Contraception consultation
Red Flags — act before continuing history
| Red flag | Why dangerous | Action |
|---|---|---|
| Positive or suspected pregnancy on current contraception | Ectopic pregnancy risk, especially if on POP or post-IUCD failure. Any contraceptive failure with delayed period demands same-day assessment. | Same day |
| Chest pain, leg swelling or breathlessness on COC | DVT or pulmonary embolism — combined oral contraceptives increase VTE risk 3-fold in average population, higher with thrombophilia. Requires immediate assessment and COC cessation. | 999 / A&E |
| Sudden severe headache or neurological symptoms on COC | Possible ischaemic stroke, especially in women with migraines with aura on COC. COC is an independent risk factor for arterial thrombosis. | 999 / A&E |
| Severe lower abdominal pain with IUD/IUS in situ | Uterine perforation (1 in 1000), IUD expulsion, or ectopic pregnancy — all present with acute pelvic pain. IUD does not protect against ectopic pregnancy; if pregnancy occurs, it is likely ectopic. | Same day / A&E |
| Post-coital bleeding or intermenstrual bleeding (new) | May indicate cervical pathology, STI-associated endocervicitis, or endometrial abnormality. Must exclude malignancy, particularly if >35 years or on tamoxifen. | Same day |
| Symptoms suggesting PID (fever, bilateral pelvic pain, purulent discharge) with IUD | PID with IUD in situ carries risk of tubo-ovarian abscess and future infertility. Treat without removing IUD unless no improvement within 72 hours of antibiotics. | Same day |
| Signs of reproductive coercion (partner removing condom, controlling contraception) | Reproductive coercion is a form of intimate partner violence. Forced unprotected sex or covert contraceptive sabotage requires safeguarding assessment and safety planning. | Safeguard |
Safeguarding Considerations — Consider in Every Consultation
🏠 Reproductive Coercion & Domestic Abuse
- Repeated EC requests without ongoing method despite previous discussion
- Partner removes condom without consent ("stealthing")
- Patient seeks contraception without partner's knowledge (fear of harm)
- Patient unable to choose own method — partner controls decisions
- Signs of physical abuse, FGM, or forced marriage
👴 Under-16s — Fraser Guidelines
- Must assess Gillick/Fraser competence before prescribing
- Patient must understand advice and its implications
- Encourage parental involvement but cannot be mandated
- Document Fraser assessment in full in clinical records
- Consider safeguarding concern if sexual partner is significantly older
👤 Learning Disability & Capacity
- Assess capacity using Mental Capacity Act 2005 framework
- Contraception for someone lacking capacity requires best-interest meeting
- Involve advocate or IMCA as appropriate
- Consider if contraception is being requested by carer rather than patient
💊 Self-Harm & Mental Health
- Depot-medroxyprogesterone (DMPA) associated with mood deterioration — ask about mental health before prescribing
- Patient with severe depression requesting EC: explore context for self-care and support
- Enquire about current mental health if requesting contraception following assault
- Post-assault: direct to ISVA / rape crisis support
👫 Relationship dynamics & partner attitudes
Partner resistance to female-controlled methods, cultural preference for male involvement in family planning, or coercive control all affect method choice. Some women cannot negotiate condom use without risk of violence.
"How does your partner feel about contraception? Is this something you feel able to discuss with them?"If partner is resistant, consider "hidden" LARC (IUS, implant, DMPA) — not visible and partner-independent.
🌞 Cultural, religious & personal beliefs
Some faiths oppose artificial contraception (certain Catholic teachings, some Islamic interpretations). Others restrict specific methods (e.g., those perceived as abortifacient, such as Cu-IUD). Imposing a preferred method without exploring beliefs damages trust.
"Are there any beliefs — religious or personal — that might influence the type of contraception you'd feel comfortable with?"Barrier methods or natural family planning may be the only acceptable option for some patients; respect this choice and provide evidence about relative efficacy.
🧠 Mental health & mood
Progestogen-containing methods (particularly DMPA) are associated with mood deterioration in women with pre-existing depression. DMPA may worsen depression significantly. POP less clear evidence. COC has mixed evidence.
"How has your mood been generally? Have you noticed any connection between your contraception and how you feel emotionally?"For women with active depression, Cu-IUD or barrier methods avoid hormonal mood effects entirely.
🍼 Body image & weight concerns
Fear of weight gain is the leading reason women stop the pill despite limited evidence. DMPA is genuinely associated with weight gain (∼2-3kg over 2 years in some studies). Implant and IUS have less effect. Addressing this proactively prevents silent discontinuation.
"Weight and body image can be really important when choosing contraception — is this something that matters to you?"Share evidence: COC & POP data shows minimal weight gain in RCTs; DMPA has genuine but modest effect.
📚 Adherence & lifestyle
Shift work, irregular sleep, frequent travel, or cognitive difficulties reduce pill-taking adherence significantly. A woman who works night shifts will often forget a pill taken at "the same time every day." Poor adherence is the leading cause of pill failure.
"How do you find it with remembering to take things at the same time each day? Does your day-to-day routine make that straightforward?"Poor adherence predictors = strong indication for LARC (no user-dependence once inserted).
💌 Future fertility timeline
A woman who wants to conceive within 12 months should not receive DMPA (fertility delay up to 1 year after last injection) and may prefer a method with immediate return of fertility (POP, implant, COC, IUS).
"Thinking ahead, are you planning to have children at any point, and is the timing of that important to you?"Fertility returns immediately on stopping POP, COC, and on removal of implant or IUS. Cu-IUD: immediate. DMPA: up to 12 months delay — counsel explicitly.
- Starting with BP or LMP before allowing patient agenda — loses GS marks
- Prescribing COC without checking smoking status + age — UKMEC 4 violation
- Not asking about migraines with aura before prescribing COC
- Not checking pregnancy status before IUD insertion discussion
- Ignoring ICE — prescribing preferred method without exploring patient's ideas
- Not addressing STI risk / dual protection
999 or Same-Day Hospital
Urgent assessment- Suspected ectopic pregnancyIUD failure + positive pregnancy test + unilateral pain = ectopic until proven otherwise
- DVT or PE on COCLeg swelling, pleuritic chest pain, breathlessness — stop COC immediately and send to A&E
- Suspected stroke on COCSudden severe headache, facial droop, visual loss, hemiplegia — 999 immediately
- Ruptured ectopicShoulder tip pain, collapse, haemodynamic instability — 999 immediately
- PID with systemic sepsis and IUD in situFever >38.5, rigors, peritonism — urgent hospital admission
Same-Day GP / Urgent
Hours to days- Emergency contraception requestTime-critical: LNG within 72h, UPA within 120h, Cu-IUD within 5 days — do not delay
- Missed pills + unprotected sexAssess EC eligibility and need; check pregnancy test if >5 weeks since LMP
- Pregnancy test positiveRefer to early pregnancy unit same day; check for ectopic features
- Suspected STI with IUD in situTreat PID without removing IUD; swabs + empirical antibiotics same day
- IUCD threads not palpableArrange pelvic USS urgently to locate device; exclude expulsion and perforation
Manage in Primary Care
GP practice- New contraception counsellingNo medical urgency; take full history, UKMEC assess, discuss options
- Method switch due to side effectsElective — continue current method until switch confirmed
- 3-month COC reviewBP check, side effect review, adherence discussion, smear reminder
- Annual LARC reviewConfirm device still in situ, check expiry date, review STI risk
- Pre-conception counsellingDiscussion of DMPA delay, folic acid, cervical screening
- Proceeding to LARC counselling without checking for pregnancy when LMP uncertain
- Not asking about EC timing — missing the window while taking history
- Failing to exclude ectopic in woman with IUD and abdominal pain
- Prescribing COC without noting BP check needed
- Proposing IUD insertion without explaining pelvic examination requirement
- Unnecessary pelvic exam for simple POP prescription
- Not mentioning pregnancy test before IUCD insertion
- Ordering routine FBC/LFTS before pill prescription without clinical indication
- Not offering STI screen before IUD insertion discussion
"There are a few different ways of preventing pregnancy and they work in different ways. Some, like the pill, you take every day — they're very effective when used perfectly but the effectiveness can drop if you forget to take one. Others, like the coil or the implant, once they're in place they work without you needing to do anything — they're the most effective options available. The right one really depends on your health, your lifestyle, and what matters most to you in terms of things like periods and side effects."
"The pill is the best option — it's what everyone uses."
"The pill is a great option for many women, but it depends very much on your health. For some women there are medical reasons to avoid it — like migraines with visual changes — and for others, something that requires no daily effort like an implant or coil might actually work better long-term. Can I run through what's best for your situation specifically?"
"I've heard the coil can make you infertile."
"That's a really understandable worry, and I'm glad you mentioned it. The evidence actually shows that fertility returns straight away when the coil is removed — there's no lasting effect on your ability to get pregnant. The coil only works while it's in place."
Combined oral contraceptive (COC)
Oestrogen + progestogen; UKMEC 1 if no CI; 99.7% perfect use; offers non-contraceptive benefits (period regulation, acne, dysmenorrhoea)
Progestogen-only pill (POP)
Desogestrel 75mcg; no oestrogen; UKMEC 1 for most; suitable in breastfeeding, migraine with aura, age >35
Implant (Nexplanon)
Etonogestrel 68mg subdermal; 3 years; >99.9% efficacy; GP with FSRH qualification can fit; no user effort after insertion
IUS (Mirena / Kyleena)
Intrauterine levonorgestrel; 5–8 years; licensed for HMB; requires trained clinician for insertion; heavy-period benefit is a major non-contraceptive advantage
Cu-IUD (copper coil)
Non-hormonal; most effective EC within 5 days; 10-year device; heavier periods a common side effect; suitable for women wanting hormone-free contraception
DMPA (Depo-Provera)
3-monthly IM/SC injection; no daily effort; fertility delay up to 12 months on stopping; bone density reduction with prolonged use; caution in depression
Emergency contraception (EC) required
LNG-EC: within 72h (best <24h); UPA: within 120h; Cu-IUD: within 5 days (most effective). Time-critical — assess and prescribe immediately.
Unintended pregnancy on contraception
Contraceptive failure with positive pregnancy test: refer EPU same-day; exclude ectopic; discuss options (continue, termination, adoption) without directive counselling
- Using "Pearl index" without explanation — jargon
- Implying LARC is "better" without patient input — paternalistic
- Not addressing patient's misconception about fertility and IUCD
- Not mentioning LARC options if patient only asks about pills
- Leaving patient unprotected while awaiting IUCD appointment
- Directing positive pregnancy test to GP routine appointment — should be EPU same day
- Not addressing Fraser competence before prescribing to under-16
Validate — name their expectation
A patient who arrives expecting the combined pill has often done research, spoken to friends, or had it before. Acknowledge that before redirecting.
"It sounds like you've been thinking about the pill, and that makes complete sense — it's one of the most commonly used methods."Explain — share your clinical reasoning
If a medical contraindication exists, or if a more effective method is clinically preferable, explain why — using plain language and without dismissing their preference.
"Because of the migraines with visual changes that you mentioned, the combined pill isn't actually safe for you — it can slightly increase the risk of a stroke. But there are really good alternatives that would work just as well."Negotiate — offer something today
Always leave with an agreed plan. If the patient declines LARC for now, give a user-dependent method with a clear invitation to revisit LARC when ready.
"Let's start with the mini-pill today — and I'll give you some information about the implant so you can have a think about it. There's no rush, and you can always come back when you're ready."No hormonal method or IUCD protects against sexually transmitted infections. Chlamydia is often asymptomatic and can cause tubal damage and infertility if untreated.
Use condoms consistently with any new or non-exclusive partner alongside your chosen contraceptive method. Free condoms are available through NHS community pharmacy and sexual health clinics.
Smoking 15+/day at age 35+ makes the combined pill absolutely contraindicated (UKMEC 4). Smoking multiplies the arterial and VTE risk from oestrogen dramatically.
Refer to NHS Stop Smoking Services; offer varenicline or NRT. If stopping COC, switch to POP or LARC. Use contraception consultation as a teachable moment for smoking cessation.
Typical-use failure rates are 7-9% per year for user-dependent methods vs <0.1% for LARC. The gap is entirely due to missed pills and inconsistent use.
Set a daily phone alarm; link pill-taking to a fixed daily routine (morning brush teeth, bedtime). Use the NHS 28-day pill checker if pills are missed. Consider LARC if adherence is repeatedly poor.
Asymptomatic chlamydia is present in up to 10% of sexually active under-25s and can cause PID, ectopic pregnancy and tubal factor infertility. Annual testing is recommended by BASHH.
Self-sampling kits available by post via SH:24 or sexual health clinic. Urine or vulvovaginal swab. Ensure testing is completed before IUD insertion to reduce PID risk.
BMI >35 increases VTE risk with oestrogen-containing methods (UKMEC 3-4). LNG-EC is significantly less effective at weight >70kg (BMI >26) — Cu-IUD or UPA preferred for EC.
If BMI >26 and requires EC, prescribe UPA or arrange Cu-IUD. For COC users with increasing BMI, recheck at annual review. Offer weight management referral if appropriate.
Enzyme-inducing drugs (rifampicin, carbamazepine, phenytoin, St John's Wort) reduce hormonal contraceptive levels. Even the implant may be affected by rifampicin.
Always check for St John's Wort specifically (often not volunteered). If on enzyme inducer, switch to Cu-IUD or add barrier method. Stop St John's Wort if possible.
NICE recommends LARC as first-line for most women (NICE CG30 2019).
- Implant (Nexplanon) — UKMEC 1 for most conditions; suitable post-partum, breastfeeding, migraine with aura
- IUS (Mirena) — UKMEC 1; added benefit for HMB; 5–8 years; consider for women approaching menopause
- Cu-IUD — UKMEC 1; only hormone-free LARC; most effective EC; 10 years; ideal if breast cancer history
Appropriate when patient declines LARC or LARC is not yet accessible.
- COC — check UKMEC 4 CIs first (migraines with aura, smoker ≥35, DVT/PE, BP ≥160/100); 21-day active + 7-day break or PH regime
- POP (desogestrel) — ±12h window; suitable when COC contraindicated; no oestrogen; category 1 for most conditions
- DMPA — 12-weekly IM or 13-weekly SC; caution depression, BMD concerns in under 18s & >2yr use
Less effective but appropriate when hormonal methods are all contraindicated or declined on personal/religious grounds.
- Male/female condom — only STI-protective method; always recommend alongside LARC in new relationships
- Diaphragm + spermicide — hormone-free; requires fitting and instruction
- Fertility awareness methods — effective with training (Sensiplan, Billings); not suitable for irregular cycles
Method choice depends on time elapsed since unprotected sex, BMI, and drug interactions.
- Cu-IUD: most effective (>99%) within 5 days; suitable regardless of BMI or drug interactions
- Ulipristal acetate (UPA) 30mg — brand ellaOne: within 120 hours; UKMEC 2 if breastfeeding (withhold milk 1 week); not with enzyme inducers
- Levonorgestrel (LNG) 1.5mg — brand Levonelle 1.5mg / Levonelle One Step (OTC as Emerres): within 72h (best <24h); reduced efficacy >70kg / BMI >26; use double dose (3mg) if BMI >26 + UPA unavailable
- Post-partum breastfeeding <6 weeks: Implant, Cu-IUD, DMPA safe; POP safe from day 21; COC contraindicated
- Peri-menopausal (>45 yrs): COC can be used to menopause if no CI; switch to HRT at 50 for menopausal symptoms; IUS provides endometrial protection for HRT
- Enzyme-inducing medication: Cu-IUD only reliable method; if COC unavoidable use EE ≥50mcg + 7-day barrier after stopping inducer
- SLE / antiphospholipid antibodies: UKMEC 4 for combined methods; POP UKMEC 2; Cu-IUD UKMEC 2
Select patient characteristics — use with UKMEC table and 7D prescribing guide above
"Take one pill every day at roughly the same time. The pill is very effective when taken correctly, but it doesn't protect against infections — you'd still need condoms for that."
SCA pearl: Ask about migraine aura BEFORE prescribing COC. Missing this is a patient safety failure. "Do you ever get visual disturbance or weakness before a headache?" scores a Tasks mark.
"Take this at the same time every day — desogestrel gives you a 12-hour window if you forget. Your periods may change — they might become irregular or stop altogether, which is safe and normal."
SCA pearl: POP is the progestogen-only pill patients mean when they say "the mini-pill." Clarify — desogestrel (12h window) vs norethisterone (3h window). Desogestrel is preferred.
"Once it's fitted you don't need to do anything for 3 years. The most common issue is irregular bleeding — your periods may become unpredictable, lighter, or stop altogether. This is safe but I want you to know in advance."
SCA pearl: Counsel explicitly on irregular bleeding BEFORE fitting. Women who weren't warned are far more likely to request early removal. This counselling is a scored Tasks item.
"Your periods are likely to become much lighter and may stop altogether — this is actually a benefit for most women. There will be some irregular spotting at first, usually for around 3–6 months."
SCA pearl: Distinguish IUS (hormonal, period-lightening) from Cu-IUD (non-hormonal, period-heavying). Candidates frequently confuse them. Period benefit = IUS; hormone-free = Cu-IUD.
"The copper coil has no hormones at all — it works by affecting how sperm move. Your periods may become heavier initially. If you ever get pregnancy symptoms or abdominal pain, contact us urgently."
SCA pearl: Cu-IUD is the most effective emergency contraception available and works regardless of weight or enzyme-inducing medication. Mention this proactively — many patients don't know it can be used as EC.
"The injection lasts 12 weeks — you don't need to think about contraception in that time. Your periods will likely change and may stop, which many women find convenient. It can take up to a year for your normal cycle to return after stopping."
SCA pearl: Always counsel on fertility delay before starting DMPA. A woman who wants to conceive within 12 months should not receive DMPA. This is a scored Tasks item under safety-netting.
Mood & mental health
DMPA has the strongest evidence for mood deterioration in women with pre-existing depression. COC and POP have weaker, mixed evidence. Some women notice significant improvement in PMS with COC.
Ask at every review: "How has your mood been since starting this method?" If DMPA-related mood change is confirmed, switch to Cu-IUD.
Document any mood change attributed to contraception in clinical records with patient's own words.
"Some women find their mood is affected by hormonal methods — if you notice any change, please don't stop taking it suddenly, come and talk to me first."Libido & sexual function
COC reduces sex hormone binding globulin (SHBG), which can lower free testosterone and reduce libido. This may persist even after stopping COC in some women.
POP and implant have less clear evidence on libido. Cu-IUD has no hormonal effect on libido.
Ask about sexual wellbeing at annual review — it is not often volunteered but is a significant quality-of-life factor.
"A small number of women notice a change in their sex drive on hormonal contraception — if this happens to you, please bring it up and we can look at alternatives."Menstrual pattern changes
All methods alter bleeding pattern. COC typically gives regular, lighter, predictable withdrawal bleeds. Implant/POP cause irregular unpredictable spotting. IUS causes amenorrhoea in 50%. DMPA amenorrhoea in 70% by year 1.
Warn of amenorrhoea explicitly before fitting IUS, implant or starting DMPA — unexpected amenorrhoea causes significant anxiety about pregnancy.
Reassure: amenorrhoea on these methods is safe — no blood is "backed up."
"It's quite common for your periods to become very light or stop on this method — that's a normal effect, not a sign of pregnancy."Relationships & partner dynamics
Some methods are not visible to partners (implant, IUS) — important for women in unsafe relationships who cannot disclose contraception use.
Male partner attitudes to contraception influence adherence significantly — address this without judgment.
Reproductive coercion (forced removal of IUD, pressure to stop pill) is a safeguarding concern — document and act on it.
"This method is completely private and your partner wouldn't know it's there — if that's something that matters for your situation, it's worth knowing."Work, study & daily life
Irregular bleeding from implant or POP can be disruptive to work and social activities. Amenorrhoea from IUS or DMPA may be advantageous for athletes and women with demanding schedules.
Pill-taking adherence is lowest in women with highly variable routines — LARC is a practical solution for these patients.
Post-insertion recovery from IUS (cramping for 1–2 days) may require brief time off work — plan the appointment accordingly.
"For the coil fitting, there might be some cramping for a day or two afterwards — it's worth planning it for when you don't have a heavy workload."Future fertility & long-term plans
Fertility returns immediately on stopping POP, COC, implant, IUS and Cu-IUD — no lasting fertility reduction from any of these methods.
DMPA is the exception: fertility delay of up to 12–18 months after last injection. This must be discussed before prescribing.
Offering LARC as a long-term option does not "lock in" a woman — all LARC methods are immediately reversible on removal.
"As soon as the implant is out, your fertility is back to what it was before — there's no need to wait before trying to conceive."3 months (COC / POP / DMPA start)
Blood pressure check (mandatory for COC); side effect review; adherence discussion; check no change in migraine, VTE symptoms, or medical history. Reassure on bleeding changes.
6 weeks (post-IUD/IUS insertion)
Thread check on speculum examination to confirm device in situ; review insertion-site pain; discuss ongoing bleeding pattern; reinforce emergency contact if threads not felt at home check.
Annual review (all methods)
BP (COC), BMI, STI risk review, cervical smear status, medication change check, UKMEC re-assessment. Review method satisfaction. Offer LARC discussion if on user-dependent method. Check future fertility plans. Document clearly.
LARC expiry review (implant 3 yrs; IUS 5–8 yrs; Cu-IUD 10 yrs)
Discuss continuation, switching method, or removal if wishing to conceive. Fit replacement LARC at same appointment as removal where possible (reduces unprotected gap). Ensure smear up to date.
Peri-menopausal transition (age ≥45)
Review whether method still appropriate. IUS (Mirena) can remain until age 55 if fitted ≥45 and provides endometrial protection for HRT. COC can continue to menopause if no CI but switch to HRT at 50–52 for menopausal symptom management. Cu-IUD fitted ≥40 can remain until 1 year post-menopause.
Memory rule
For user-dependent hormonal methods: BP at 3 months then annually (COC). For LARC: thread check at 6 weeks then annually. STI screen offer at every annual review if at-risk. DMPA: bone density review if >2 years use. UKMEC re-assessment at every change in medical history.
⚠ Three scenario-specific phrases — use these verbatim
Why safety-netting matters beyond clinical care
- No summary of plan at end of consultation — loses Tasks and GS marks
- No safety-netting — missing ectopic warning for IUD is patient safety failure
- No follow-up arranged — even if patient declines, offer must be documented
- No closing question ("anything else?") — loses Relating to Others mark
- No written information offered — NICE recommends written support for all contraception decisions
- Not documenting BP value / UKMEC assessment — medicolegally incomplete
- UKMEC assessment completed and documented
- Most appropriate method recommended with clinical justification
- EC or bridging method offered where relevant
- Pregnancy excluded before IUCD/hormonal start
- Follow-up arranged with specific timeframe
- Patient's own contraceptive preference elicited and acknowledged
- Hidden concerns (weight, cancer, fertility) explored and addressed
- Shared decision making — patient chose method, not examiner
- Non-judgmental throughout sexual history and risk assessment
- Reproductive coercion / safeguarding explored if cues present
- Closing question asked: "Is there anything else you'd like to ask?"
Who you are
Emma, 28 years old, primary school teacher. You've been with your boyfriend for 6 months and want to start contraception. Currently using condoms. You smoke 5 cigarettes a day but are embarrassed about this and don't volunteer it unless asked. You get migraines about once a month — you sometimes get a visual "zig-zag" before them that lasts about 15 minutes.
Hidden agenda
You're worried about weight gain on the pill — you've heard from friends that it makes you gain weight and you're self-conscious about this. You're also secretly worried it might affect your fertility when you want to try for a baby in 2-3 years. You won't mention these unless the doctor specifically asks about concerns.
Symptoms if asked directly
- Migraines: once a month, moderate severity; they last 6-8 hours; you get a visual "zigzag" (aura) for 15 minutes before them
- No personal history of blood clots; no family history (if specifically asked)
- Last period: 3 weeks ago; regular 28-day cycles
- No current medications
- Smoking: 5 cigarettes/day; reluctant to admit this initially
Lifestyle + bonus details
- BMI approximately 22 (slim build)
- Drinks alcohol at weekends (8-10 units)
- Exercises 3x per week; worried any weight gain would affect this
- Would be open to the implant if explained well — reveal this only if asked about preferences for something she doesn't need to take daily
Resolution: Accept the plan if: (1) The doctor explains the migraine aura finding in plain language without alarming language; (2) Offers an alternative that is equally effective (POP or ideally implant); (3) Addresses the weight gain concern with evidence; (4) Acknowledges the fertility question and provides accurate information about return of fertility; and (5) Offers a follow-up appointment.
- Ectopic features (unilateral pain, shoulder tip, collapse)
- DVT / PE on COC
- Stroke symptoms on COC
- Haemodynamic instability
- Sepsis with IUD in situ
- EC request — time-critical
- Pregnancy test positive
- Missed pills + unprotected sex
- Suspected PID with IUD
- Missing IUD threads
- New method counselling
- Method change (side effects)
- 3-month COC review
- Annual LARC check
| Method | What to check | Timing | Action if abnormal |
|---|---|---|---|
| COC | Blood pressure | Before start; 3m; annually | ≥160/100 = stop COC; switch POP/Cu-IUD |
| All | BMI / weight | Annually | BMI >35 = COC UKMEC 4; EC >70kg = UPA/Cu-IUD |
| IUD/IUS | Thread check | 6 weeks; annually | Missing threads = pelvic USS |
| DMPA | BMD; weight; mood | >2 years use | BMD loss = switch; supplement calcium/vit D |
| Implant | Palpability | 3m; annually | Non-palpable = X-ray/USS |
| All | STI screen (NAAT) | Annually if <25; new partner | Positive = treat; gonorrhoea = GUM referral |
→ "Do you get visual changes before headaches?" — UKMEC 4 if yes
→ Smoker ≥35 + ≥15/day = absolute COC CI
→ Must document pregnancy excluded before any IUCD insertion
→ Ask EC timing first; 72h LNG / 120h UPA / 5d Cu-IUD
→ UPA 30mg or Cu-IUD; LNG significantly less effective
→ Document: fertility up to 12 months to return; patient counselled
→ Always probe ideas, concerns (weight/fertility/cancer) and expectations
→ "One-sided pain or +ve test with coil → A&E immediately" — document
→ Document Fraser criteria in full; never refuse to a competent under-16