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Women Requesting Contraception β€” Clinical Algorithm UKMEC-guided method selection Β· Emergency contraception Β· Special populations Β· FSRH 2023
Progress 0 / 9
The full reasoning pathway β€” match the method to the person using UKMEC, reasonably exclude pregnancy, and use the categories to avoid prescribing where risks outweigh benefits. Counsel, modify factors, and safety-net.StartDecisionInvestigateActionReferStop / Admit
PresentationContraception request
Preferences, medical history, VTE/migraine/BP, current method. Reasonably exclude pregnancy. Check BP/BMI for hormonal methods.
Step 1 Β· Safety β€” UKMEC 4 / red flagsUKMEC 4 / red flags?
Migraine with aura + CHC (UKMEC 4 β€” stroke risk) Β· <6 weeks postpartum breastfeeding + CHC Β· high VTE risk Β· breast cancer Β· uncontrolled hypertension.
YES
Stop Β· EscalateAvoid / alternative
UKMEC 4 conditions β†’ avoid that method; offer a safe alternative (progestogen-only/LARC).
NO
AssessBy pattern
History + examination guide management.
Step 3 Β· choose by effectiveness & preference
LARC (most effective)
First-line β€” >99.9%, fit-and-forget
LNG-IUS: Mirena/Levosert 52mg (5yr, lightens periods, licensed for HMB/HRT) or smaller Kyleena 19.5mg/Jaydess 13.5mg for narrow canal. Implant: Nexplanon (etonogestrel, 3yr). Copper IUD: T-Safe Cu380A (non-hormonal, 5–10yr). Side effects: irregular bleeding early is normal β€” troublesome implant bleeding β†’ 3-month COC trial or mefenamic acid; copper IUD heavy periods β†’ switch to LNG-IUS.
CHC
If no contraindication (FSRH)
First-line: Microgynon 30 / Rigevidon (levonorgestrel + EE 30Β΅g) β€” lowest VTE. Acne/PMS: Yasmin (drospirenone) or Marvelon. Patch (Evra) / ring (NuvaRing) if daily pill the barrier. Typical failure ~9%/yr. Side effects: breakthrough bleeding >3 months β†’ change progestogen/generation; bloating β†’ drospirenone pill; new aura β†’ stop (UKMEC 4). Benefits: lighter bleeds, helps PMS/PCOS, ↓ ovarian/endometrial cancer.
POP / emergency
Flexible β€” no oestrogen
POP: Cerazette/Cerelle (desogestrel 75Β΅g, 12hr window) or Slynd (drospirenone, 24hr window). Injectable: Depo-Provera / Sayana Press (12-weekly). EC: ellaOne (UPA, ≀120hr, most effective) Β· Levonelle 1.5mg (≀72hr; double dose if >70kg) Β· Cu-IUD most effective. Side effects: irregular bleeding commonest reason to stop β†’ trial different POP or switch method.
Step 6 Β· ReferEscalation
Sexual health / contraception clinic LARC fitting, complex medical history, or UKMEC uncertainty. Use UKMEC for every prescribing decision.
Step 8 Β· counselling & modifiable factors
Step 8 Β· Counselling & modifiable factorsEffectiveness, STIs & risk reduction
Counsel on typical-use failure and that LARC is the most effective; advise condoms for STI protection alongside hormonal methods, and offer chlamydia screening. Address modifiable VTE/cardiovascular risk for CHC β€” BP, BMI, smoking (CHC contraindicated if β‰₯35 and smoking β‰₯15/day). Discuss bleeding-pattern expectations to aid continuation, and quick-start where pregnancy reasonably excluded.
Step 9 Β· review & safety-net
Step 9 Β· Review & safety-netFollow-up & urgent return advice
BP + review ~3 months after starting CHC, then annually; review LARC at expiry. Stop CHC and seek help for new migraine with aura, severe calf pain/swelling (VTE), chest pain or breathlessness (PE), or sudden neurological symptoms. Safety-net missed-pill rules and emergency-contraception access; reassess if bleeding is unscheduled beyond 3 months (exclude STI/pregnancy/pathology).
⚠️ Migraine with aura is UKMEC 4 for combined hormonal contraception β€” the oestrogen raises ischaemic stroke risk; switch to a progestogen-only or non-hormonal method.
1
Safety

Red Flags β€” Absolute contraindications & emergency presentations

Identify UKMEC 4 conditions (absolute contraindications) and presentations requiring urgent management before prescribing.

Current pregnancy Confirmed or suspected pregnancy β€” contraception is inappropriate. Urine Ξ²hCG if any doubt β†’ manage accordingly
Undiagnosed abnormal PV bleeding Must be investigated before initiating hormonal contraception β†’ could mask malignancy
Breast cancer (current or <5 years) All hormonal contraception UKMEC 4. Copper IUD only option. Refer to oncology if uncertain β†’ do not prescribe oestrogen or progestogen
Severe cardiovascular disease MI, stroke, TIA, pulmonary hypertension, complicated valvular disease β€” COCP UKMEC 4. Use POP, IUD, or specialist input.
Migraines with aura + COCP Absolute contraindication (UKMEC 4) β€” 2Γ— increased stroke risk. Switch to progestogen-only or copper IUD β†’ do not prescribe COCP
DVT/PE on anticoagulation COCP UKMEC 4 (thrombogenic). Use POP, IUS, or copper IUD. Check drug interactions with anticoagulants (e.g. liver enzyme inducers)
Emergency contraception window exceeded Levonorgestrel EC >72hr without extension. UPA-EC >120hr. Refer for copper IUD if ≀5 days post-unprotected intercourse β†’ most effective EC
Safeguarding / Fraser criteria concern Under 16: apply Fraser guidelines. Any concern about coercion, trafficking, or CSE β†’ safeguarding referral before prescribing. Document capacity and competence.
UKMEC (UK Medical Eligibility Criteria for Contraceptive Use, FSRH 2016 updated 2019) provides evidence-based framework for all contraceptive prescribing decisions. UKMEC 4 = absolute contraindication (risk unacceptable). Migraines with aura + COCP increases ischaemic stroke risk 2–8 fold β€” this interaction is one of the most commonly missed contraindications in general practice. Copper IUD is the most effective emergency contraceptive (99.9% effective up to 5 days) and can then serve as ongoing contraception.
2
Diagnose

Establish need & assess current situation

Understand why the patient is requesting contraception and their current contraceptive status.

Reason for request
New start, switching method, emergency contraception (EC), post-pregnancy, post-abortion, pill running out
Current contraception
What are they using now? Why switching? (side effects, failure, inconvenience, partner change, new relationship)
Pregnancy test
Urine Ξ²hCG β€” mandatory before IUD/IUS insertion and whenever pregnancy possible. Also before UPA-EC (can inhibit implantation of existing pregnancy)
LMP
Last menstrual period β€” to confirm current pregnancy status. Quick start criteria: can start hormonal contraception at any time if pregnancy excluded or 21 days post-delivery
Current medications
Enzyme inducers (rifampicin, carbamazepine, phenytoin, St John's Wort) β†’ render COCP, POP, implant, and patch ineffective. Switch to DMPA, IUD, or IUS
STI screen needed?
If new partner or <25 years and sexually active β†’ opportunistic chlamydia screen (NAAT) before IUD/IUS insertion. Treat active PID before fitting.
Smear due?
Check cervical screening status β€” opportunistic reminder. Overdue smear does not delay contraception start.
Future fertility plans
Timing of desired pregnancy influences method choice. Reversibility and return to fertility timeline must be discussed.
FSRH 2023 Quick Start Guidance allows contraception initiation at any point in the menstrual cycle β€” this removes barriers to access without waiting for "day 1" and is evidence-based. Enzyme inducers reduce levonorgestrel levels by up to 50% β€” a missed drug interaction is a significant cause of contraceptive failure. Undiagnosed chlamydia at IUD insertion increases pelvic infection risk; BASHH guidelines recommend STI screening before intrauterine device insertion in women at risk.
3
Diagnose

UKMEC Eligibility Assessment β€” Systematic medical history

Apply UKMEC categories systematically. UKMEC 1 = use freely; 2 = benefits outweigh risks; 3 = risks outweigh benefits (relative CI); 4 = absolute CI.

Age
<16: Fraser criteria + capacity assessment. >35 + smoker: COCP UKMEC 3–4. >40: consider perimenopause management. >50: contraception until 2 years after LMP
BMI
BMI >35: COCP UKMEC 3 (VTE risk). Norethisterone patches less effective if >90kg. POP, IUD, IUS, implant unaffected by weight.
BP
Check BP before COCP. Systolic >160 or diastolic >100: COCP UKMEC 4. POP UKMEC 1 at all BP levels.
Smoking
>35 years + >15 cigarettes/day: COCP UKMEC 4. <35 or <15/day: COCP UKMEC 2. Always advise smoking cessation.
Migraine
Without aura: COCP UKMEC 2. With aura: COCP UKMEC 4. POP UKMEC 2 in both. Implant UKMEC 2.
Diabetes
Without complications: COCP UKMEC 2. With vascular disease: COCP UKMEC 3–4. IUS UKMEC 2 for all.
VTE history
History of DVT/PE: COCP UKMEC 4. POP UKMEC 2. Copper IUD UKMEC 1. Factor V Leiden: seek specialist advice before COCP.
Breastfeeding
COCP: avoid <6 weeks postpartum (affects milk). POP, IUS, IUD, implant: safe from day 21 post-delivery even while breastfeeding
Liver disease
Active liver disease, hepatocellular carcinoma, hepatitis: COCP UKMEC 4. Copper IUD UKMEC 1 (non-hormonal).
The UKMEC framework replaces clinical judgment with evidence-based categorical risk assessment β€” reducing both under-prescribing (denying contraception inappropriately) and over-prescribing (prescribing in absolute contraindications). Studies show GP prescribing errors are most common in women with migraines with aura, hypertension, and enzyme-inducing medications. The FSRH provides an online UKMEC tool (ukmec.org) that can be used in consultations.
4
Diagnose

Patient Preference & Tailored Method Selection

After excluding UKMEC contraindications, establish patient preference. All UKMEC 1–2 methods are medically appropriate β€” patient choice drives selection.

Efficacy priority
LARC (Long-Acting Reversible Contraception) = most effective. Implant, IUS, and copper IUD >99.9% typical use. No user-dependent failure.
Period preferences
Wants lighter/no periods: LNG-IUS (Mirena) or implant β†’ amenorrhoea in many. Wants normal periods: copper IUD or barrier methods. Irregular bleeding acceptable? β€” implant, DMPA.
Convenience
Daily: COCP, POP. Weekly: patch. Monthly: vaginal ring. 3-monthly: DMPA injection. 3–10 years: IUS, IUD. 3 years: implant
Fertility return
Wants pregnancy soon: avoid DMPA (median 9–10 months return). Fastest return: POP, COCP (within 1 month), IUD/IUS (immediate on removal), implant (within 1 week)
Non-hormonal preference
Copper IUD (10 year, most effective) or barrier methods (condom β€” also STI protection). Discuss efficacy honestly: condoms 82% typical use vs IUD 99.9%
Hormonal concerns
Validate concerns empathetically. Discuss actual evidence for mood changes, libido, weight. Some have genuine adverse hormonal responses β€” offer alternatives, not dismissal.
FSRH standards mandate that contraception counselling covers all available methods (not just what the prescriber is familiar with) and documents that patient preference has been explored. LARCs are 20Γ— more cost-effective than user-dependent methods (NICE 2019 costing report) because they eliminate user failure β€” the main driver of unintended pregnancy. Shared decision-making, not prescriber preference, should determine method selection.
5
Diagnose

Investigations Before Prescribing

Blood pressure
Mandatory before COCP, patch, ring. Target <140/90. Recheck 3 months after starting. Annual thereafter.
Pregnancy test
Urine Ξ²hCG β€” mandatory before IUD/IUS insertion. Quick start: if >21 days since LMP without unprotected sex, test is not required but document reasoning.
STI screen
Chlamydia NAAT before IUD/IUS in women <25 or new/multiple partners. Can insert same visit if swab taken (treat positive result, remove device if develops PID)
Weight/BMI
For COCP (UKMEC risk stratification). DMPA: document weight β€” average gain 2–3kg over 2 years, counsel before prescribing. Not a CI but affects counselling.
NOT routinely needed
Clotting screen (unless personal/family history VTE). Pelvic USS (unless symptomatic). Hormone levels (FSH/LH/oestradiol). Cervical smear before starting contraception (arrange separately if overdue).
Blood pressure measurement before COCP is the single most important investigation β€” oestrogen-containing contraceptives increase BP in approximately 5% of users and can precipitate hypertensive crisis. Routine thrombophilia screening before COCP is not cost-effective or evidence-based (FSRH 2019) β€” it does not significantly reduce VTE risk in unselected populations and causes inappropriate anxiety and delays. STI testing before IUD insertion is targeted, not universal.
6
Refer

Referral Criteria β€” When to involve specialist services

Sexual Health Clinic
Complex UKMEC 3–4 scenarios. IUD/IUS insertion if GP not trained. Difficult cervix / previous failed insertion. Adolescents requiring enhanced support.
Gynaecology
Failed/problematic IUD removal. Lost threads. Suspected IUD perforation (post-insertion pain + negative threads). Sterilisation request.
Urgent Gynaecology
Suspected IUD perforation with acute symptoms. PID not responding to oral antibiotics within 72hr. Actinomyces on cervical smear + symptomatic.
Specialist Contraception
Enzyme-inducing medication + needing highly effective contraception. Multiple UKMEC 3 conditions. Medically complex patients (HIV, transplant, autoimmune conditions on immunosuppressants).
Oncology liaison
Breast cancer (current/recent) requesting contraception β€” copper IUD is likely only option; confirm with oncology team
GP manages
All standard UKMEC 1–2 prescribing. Follow-up for side effect management. Switching between methods. EC (LNG-EC and UPA-EC).
GPs with DFSRH/DRCOG qualifications can fit IUDs and implants β€” but this requires formal training and ongoing competency maintenance. Non-trained GPs should refer for LARC insertion rather than default-prescribing user-dependent methods, which have higher failure rates. Sexual health clinics offer same-day access to full contraceptive range including LARC, EC, and STI services β€” patients should be aware of direct-access options.
7
Treat

Method-Specific Prescribing & Emergency Contraception

Long-Acting Reversible Contraception (LARC) β€” Recommend as first-line:

Wants no hormones
Copper IUD >99.9%
UK brands: T-Safe Cu380A, TT380 Slimline, Nova-T 380, Flexi-T. Lasts 5–10 yr. Also EC if fitted ≀5 days. Refer if not trained to fit.
Wants lighter periods
LNG-IUS
Mirena 52mg (5 yr; licensed for HMB & HRT) or Levosert/Benilexa 52mg. Smaller frame: Kyleena 19.5mg (5 yr) or Jaydess 13.5mg (3 yr) β€” better for nulliparous/narrow canal. Reduces HMB ~90%; amenorrhoea ~20% at 1 yr.
Wants set-and-forget
Subdermal Implant (Nexplanon)
Etonogestrel 68mg. 3 years. >99.9% effective. Insertion: inner upper arm. Irregular bleeding is main side effect (~40%).

Combined hormonal contraception (COCP) β€” if no UKMEC 3/4 contraindication:

First-line (2nd gen)
Microgynon 30 / Rigevidon / Ovranette / Levest / Maexeni β€” levonorgestrel 150Β΅g + EE 30Β΅g, OD 21 days then 7-day break (or tricycle). Lowest VTE risk β€” start here. Loestrin 20/30 (norethisterone) if lower oestrogen wanted.
Acne / PMS / bloating
Anti-androgenic pills β€” Yasmin/Lucette (drospirenone), Marvelon/Mercilon (desogestrel), Femodene/Millinette (gestodene). Slightly higher VTE than 2nd-gen β€” reserve for a clear indication.
Marked acne / hirsutism
Co-cyprindiol (Dianette/Clairette) β€” cyproterone + EE. Effective contraceptive but higher VTE; stop 3–4 months after acne controlled, not for long-term contraception alone.
Non-daily combined
Patch β€” Evra weekly Γ—3/4 weeks (less effective if >90kg). Ring β€” NuvaRing/SyreniRing, one ring for 3 weeks. Same CIs as COCP. Useful if daily pill burden is the barrier.

Progestogen-only methods:

POP (desogestrel)
Cerazette / Cerelle / Feanolla / Zelleta β€” desogestrel 75Β΅g OD continuously, 12hr missed-pill window, inhibits ovulation in 97%. Preferred over traditional POPs. No VTE increase β€” safe where COCP contraindicated.
POP (drospirenone)
Slynd β€” drospirenone 4mg, 24/4 regimen with a 24hr window and a hormone-free interval; useful if missed-pill timing is a problem.
POP (traditional)
Noriday (norethisterone) / Norgeston (levonorgestrel) β€” strict 3hr window. Largely superseded by desogestrel; only if specifically needed.
Injectable
Depo-Provera (medroxyprogesterone 150mg) IM every 12 weeks, or Sayana Press (SC, self-administered). Warn: irregular bleeding then amenorrhoea, ~2–3kg weight gain, reversible BMD loss, delayed fertility return (median ~10 months).

Emergency Contraception:

Levonorgestrel EC
Levonelle 1.5mg stat ≀72hr (licensed). Can use ≀96hr off-label. Double dose (3mg) if >70kg / BMI >26 or on an enzyme inducer. Efficacy 95% at ≀24hr, falls to 58% at 48–72hr. No effect on existing pregnancy. Quick-start ongoing method same day.
Ulipristal acetate
ellaOne 30mg stat ≀120hr. More effective than LNG-EC, especially 72–120hr and around ovulation. Avoid if on/just-started hormonal contraception (reduces efficacy) β€” wait 5 days before starting/restarting COCP/POP; avoid in severe asthma on oral steroids.
Copper IUD
Most effective EC (>99.9%). Insert ≀5 days post-UPSI or ≀5 days of estimated ovulation. Becomes ongoing contraception. FSRH: offer to all women requesting EC.

Side effects & switching β€” next steps if not tolerated:

COCP breakthrough bleeding
Common in first 3 months β€” reassure, check pill-taking, exclude missed pills, STI & pregnancy. Persisting >3 months β†’ try a different progestogen/generation (e.g. Microgynon β†’ Marvelon or Femodene) or a higher-progestogen pill; consider tricycling.
COCP nausea / breast tenderness / bloating
Usually settles by 3 months β€” take at night with food. Persistent bloating/fluid β†’ trial drospirenone pill (Yasmin). Breast tenderness β†’ lower oestrogen (20Β΅g, e.g. Loestrin 20/Gedarel 20).
COCP low mood / reduced libido
Trial a different progestogen, or switch to a non-hormonal/LARC method. Don’t add an antidepressant without a method switch first.
COCP headaches in pill-free week
Try tricycling (3 packs back-to-back) or continuous use. New aura β†’ stop COCP immediately (UKMEC 4) and switch to POP/IUS/copper IUD.
POP / implant irregular bleeding
Commonest reason for stopping β€” exclude STI/pregnancy, reassure. FSRH: a 3-month trial of a COC (if no CI) or mefenamic acid can help troublesome implant bleeding. Persistent on POP β†’ trial a different POP or switch method (no POP proven better for bleeding).
DMPA weight gain / BMD concern
Counsel on ~2–3kg gain; if troublesome, switch to implant/IUS/POP. Reassess after 2 years (reversible BMD loss); review at age 50 β†’ consider IUS for perimenopause.
Copper IUD heavier / more painful periods
Tranexamic + mefenamic acid for the first few months; if persistent and unacceptable, switch to LNG-IUS (lightens bleeding).
NICE PH51 (Contraception 2019) recommends LARC as first-line for all eligible women β€” typical use failure rates: IUD 0.1%, implant 0.05%, COCP 7–9%, condoms 13–18%. Desogestrel POP (Cerazette) inhibits ovulation in 97% of cycles (vs traditional POPs: 60%) β€” this is a clinically significant advantage in younger women. UPA-EC (ellaOne) maintains 85% efficacy at 72–120hr vs LNG-EC which drops to <60% β€” the difference is clinically meaningful and women should be informed of this choice.
8
Lifestyle

Counselling, Adherence & STI Prevention

Missed pill rules COCP: <24hr late β€” take immediately, continue as normal. >24hr late β€” use condoms 7 days, consider EC if missed week 1 pills. POP (desogestrel): >12hr late β€” use condoms 2 days.
STI protection No contraceptive method except condoms protects against STIs. Discuss dual protection β€” especially with new partners. Recommend condom use even with hormonal method if STI risk present.
Smoking cessation Mandatory discussion for all COCP users β€” smoking + oestrogen synergistically increases cardiovascular risk. Refer to NHS Stop Smoking Service. Reduces VTE and stroke risk substantially.
Drug interactions β€” patient awareness St John's Wort (available OTC) reduces hormonal contraceptive efficacy. Broad-spectrum antibiotics do NOT reduce COCP efficacy (FSRH 2017) β€” no additional precautions needed routinely.
D&V protocol Vomiting within 2 hours of COCP/POP β†’ repeat pill immediately. Severe diarrhoea lasting >24hr β†’ use barrier method. Provide written instructions at first prescribing.
Implant/IUD aftercare Implant: arm bruising normal for 1 week. IUD: period-type cramps 24–48hr. Check threads 4–6 weeks after IUS/IUD insertion. Contact if pain, fever, missing threads, or pregnancy symptoms.
Mood & mental health Some women experience mood changes on hormonal contraception. Validate and offer alternatives. Progesterone in DMPA may affect mood β€” monitor. Not evidence-based to prescribe antidepressants alongside hormonal contraception without trial of method switch.
Cervical screening reminder Ensure cervical smear is up to date (25–49: every 3 years; 50–64: every 5 years). Hormonal contraception does not increase cervical cancer risk (HPV infection is the driver).
Incorrect missed pill advice is a major driver of contraceptive failure in UK primary care. FSRH 2011 updated missed pill guidance β€” old advice about antibiotics reducing efficacy was wrong and has been corrected. A large Danish cohort study (NEJM 2016, n=1 million women) found a modest increased risk of depression with hormonal contraception β€” this is real but NNT is large. Women deserve accurate information, not minimisation, to make informed choices. LARC counselling should explicitly address the benefit of no missed doses.
9
Safety

Follow-Up, Monitoring & Safety-Netting

3 months
First COCP/POP review: BP recheck, side effects, adherence, satisfaction. Address bleeding changes (IUS/implant: spotting is expected for up to 6 months).
6 weeks post-IUD/IUS
Thread check β€” confirm threads palpable at cervical os. If threads missing β†’ USS to confirm in situ. Ask about pain, fever, discharge.
Annual
COCP repeat prescription: BP check (mandatory). Reassess UKMEC eligibility as medical history changes. Reassess ongoing need and satisfaction with method.
DMPA
Every 12 weeks (Β±2 weeks) for injection. After 2 years of use: discuss bone density (reversible reduction). Reassess at age 50 β€” consider switch to IUS/IUD for perimenopausal management.
Implant
Replace at 3 years. Annual check: arm β€” confirm device still palpable. Provide card with insertion date and removal due date.
999 safety-net
Post-IUD/IUS: severe abdominal pain + fever + haemodynamic instability (uterine perforation, sepsis). VTE symptoms on COCP: unilateral leg swelling, chest pain, breathlessness.
Same-day safety-net
Positive pregnancy test on contraception. Missing IUD threads. New severe headache on COCP (possible migraine with aura β€” must stop immediately). Signs of PID after IUD.
Blood pressure monitoring at 3 months and annually is a contractual Quality Outcomes Framework (QOF) requirement for COCP prescribing, and is evidence-based β€” new hypertension on COCP occurs in approximately 5% of users and requires method switch. Thread check at 6 weeks post-IUD catches the highest-risk period for expulsion (5% first-year rate) and perforation (1–2 per 1000 insertions). DMPA bone density reduction is clinically significant in adolescents β€” FSRH recommends reassessing DMPA use after 2 years in women under 18.
Educational use only. Pathway based on: FSRH Contraception Guidelines 2023, UKMEC 2016 (updated 2019), NICE PH51 Long-Acting Reversible Contraception 2019, BASHH Guidelines, FSRH Emergency Contraception 2020, FSRH Quick Starting Contraception 2017. Always adapt to individual patient context and local formulary.