01Role and principlesWho benefits and the main preventive aims.
Shared decision-making begins before naming a preferred product. Ask what matters today, whether pregnancy would be acceptable, how long protection is wanted, whether a daily or pericoital task is realistic, and how the patient feels about bleeding changes, hormones, pelvic procedures and injections. Include non-contraceptive benefits such as lighter bleeding or dysmenorrhoea control. Use gender-inclusive anatomical language and do not infer pregnancy risk from identity, relationship status or age. A method is effective only if it is acceptable enough to start and continue.
Present effectiveness using the same denominator and distinguish typical from perfect use. NHS figures show over 99% typical-use effectiveness for the implant, copper IUD and hormonal IUD; 94% for injections; 91% for the combined pill, progestogen-only pill, patch and ring; 82% for external condoms; 79% for internal condoms; and 76% for natural family planning. This hierarchy reflects both biological effect and opportunities for human error. Avoid converting these figures into coercive pressure for a long-acting method.
Medical eligibility is a safety filter, not a ranking system. Take a focused history of migraine aura, smoking, blood pressure and vascular disease, venous thromboembolism, breast cancer, liver disease, postpartum status, medicines and relevant procedures. UKMEC 1 and 2 generally permit use, while category 3 requires careful expert judgement because risks usually outweigh benefits, and category 4 means do not use. Multiple category 2 factors can collectively matter even when no single factor prohibits a method.
Assess pregnancy risk through last normal menstrual period, cycle regularity, recent intercourse and correctly used contraception. A negative test detects hCG, not intercourse too recent to implant, so it cannot by itself exclude a very early pregnancy. When a method can be quick-started, explain uncertainty, provide the correct duration of additional precautions and arrange a urine pregnancy test 21 days after the latest relevant unprotected intercourse. Intrauterine insertion requires a sufficiently secure pregnancy exclusion because it cannot be managed by later testing alone.
Ask about condoms and STI testing separately. Condoms are the contraceptive method that also reduces STI transmission, but effectiveness depends on use from first genital contact, compatible lubricant, correct removal and a new device for every act. Offer testing according to exposure and local pathways without assuming monogamy. Emergency contraception should be discussed in advance for user-dependent methods so a failure becomes an actionable event rather than a delayed worry.
Preserve voluntariness. Offer part of the consultation without partners or carers, explain confidentiality and its safeguarding limits, check who controls medicines and appointments, and ask neutrally whether anyone is pressuring the patient to become pregnant or avoid pregnancy. Capacity is decision-specific and support should maximise understanding. Learning disability, young age, previous pregnancy, parity, housing status or clinician preference cannot justify steering a decision. A capable person may choose a less effective method after balanced counselling.
Close the consultation with operational details. State the exact method, start date, when contraceptive protection begins, what bleeding may occur, how to manage late or missed use, serious warning symptoms, and where to obtain supplies, removal or review. Record the person’s priorities and reasons in their own terms. Review is especially useful for adverse bleeding, new medicines or diagnoses, pregnancy intention change and methods nearing replacement, but routine attendance should not become a barrier to continuing a safe method.
Key points
- Start with the patient’s goal: avoiding pregnancy now, preferred timing of a future pregnancy, menstrual control, privacy, autonomy, infection protection and tolerance of procedures or daily tasks.
- Typical-use effectiveness is the fairest comparison for user-dependent methods: implant and intrauterine methods are over 99%, injection 94%, pills, patch and ring 91%, external condoms 82%, internal condoms 79% and fertility awareness 76%.
- Long-acting reversible contraception minimises adherence failure but is an option, not a default; obtain affirmative consent and make removal accessible whenever the patient requests it.
- Only external and internal condoms reduce transmission of sexually transmitted infections; another method can be combined with condoms when both pregnancy and infection prevention matter.
- Apply UKMEC to medical safety after identifying the patient’s acceptable methods: category 1 means no restriction, 2 generally usable, 3 usually not recommended without expert judgement and 4 unacceptable risk.
- Pregnancy can often be reasonably excluded from menstrual, sexual and contraceptive history; if uncertainty remains, quick-start many hormonal methods with backup and a correctly timed repeat pregnancy test.
- Discuss expected bleeding explicitly. Amenorrhoea may be welcome or concerning, irregular bleeding commonly drives discontinuation, and stopping a hormonal method may reveal the person’s untreated baseline periods.
- Document the decision, information given, method start, when protection begins, missed-use instructions, medicine interactions, follow-up and how to obtain emergency contraception or removal.
02Assessment and patient selectionRisk features, eligibility and important cautions.
Repeated missed pills, delayed injections or condom failures suggest that the practical workload does not match the patient’s life rather than a lack of motivation.
A copper device may worsen heavy periods while a levonorgestrel device may lighten them; the same efficacy ranking can therefore produce very different acceptable choices.
A partner answering every question, controlling transport or contraception, insisting on a particular method or opposing removal should prompt a private, safety-aware conversation.
Recent unprotected intercourse with a negative urine test can still precede detectable hCG, so timing and follow-up testing remain essential.
New or concurrent partners, uncertain testing status or an STI exposure makes condom counselling relevant even when a highly effective pregnancy-prevention method is used.
03Baseline assessmentMeasurements that guide the plan and track progress.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Pregnancy-risk historyFirst step - Why
- Determine whether pregnancy can be reasonably excluded and whether emergency contraception is still indicated.
- Interpretation and limitations
- Cycle dates, intercourse and correct method use provide timing context. A test alone cannot exclude conception from intercourse in the preceding three weeks.
- 02
Urine pregnancy test - Why
- Detect established pregnancy before methods or procedures for which pregnancy status changes care.
- Interpretation and limitations
- A positive result requires options and location assessment when symptomatic. Repeat 21 days after the latest relevant intercourse if a method is quick-started during uncertainty.
- 03
Blood pressure and body mass index - Why
- Identify important combined-hormonal eligibility factors and support safe baseline prescribing.
- Interpretation and limitations
- Blood pressure must be measured before CHC. BMI informs UKMEC and broader risk discussion but is not a universal barrier to effective contraception.
- 04
Focused medicine reconciliation - Why
- Detect enzyme induction, teratogenic treatment and reciprocal interactions before selecting a hormonal method.
- Interpretation and limitations
- Check prescribed, non-prescribed and herbal products. Carbamazepine, rifampicin and St John’s wort can alter options; lamotrigine has a different bidirectional interaction with CHC.
- 05
Targeted STI testing - Why
- Identify asymptomatic infection according to age, exposure, symptoms and local screening criteria.
- Interpretation and limitations
- Testing need is independent of contraceptive efficacy. Do not delay every method while awaiting results; intrauterine insertion has specific infection-risk procedures.
04InterventionsLifestyle, treatment and escalation options.
01ChoiceBuild the acceptable shortlistFirst stepA patient requests contraception or wants to change an existing method.+
- 1PreferredClarify pregnancy intentions, method duration, bleeding goals, STI needs, privacy, procedures, daily routines and prior experiences without assuming a preferred hierarchy.
- 2Compare typical-use effectiveness, reversibility, adverse effects and non-contraceptive benefits in absolute, consistent terms, then remove medically unsuitable options using current UKMEC.
- 3Let the patient choose among the remaining methods, document voluntary consent and provide a practical start, supply, removal and follow-up plan.
02Quick startAvoid an unnecessary access delayPreferredThe preferred hormonal method is requested outside its conventional menstrual start window.+
- 1Assess recent intercourse and offer emergency contraception first when indicated; use history and testing to define what is and is not known about pregnancy.
- 2Start an eligible method now when guidance permits, give method-specific additional precautions and explain that oral emergency contraception may alter timing.
- 3Arrange a pregnancy test 21 days after the latest unprotected intercourse and provide urgent advice for pain, collapse or pregnancy symptoms.
03Method problemRespond without blameA dose is missed, a device is late, a condom fails or the patient wants removal.+
- 1Establish the exact product, dates, intercourse and medicine changes because rules differ between formulations and replacement intervals.
- 2Apply product-specific missed-use and emergency-contraception guidance, supply bridging contraception and test for pregnancy at the correct interval.
- 3Offer continuation, switching or removal according to the patient’s preference and address the practical reason for failure rather than repeating generic instructions.
05Targets, monitoring and follow-upResponse, safety and longer-term review.
- Confirm method continuation, correct use, bleeding acceptability, adverse effects and whether pregnancy intentions or relationships have changed.
- Review new diagnoses, blood pressure where relevant and every prescribed, over-the-counter or herbal medicine for altered eligibility or effectiveness.
- Track replacement, injection and repeat-prescription dates with enough notice to prevent gaps, while keeping urgent access available after method failure.
- Revisit STI testing and condom needs according to exposure rather than treating a long-acting method as complete sexual-health care.
- Ask privately about control, concealment and reproductive pressure when behaviour or attendance suggests coercion, and avoid documenting details where unsafe access is possible.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Typical use is clinically honest
It captures missed doses and late replacements, allowing a patient to compare methods as they are lived rather than only under trial-perfect conditions.
Effectiveness is not acceptability
An over-99% method that a patient dislikes or cannot have removed promptly may be a worse decision than a voluntarily chosen user-dependent method.
A negative test has a clock
Urine testing reflects hCG production; it cannot exclude pregnancy from very recent sex, so the intercourse date determines when repeat testing becomes meaningful.
Removal is part of consent
Consent to insertion does not imply consent to continue, and access to timely removal is central to reproductive autonomy.
Condoms answer another question
Their lower typical pregnancy effectiveness does not reduce their unique value for infection prevention alongside a more effective contraceptive method.
07Common pitfallsFrequent interpretation and management errors.
- 01
Listing methods without first asking which outcomes, burdens and side effects matter to the patient.
- 02
Quoting perfect-use figures for pills or condoms while quoting typical-use figures for other methods.
- 03
Treating UKMEC category 2 as a contraindication or category 3 as routine prescribing without expert judgement.
- 04
Using a negative pregnancy test to dismiss intercourse that is too recent for hCG detection.
- 05
Pressuring a patient towards LARC, requiring partner agreement or delaying a requested removal.
- 06
Forgetting STI prevention, emergency contraception and the operational details needed after a method failure.