation. This is because most women weeks (2 or 3 packets in a row) and then take a 4
who become pregnant while using the pill do so or 5 day break. Choosing to take the pill like this
because of missing a pill (even just 1) close to the ‘7 should give a predictable pattern of bleeding
day break’. It is now believed that 7 days is too long (you will get your period shortly after you take
as a break, and taking a break of only 4 or 5 days is your break). It will also mean fewer periods in a
better. Taking the pill with a shorter break should year. You can modify when you take your break
reduce your chance of an unplanned pregnancy. according to events or activities happening in
your life (e.g. after 7 weeks, instead of 6, to avoid
There are 4 options for how to take your pill: having your period on a holiday). Choosing to
take the pill this way gives you a lot of control
• Option 1: If you have already been on the pill, over your cycle.
and are used to taking a 7 day break and want
to continue like that, you can. However experts • Option 4 – Flexible pill-taking: Flexible pill-
recommend that or 4 or 5 day break is better at taking means you take your pill continuously,
preventing unplanned pregnancy. until you have 3 days of bleeding or spotting
in a row, and then you take a 4 or 5 day break.
• Option 2: You can take the pill continuously, Choosing to take the pill like this means you
and never take a break. This is perfectly healthy are taking the cues for when to take your break
– there is no medical need for you to have a from your body, instead of at a fixed time.
period. Eventually however you will have some However, it will be less predictable.

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ICGP QUICK REFERENCE GUIDE – Contraception Management in General Practice | 28

References 9. The Faculty of Sexual & Reproductive Healthcare. FSRH Guideline

1. Center for Reproductive Rights, UNFPA. Briefing paper: The Right to (August 2022) Progestogen-only Pills. BMJ Sex Reprod Health. 2022
Contraceptive information and services for Women and Adolescents. Aug;48(Suppl 1):1–75. [Internet]. [cited 2024 Jan 11]. Available here.
[Internet]. 2010. [cited 2024 Jan 11]. Available here. 10. The Faculty of Sexual & Reproductive Healthcare. FSRH Clinical
2. CSO. Census of Population 2016 - Profile 3 An Age Profile of Ireland: Guideline: Progestogen-only Injectable (December 2014, Amended
Age Structure and Sex Ratio - CSO - Central Statistics Office [Internet]. July 2023) - Faculty of Sexual and Reproductive Healthcare [Internet].
Dublin: Central Statistics Office; 2017. [cited 2024 Jan 11]. Available [cited 2024 Jan 11]. Available here.
here. 11. The Faculty of Sexual & Reproductive Healthcare. FSRH Guideline
3. Dublin Well Woman Centre. The Contraception Conversation (February 2021) Progestogen-only Implant. BMJ Sex Reprod Health.
[Internet]. Dublin: Dublin Well Woman Centre; 2020. [cited 2024 Jan 2021 Feb;47(Suppl 1):1–62. [Internet]. [cited 2024 Jan 12]. Available
11]. Available here. here.
4. The Faculty of Sexual & Reproductive Healthcare. FSRH Guideline 12. The Faculty of Sexual & Reproductive Healthcare. Intrauterine
(January 2019, amended October 2023) Combined Hormonal Contraception - Faculty of Sexual and Reproductive Healthcare
Contraception. BMJ Sex Reprod Health. 2019 Jan;45(Suppl 1):1–93. [Internet]. [cited 2024 Jan 11]. Available here.
[Internet]. [cited 2024 Jan 12]. Available here. 13. Mirena 52mg Intrauterine Delivery System | SPC | Medicines.ie
5. The Faculty of Sexual & Reproductive Healthcare. FSRH Guideline [Internet]. [cited 2024 Jan 11]. Available here.
(April 2019) Overweight, Obesity and Contraception. BMJ Sex Reprod 14. Baram I, Aharon A, Klein R, Shkolnik K. Real-world experience with the
Health. 2019 Apr;45(Suppl 2):1–69. [Internet]. [cited 2024 Jan 12]. IUB Ballerine MIDI copper IUD: an observational, single-centre study in
Available here. Israel. Eur J Contracept Reprod Health Care. 2020 Feb;25(1):49–53.
6. The Faculty of Sexual & Reproductive Healthcare. UKMEC April 2016 15. The Faculty of Sexual & Reproductive Healthcare. FSRH Clinical
(Amended September 2019) - Faculty of Sexual and Reproductive Guideline: Contraception for Women Aged over 40 Years (August
Healthcare [Internet]. [cited 2024 Jan 11]. Available here. 2017, amended July 2023) - Faculty of Sexual and Reproductive
7. The Faculty of Sexual & Reproductive Healthcare. FSRH Clinical Healthcare [Internet]. [cited 2024 Jan 11]. Available here.
Guideline: Quick Starting Contraception (April 2017) - Faculty of 16. The Faculty of Sexual & Reproductive Healthcare. Updated FSRH CEU
Sexual and Reproductive Healthcare [Internet]. [cited 2024 Jan 11]. Guidance published: Drug Interaction with Hormonal Contraception
Available here. (May 2022) - Faculty of Sexual and Reproductive Healthcare [Internet].
8. The Faculty of Sexual & Reproductive Healthcare. FSRH CEU Guidance: [cited 2024 Jan 11]. Available here.
Recommended Actions after incorrect Use of Combined Hormonal 17. 17. The Faculty of Sexual & Reproductive Healthcare. FSRH Clinical
Contraception (e.g. late or missed pills, ring and patch) (March 2020, Guideline: Contraception After Pregnancy (January 2017, amended
amended July 2021) - Faculty of Sexual and Reproductive Healthcare October 2020) - Faculty of Sexual and Reproductive Healthcare
[Internet]. [cited 2024 Jan 11]. Available here. [Internet]. [cited 2024 Jan 11]. Available here.

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 The Irish College of General Practitioners (ICGP) is the professional body
for general practice in Ireland. The College was founded in 1984 and is
based in Lincoln Place, Dublin 2. The College’s primary aim is to serve the
patient and the general practitioner by encouraging and maintaining
the highest standards of general medical practice. It is the representative
organisation on education, training and standards in general practice.

The Irish College of General Practitioners, 4/5 Lincoln Place, Dublin 2

Tel. 01-676 3705 Email. [email protected] Web. www.icgp.ie

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