• Discuss:
• What method the woman has in mind, and what she understands about the method.
• Other methods that are available.
• Her requirements for contraception, including future plans for having children.
• Her age, health, and any drugs she is using — see Common situations which influence contraceptive choice.
• Pros and cons of suitable methods, including effectiveness, convenience, advantages, disadvantages, and risks.
• Her personal beliefs and views.
• Her circumstances, including the attitudes of her partner and family towards contraception.
• Her previous experience with contraception.
• Her sexual health risks and advice on safer sex.
• Explain that she can try any suitable non-permanent method for a few weeks or months to see how she likes it.
• Identify any relevant conditions or medication which could affect choice of contraceptive.
• Common situations which influence contraceptive choice include:
• Age approaching menopause
• Age under 18 years
• Antibiotics, antifungals, anticonvulsants, St John's Wort, and antiretrovirals
• Breastfeeding or a recent delivery
• Diabetes
• Epilepsy
• Headache (migrainous or non-migrainous)
• Hypertension
• Menorrhagia, fibroids, previous ectopic pregnancy
• Multiple risk factors for cardiovascular disease
• Obesity
• Sexually transmitted infection or pelvic inflammatory disease
• Smoking
• Venous thromboembolism (current and risk factors for)
• For more information, check the UK Medical Eligibility Criteria.

• Person-centred care:
• Treatment and care should take into account women's individual needs and preferences [National Collaborating Centre for Women's and Children's Health, 2005; WHO, 2005; FFPRHC, 2006c; FPA, 2007].
• Counselling about contraception should be sensitive to cultural differences and religious beliefs [National Collaborating Centre for Women's and Children's Health, 2005; WHO, 2005; FPA, 2007].
• Recommended standards for person-centred care in sexual health services are given on the MedFASH website — www.medfash.org.uk.
• Clinical standards on person-centred care in service provision (e.g. consent, confidentiality, record keeping, medicine risk management) are published by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC), on their website www.ffprhc.org.uk.
• Compare the advantages and disadvantages of contraceptive methods appropriate to the woman.
• If appropriate, take cost-effectiveness into account when advising on a suitable method [National Collaborating Centre for Women's and Children's Health, 2005]:
• All currently available long-acting reversible contraceptive methods — copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (IUS), progestogen-only injectables and implants — are more cost effective than combined oral contraceptives (COCs), even at 1 year of use.
• Copper IUDs, the levonorgestrel-releasing IUS, and progestogen implants are more cost effective than progestogen injectables.
• Increasing the uptake of long-acting reversible contraceptive methods will reduce the number of unintended pregnancies.
• For details about each method, see:
• Combined oral contraceptive pills (COCs)
• Combined contraceptive patch
• Combined contraceptive vaginal ring
• Progestogen-only contraceptives (pills, implant, injectables)
• Copper intrauterine devices (IUDs); levonorgestrel-releasing intrauterine system (IUS)
• Barrier methods (male and female condoms; diaphragm and cap), and spermicides
• Sterilization, male and female
• Natural family planning (fertility awareness-based methods, lactational amenorrhoea method)

When providing contraception to young people, take account of:

• Communication of the level of confidentiality [FFPRHC, 2004b]:
• Inform young people seeking contraceptive advice and services that confidentiality is to be expected from all members of the healthcare team, but that other professionals, such as teachers and youth workers, may not have the same duty of confidentiality.
• Inform a young person under 16 years of age in advance that confidentiality might be broken if maltreatment, exploitation, or coercion is suspected:
• If information is to be shared or confidentiality breached, the young person will be informed and her consent sought.
• Consent is not essential if the disclosure is justified.
• The timing of any reporting or breach of confidentiality will be carefully considered.
• Legal and ethical issues:
• The legal age of consent to sexual activity is 16 years in Scotland, England, and Wales, and 17 years in Northern Ireland. Sexual activity under the age of consent is an offence even if consensual and is considered more serious (statutory rape) when the person is less than 13 years of age [FFPRHC, 2004b].
• In England and Wales, it is lawful to provide contraceptive advice and treatment to girls under the age of 16 years without parental consent, provided that the healthcare professional is satisfied that the Fraser guidelines have been met [Teenage Pregnancy Unit, 2001; FFPRHC, 2004b; Wheeler, 2006].
• The Fraser guidelines are a set of criteria which must be fulfilled when contraceptive services are provided to people less than 16 years of age without their parent's knowledge or permission:
• The young person understands the advice given to her by the health professional.
• The young person cannot be persuaded to inform her parents, or to allow the health professional to inform them.
• It is likely that the young person will continue to have sexual intercourse, with or without the use of contraception.
• The young person's physical or mental health may suffer as a result of withholding contraceptive advice or treatment.
• It is in the best interests of the young person for the clinician to provide contraceptive advice or treatment, or both, without parental consent.
• In Scotland, similar criteria apply under The Age of Legal Capacity Act 1991. The Act appears to assign more legal rights to children under 16 years of age, in that parental responsibility cannot authorize procedures that a competent child has refused [Sterrick, 2006; Wheeler, 2006].
• Consider child protection issues, including the possibility of exploitation or coercion, when providing contraception to girls younger than 16 years of age [National Collaborating Centre for Women's and Children's Health, 2005].
• Competence to consent to treatment [FFPRHC, 2004b]:
• Assess a young person's competence to consent to treatment by her ability:
• To understand the information provided and
• To weigh up the risks and benefits and
• To express her own wishes.
• If a young person is determined to be competent, this should be documented in the case notes.
• Documentation [FFPRHC, 2004b]:
• Document assessments made of vulnerabilities, e.g. Fraser criteria.

• The mnemonic UPSIC (UnProtected Sexual InterCourse) can help to remember all these points:
• Understands
• Parents
• Sex/Suffer
• Interests
• Confidentiality; Coercion an issue?

[Guillebaud, 2007]

• Women with learning and/or physical disabilities should be supported in making their own decisions about contraception [National Collaborating Centre for Women's and Children's Health, 2005].
• Contraception should be seen in terms of the needs of the individual rather than in terms of relieving the anxieties of carers or relatives [National Collaborating Centre for Women's and Children's Health, 2005].
• Assess a woman's competence to consent to treatment by her ability [FFPRHC, 2004b]:
• To understand the information provided and
• To weigh up the risks and benefits and
• To express her own wishes.
• When a woman with a learning disability cannot understand and take responsibility for decisions about contraception, carers and other involved parties should meet to address issues around the woman's contraceptive need and to establish a care plan [National Collaborating Centre for Women's and Children's Health, 2005].
• For more information, see the Reference guide to consent for examination or treatment published by the Department of Health [DH, 2001].

• Take into consideration the local prevalence of sexually transmitted infections, the person's age, and their sexual activity.
• Consider their risk for having been exposed to sexually transmitted infection, including HIV:
• Ask about their current circumstances, current and recent sexual partners, age of onset of sexual activity, type of sexual activity and use of alcohol and other substances.
• Key groups at risk of sexually transmitted infections include:
• People involved in prostitution.
• Men who have sex with men.
• People who have come from or who have visited areas of high HIV prevalence (and have been sexually active there).
• Behaviours that increase the risk of sexually transmitted infections include:
• Misuse of alcohol and/or substances ('recreational' drugs), and especially sharing equipment such as needles.
• Early onset of sexual activity.
• Sexual activity without protection (e.g. provided by condoms).
• Frequent change of and/or multiple sexual partners.

• Basic rules on sexual history taking [RCGP and BASHH, 2006]:
• Privacy and the assurance of confidentiality are essential.
• Many STIs can be asymptomatic, but when symptoms are present (see below), the patient may not link them to an STI, so you may have to raise the subject sensitively.
• Do not make assumptions about:
• Sexual orientation (a married man may still have sex with other men).
• Age (sexual liberation is not exclusive to the young).
• Anything!
• Sometimes you will need to ask direct questions when the person does not volunteer information; explain why you need to ask something, but only ask what is relevant.
• Embarrassment can be infectious; try not to let your own feelings/opinions interfere.
• Have a non-judgemental attitude.
• Clarify terms: 'sex' does not always mean peno-vaginal penetration, and many sexually transmitted infections are spread easily from oral or anal sex.
• Be aware that condoms are often put on after some penetration has already taken place, and condoms also split/come off.
• Be alert to non-consensual sex and child protection issues.
• Alcohol and drug use can lead to risk-taking sexual behaviour, and financial difficulties may lead to prostitution.

• These recommendations are based on guidelines from the Faculty of Sexual and Reproductive Healthcare (FSRH), (formerly the Faculty of Family Planning and Reproductive Healthcare [FFPRHC]), and the National Institute for Health and Clinical Excellence, and information from the fpa (Family Planning Association) [Belfield et al, 2006; FFPRHC, 2006b; RCGP and BASHH, 2006; NICE, 2007a].

Advise that:

• The risks of unsafe sex include:
• Unwanted pregnancy
• Cervical cancer
• Infertility
• Sexually transmitted infections (STIs), such as:
• Chlamydia
• Genital herpes
• Genital warts
• Gonorrhoea
• Hepatitis A, B, and C
• HIV
• Non-specific urethritis
• Syphilis
• Trichomonas vaginalis
• Infections can be passed from one person to another by:
• Penetrative sex (vaginal, oral, or anal)
• Non-penetrative sex, intimate skin-to-skin or hair-to-hair contact, and kissing, especially if semen or vaginal fluids come into contact with the genitals, anus, mouth, eyes, or broken skin.
• Sharing sex toys.
• People are often not aware that they have a sexually transmitted infection. It is therefore important to practice safe sex even when both partners believe that they are not infected.
• Tips for safe sex:
• The safest sex (apart from masturbation alone) is with a regular, 100% faithful partner. Sex with 'anonymous' partners is the riskiest. Sex with a best friend can be a risk if there is no discussion about other/previous partners.
• Any cut, sore, or open skin lesion on the finger, should be covered (e.g. with waterproof plasters, or by wearing latex gloves) during genital or anal foreplay. Hands should be washed after anal foreplay.
• A condom (male or female) should be used when having sex with someone who is not a regular, faithful partner, or when the regular, faithful partner has a sexually transmitted infection.
• A condom should be put on before the penis contacts the partner's genitals, anus, or mouth.
• When having oral sex, a male or female condom should be used, or a dam used to cover the anus or female genitals.
• Oral sex and genital sex should be avoided if either partner:
• Has a sexually transmitted infection.
• Has sores, cuts, ulcers, blisters, warts, or rashes around the genitals, anus, or mouth.
• Has any unhealed or inflamed piercings in the mouth or genitals.
• Oral sex should be avoided if either partner has a throat infection.
• Where there is a risk of STI, avoid:
• Giving oral sex to a woman who is menstruating.
• Brushing or flossing teeth shortly before or after giving someone oral sex (as this can cause the gums to bleed).
• Semen and vaginal fluid should be kept out of the eyes.
• Sex toys should be washed and/or covered with a new condom before they are shared.
• When having penetrative anal sex, the condom should be lubricated with a water-based or silicone lubricant, avoiding oily lubricants and spermicides (as they can weaken the condom enough for it to split). The condom should be changed when moving between anal and vaginal sex. If no spare condom is available, progress should be from the vagina to the anus rather than from the anus to the vagina.
• Any symptoms that might be caused by a sexually transmitted infection, such as itchiness or swelling around the genitals, or an unusual discharge, should prompt abstinence. The partner should be told, and a GP or sexual health clinic consulted.

Reassure that:

• People cannot catch, or pass on, sexually transmitted infections by: hugging; sharing baths or towels; swimming pools, toilet seats; or sharing cups, plates, or cutlery. However, genital warts, pubic lice, and scabies can be passed on by intimate contact, including skin-to-skin or hair-to-hair.
• Except for herpes, people cannot catch, or pass on, sexually transmitted infections by kissing.
• Warts on the hand cannot be passed to the genitals.

[Belfield et al, 2006]

• A woman is unlikely to be pregnant if she has no signs or symptoms of pregnancy and meets at least one of the following criteria. She:
• Has not had intercourse since the start of the last normal period.
• Has been correctly and consistently using a reliable method of contraception.
• Some experts would not regard condoms or natural family planning as reliable enough to exclude the possibility of pregnancy.
• Is within 7 days after the start of a normal period.
• Is within 7 days after abortion or miscarriage.
• Is fully or nearly fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
• Is not breastfeeding and less than 3 weeks postpartum, or has had no unprotected sex since delivery.
• A pregnancy test can support the assessment, but only if 3 weeks have elapsed since the date of last intercourse.

• These criteria are helpful in ruling out pregnancy in most clinical circumstances. However, other means must be used to exclude pregnancy when these criteria do not apply:
• For example, the criteria cannot be used to exclude pregnancy in women who are 4 weeks or more postpartum and not breastfeeding, or in women who are amenorrhoeic and not less than 6 months postpartum.

• These criteria for ruling out pregnancy are recommended by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FFPRHC, 2002].
• Inconsistency in current FFPRHC guidance with regard to requiring additional contraception between day 21 or 28 will be removed by the end of 2007 [Brechin, Personal Communication, 2007].

• If pregnancy cannot be excluded (for example, following emergency contraception) but the woman wishes to start contraception without delay, the following methods can be used:
• Combined hormonal contraception (pill, patch, vaginal ring).
• Progestogen-only pill.
• Progestogen-only implant.
• If pregnancy cannot be excluded and the woman's preferred method is not available or appropriate, combined hormonal contraception or the progestogen-only pill can be used as a bridging method.
• In either case, the woman should be informed of the potential risks and of the need to have a pregnancy test 3 weeks after the last episode of unprotected sex.

• The recommendations are based on the guidance Quick starting contraception issued by the Faculty of Reproductive and Sexual Healthcare (FSRH) [FSRH, 2010e].
• Inadvertent fetal exposure to contraceptive hormones is common. A USA study estimated that about 70,000 fetuses are exposed to oral contraceptive annually. Most of the data on fetal outcomes relates to COC. The available data do not suggest that the COC is associated with any specific abnormalities.

Provided that there are no medical contraindications, a girl should be enabled to use her chosen method of contraception.

• From menarche to 17 years of age:
• Combined hormonal contraception (the pill, vaginal ring, or patch), the progestogen-only pill or implant, and barrier methods can be used.
• The benefits of long-acting reversible contraception should be highlighted.
• Depot medroxyprogesterone acetate or an intrauterine device or system can be used in young women under the age of 18 years, after consideration of other methods.
• Before menarche:
• Sexually active girls who have not yet started menstruating should be advised against regular hormonal contraception.
• Advocate the use of condoms — as a contraceptive and to prevent sexually transmitted infection.
• Give advice about prevention of sexually transmitted infections.
• The correct and consistent use of condoms should be advised to reduce the risk of sexually transmitted infections.
• Young people should be advised to get tested for sexually transmitted infections 2 and 12 weeks after unprotected sexual intercourse.
• Concerns about possible effects — reassure girls and young women that:
• Bone mineral density is influenced by normal pubertal development, exercise, diet, smoking, and some hormonal contraception.
• The use of depot medroxyprogesterone acetate is associated with a small loss of bone mineral density which is usually recovered after discontinuation.
• However, this should not deter a girl should she choose a progestogen-only injectable over other contraceptive methods, provided that she is not at increased risk for osteoporosis.
• Risk of cancer — combined oral contraceptives (COC) use is not associated with an overall increased risk of cancer.
• COCs reduce the risk of ovarian and endometrial cancer and, with less than 5 years' use, do not increase the risk of cervical cancer.
• Depot medroxyprogesterone acetate does not appear to have any effect on the risk of ovarian, endometrial, or cervical cancer.
• Any increase in risk of breast cancer associated with hormonal contraception is small, and there is no effect of duration of use.
• Acne — COCs may improve acne vulgaris. The occurrence of acne can be a reason for discontinuing progestogen-only implants and progestogen-only injectables. Co-cyprindiol is indicated to treat severe acne which has not responded to oral antibiotics. The incidence of venous thromboembolism is about 4 times higher in women using co-cyprindiol than in women using low-dose oestrogen COCs. It should be withdrawn 3–4 months after the treated condition has resolved. If there is no improvement after 6 months consider withdrawing it. For more information see the CKS topic on Acne vulgaris.
• Venous thromboembolism — the risk of venous thromboembolism is increased with use of COCs, but the absolute risk is very low. Progestogen-only contraceptives do not appear to increase the risk of venous thromboembolism.
• Weight gain — there is no evidence of weight gain with use of COCs or patch. Weight gain may occur with depot medroxyprogesterone. However, weight gain is common in all women, and may simply reflect the normal increase in weight expected during the early reproductive years, and with changes in eating habits and activity levels.
• Mood — it is unclear whether hormonal contraception has an adverse effect on mood.
• Bleeding patterns and dysmenorrhoea — young women should be informed that altered bleeding patterns can occur with hormonal contraception use. However, dysmenorrhoea may improve with use of combined hormonal contraception.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FFPRHC, 2004b; FFPRHC, 2007b; FSRH, 2010b], and those issued by the Committee on the Safety of Medicine regarding the use of cyproterone acetate and its risk of venous thromboembolism [CSM, 2002].

• The usual (non age-related) UK Medical Eligibility Criteria apply, but if there are no other contraindications to use:
• Methods that can be used without restriction by perimenopausal women include:
• Copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (IUS), progestogen-only pill, progestogen-only implants, barrier methods, and sterilization.
• Progestogen-only injectables can be used without restriction up to the age of 45 years. In women over the age of 45 years, the benefits generally outweigh the risks.
• Natural family planning is not generally recommended because irregular menstrual cycles in the menopause make this method difficult to learn and use.
• Combined hormonal contraception (the combined contraceptive pill, patch, or vaginal ring) is not contraindicated by age alone in perimenopausal women, however:
• It should not be used (unacceptable health risk) by women 35 years of age or older who smoke 15 or more cigarettes a day, or who develop migraine without aura while using combined hormonal contraception.
• It is not usually recommended (risks usually outweigh the advantages) for women 35 years of age or older who smoke less than 15 cigarettes a day, or who quit smoking less than 1 year ago, or for women 35 years of age or older who have a history of migraine without aura.
• Where the combined oral contraceptive (COC) pill is suitable, a pill containing 20 micrograms ethinylestradiol is a reasonable first choice.
• Non-contraceptive benefits can influence the choice of contraceptive for women with:
• Vasomotor symptoms (hot flushes): combined hormonal contraception may reduce symptoms.
• Women experiencing menopausal symptoms while using combined hormonal contraception may wish to try an extended regimen.
• Osteoporosis: combined hormonal contraception may increase bone mineral density; depot medroxyprogesterone acetate may reduce bone mineral density.
• Menstrual pain, bleeding, and irregularity: combined hormonal contraception may reduce symptoms.
• Menstrual pain: progestogen-only methods may reduce symptoms.
• Heavy menstrual bleeding: the levonorgestrel-releasing IUS reduces menstrual bleeding and can cause amenorrhoea.
• Hormone replacement therapy (HRT):
• Women using combined HRT should not rely on this as contraception.
• A progestogen-only pill can be used with combined sequential HRT to provide effective contraception and adequate endometrial protection (a progestogen-only pill used with oestrogen-only HRT will not provide an adequate level of endometrial protection; combined continuous HRT regimens are not appropriate in this age group due to bleeding).
• The levonorgestrel–releasing IUS can be used as the progestogenic component for HRT for 5 years (the licence states 4 years), and provide concurrent contraception.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Healthcare [FSRH, 2010c].

• The copper intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (IUS) can be retained longer during the perimenopause
• Women who have an IUD inserted at age 40 years or older may retain the device until they no longer require contraception, even if this is beyond the duration of UK Marketing Authorisation.
• Women who have an IUS inserted at age 45 years or older may retain the device until they no longer require contraception, even if this is beyond the duration of UK Marketing Authorisation.
• Stopping non-hormonal contraception (copper intrauterine device, condoms) at the menopause
• Women less than 50 years of age should continue contraception for 2 years after the last period.
• Women aged 50 years or more should continue contraception for 1 year after the last period.
• Stopping hormonal contraception at the menopause
• Menstrual bleeding patterns are unhelpful in determining menopause when a woman is using hormonal contraception. Amenorrhoea may be due to contraceptive hormones (progestogen-only pills, progestogen-only injectables and implants, or the levonorgestrel-releasing IUS). Regular bleeding may be due to use of combined oral contraceptives.
• Combined hormonal contraception (pill, patch or vaginal ring) or a progestogen-only injectable
• Switch to another suitable contraceptive method at 50 years of age (amenorrhoea may not indicate the menopause).
• Condoms or another method should be used for 2 years after stopping progestogen-only injectables (return of ovulation can be delayed).
• The follicle-stimulating hormone (FSH) level is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free interval.
• Progestogen-only pills, progestogen-only implants, or levonorgestrel-releasing IUS
• Continue use to age 55 years, when natural loss of fertility can be assumed for most women (96%), or
• For women over the age of 50 years who are amenorrhoeic, check FSH on two occasions, with an interval of 6 weeks between tests. If both levels are more than 30 IU/L, this is highly suggestive of ovarian failure, and contraception may be stopped after 1 more year.

• These recommendations are based on guidelines published by the National Institute for Health and Clinical Excellence [National Collaborating Centre for Women's and Children's Health, 2005] and the Faculty of Sexual and Reproductive Healthcare [FSRH, 2010c].

Anticonvulsants

• For women taking anticonvulsants, see Epilepsy.

Antibiotics

• No contraceptive reduces the antibiotic effect but in certain circumstances the contraceptive effect is reduced.
• For women taking antibiotics that induce liver enzymes (rifampicin and rifabutin):
• Methods that can be used without restriction: depot medroxyprogesterone, copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (IUS), barrier methods, and natural family planning methods.
• Methods that generally can be used (advantages generally outweigh the risks): progestogen-only implant or depot norethisterone enantate (the consistent use of condoms is also recommended).
• Methods that should not usually be used (risks usually outweigh the benefits): combined oral contraceptives (COCs), combined contraceptive patch, combined contraceptive vaginal ring, progestogen-only pill.
• For women taking antibiotics that do not induce liver enzymes:
• Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper IUDs, the levonorgestrel-releasing IUS, and barrier methods.
• Methods that generally can be used (advantages generally outweigh the risks): COCs, combined contraceptive patch, and combined contraceptive vaginal ring.
• Additional protection (such as condoms) should be used for the first three weeks of a long antibiotic course, and during a short antibiotic course and for up to 7 days after stopping it.
• Note: the combined contraceptive vaginal ring can be used with amoxicillin and doxycyline without the need for additional barrier contraception.
• There are no methods that should not be used.

Antifungals

• Women taking fluconazole, itraconazole, and ketoconazole, and griseofulvin: all methods can be used without restriction. Note: antifungal pessaries may increase the risk of ring breakage if used with a combined contraceptive vaginal ring.

Antiparasitics

• All methods can be used without restriction.

Antiretroviral therapy

• Antiretroviral drugs have the potential to either decrease or increase the bioavailability of steroid hormones in hormonal contraceptives. These interactions may alter the safety and effectiveness of the hormonal contraceptive and the antiretroviral drug. Consider consulting a specialist as advances in knowledge are rapid in this area.
• If a woman on antiretroviral therapy decides to start or continue a hormonal contraceptive, the consistent use of condoms is recommended to prevent HIV transmission and to compensate for potential reductions in the effectiveness of the hormonal contraceptive.
• Nucleoside reverse transcriptase inhibitors:
• Methods that can be used without restriction: COCs, combined contraceptive patch, combined contraceptive vaginal ring, progestogen-only pill, depot medroxyprogesterone, and progestogen-only implants.
• Methods that generally can be used (advantages generally outweigh the risks): copper IUDs and the levonorgestrel-releasing IUS can be inserted or continued if the woman is clinically well on antiretroviral therapy. However, if the woman is not clinically well, a copper IUD or the levonorgestrel-releasing IUS should not usually be inserted (the risks usually outweigh the advantages). Depot norethisterone enantate can generally be used.
• Non-nucleoside reverse transcriptase inhibitors:
• Methods that can be used without restriction: depot medroxyprogesterone.
• Methods that generally can be used (advantages generally outweigh the risks): COCs, combined contraceptive patch, combined contraceptive vaginal ring, progestogen-only pill, progestogen-only implants, depot norethisterone enantate. Copper IUDs and the levonorgestrel-releasing IUS can be inserted or continued if the woman is clinically well on antiretroviral therapy. However, if the woman is not clinically well, a copper IUD or the levonorgestrel-releasing IUS should not usually be inserted (the risks usually outweigh the advantages).
• Ritonavir-boosted protease inhibitors:
• Methods that can be used without restriction: depot medroxyprogesterone.
• Methods that generally can be used (advantages generally outweigh the risks): progestogen-only implants, depot norethisterone enantate. Copper IUDs and the levonorgestrel-releasing IUS can be inserted or continued if the woman is clinically well on antiretroviral therapy. However, if the woman is not clinically well, a copper IUD or the levonorgestrel-releasing IUS should not usually be inserted (the risks usually outweigh the advantages).
• Methods that should not usually be used (risks usually outweigh the benefits): combined oral contraceptives (COCs), combined contraceptive patch, combined contraceptive vaginal ring, and progestogen-only pills.
• Sterilization can be done with extra precautions, and the procedure may need to be delayed if the woman has an AIDS-related illness. The consistent use of condoms is recommended after sterilization.

St John's wort

• Methods that can be used without restriction: progestogen-only injectables, copper IUDs, levonorgestrel-releasing IUS, barrier methods, natural family planning methods, and sterilization.
• Methods that should not usually be used (risks usually outweigh the benefits): COCs, combined contraceptive patch, combined contraceptive vaginal ring, progestogen-only pill, and progestogen-only implants.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FFPRHC, 2005d; FFPRHC and BASHH, 2006; FSRH, 2009b].
• Drugs that induce liver enzymes may reduce the efficacy of hormonal contraception by increasing the metabolism of ethinyl estradiol and progestogens.
• Some antibiotics that do not induce liver enzymes can temporarily reduce the efficacy of some hormonal contraceptives by altering colonic bacteria. Therefore women using these antibiotics should use additional protection (such as condoms) for the first three weeks of a long antibiotic course, and during a short antibiotic course and for up to 7 days after stopping it.
• The recommendations relating to the combined contraceptive vaginal ring are based on the Summary of Product Characteristics of NuvaRing^® [ABPI Medicines Compendium, 2009b] and a New product review from the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FSRH, 2009a].

• Contraception is not needed in the first 20 days after delivery, but is required from day 21 if the woman is not fully breastfeeding and does not want to become pregnant.
• Women who are breastfeeding and are less than 6 weeks postpartum
• Methods that can be used without restriction: lactational amenorrhoea method (if fully or almost fully breastfeeding and amenorrhoeic), progestogen-only pill, progestogen-only implants, copper intrauterine devices (IUDs) and the levonorgestrel-releasing intrauterine system (IUS) (use within 48 hours or from 4 weeks after delivery), and barrier methods.
• The National Institute for Health and Clinical Excellence recommends that the IUD and IUS be inserted at least 4 weeks after delivery.
• Methods that can generally be used (advantages generally outweigh the risks): progestogen-only injectables.
• Methods that are not usually recommended (risks usually outweigh the advantages): copper IUDs (from 48 hours up to 4 weeks after delivery) and the levonorgestrel-releasing IUS (from 48 hours up to 4 weeks after delivery).
• Methods that should not be used (because of unacceptable health risk): combined oral contraceptives (COCs), combined contraceptive patch, and combined contraceptive vaginal ring.
• Fertility awareness–based methods: a previous user can start from day 21, but a new user should delay learning to use the method until her periods start.
• Sterilization is usually delayed until the woman is 6 weeks or more postpartum.
• Women who are fully or almost fully breastfeeding and are between 6 weeks and 6 months postpartum
• Methods that can be used without restriction: lactational amenorrhoea method (if amenorrhoeic), progestogen-only pill, progestogen-only injectables and implants, copper IUDs, levonorgestrel-releasing IUS, barrier methods, and sterilization.
• Fertility awareness–based methods: a previous user can start, but a new user should delay learning to use the method until her periods start.
• Methods that are not usually recommended: COCs, combined contraceptive patch, and combined contraceptive vaginal ring.
• Women who are not fully or almost fully breastfeeding and are between 6 weeks and 6 months postpartum
• Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper IUDs, the levonorgestrel-releasing IUS, barrier methods, and sterilization.
• Methods that can generally be used (advantages generally outweigh the risks): COCs, combined contraceptive patch, and combined contraceptive vaginal ring.
• Fertility awareness–based methods: a previous user can start, but a new user should delay learning to use the method until her periods start.
• There are no methods that should not be used (because of unacceptable health risk).
• For women who are breastfeeding and are 6 months or more postpartum
• Methods that can be used without restriction: COCs, combined contraceptive patch, combined contraceptive vaginal ring, progestogen-only pill, progestogen-only injectables and implants, copper IUDs, the levonorgestrel-releasing IUS, barrier methods, and sterilization.
• Fertility awareness–based methods: a previous user can start, but a new user should delay learning to use the method until her periods start.
• The lactational amenorrhoea method does not provide adequate protection from unplanned pregnancy after 6 months postpartum.
• Fertility awareness–based methods should be delayed. Fertility signs and hormonal changes are unlikely to be detectable before 4 weeks postpartum.
• Sterilization is usually delayed until the woman is 6 weeks or more postpartum.

• Full and partial breastfeeding
• The term postpartum includes any births, including stillbirths from 24 weeks' gestation.
• Full breastfeeding is defined as exclusive when no other liquids or solids are given, and as almost exclusive when vitamins, water, or juice is given infrequently in addition to breastfeeds.
• Partial breastfeeding is defined as:
• High when the majority of feeds are breastfeeds.
• Medium when about half of feeds are breastfeeds.
• Low when the majority of feeds are not breastfeeds.
• The term almost fully breastfeeding includes almost exclusive breastfeeding and high partial breastfeeding.

[FFPRHC, 2006a]

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FSRH, 2009b].
• Combined hormonal contraceptives may reduce the volume of breast milk if used before 6 weeks postpartum.
• Combined hormonal contraceptives do not appear to affect infant growth if used after 6 weeks postpartum, although the evidence of their effect on the quality and quantity of breast milk is poor.
• Combined hormonal contraceptives can be used safely, but are unlikely to be required, in women who are fully or almost fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
• The National Institute for Health and Clinical Excellence recommends that the IUD and IUS be inserted at least 4 weeks after delivery [National Collaborating Centre for Women's and Children's Health, 2005].

• Women with diabetes mellitus (insulin and non–insulin dependent) and no vascular disease
• Methods that can be used without restriction: copper intrauterine devices (IUDs), barrier methods, and natural family planning methods.
• Methods that can generally be used (advantages generally outweigh the risks): combined oral contraceptives (COCs), combined contraceptive patch, combined contraceptive vaginal ring, progestogen-only pill, progestogen-only injectables and implants, and the levonorgestrel-releasing intrauterine system (IUS).
• Sterilization should be undertaken with caution.
• There are no methods that should not be used.
• Women with diabetes mellitus and nephropathy, retinopathy, neuropathy, or other vascular disease
• Methods that can be used without restriction: copper IUDs, barrier methods, and natural family planning methods.
• Methods that can generally be used (advantages generally outweigh the risks): progestogen-only pill, progestogen-only implant, and the levonorgestrel-releasing IUS.
• Methods that should not usually be used (risks usually outweigh the advantages): progestogen-only injectables.
• COCs, the combined contraceptive patch, and the combined contraceptive vaginal ring should either not be used (unacceptable health risk) or should generally not be used (risks generally outweigh the advantages), depending on the severity of the vascular complications.
• Sterilization can be used but should be done in a setting with experienced healthcare professionals and back-up medical support.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FSRH, 2009b].

• Women with a history of epilepsy who are not taking anticonvulsants
• All methods can be used without restriction.
• Women taking anticonvulsants that do not induce liver enzymes (i.e. gabapentin, levetiracetam, sodium valproate, vigabatrin)
• All methods can be used without restriction, except that sterilization should be undertaken with caution and seizures should be adequately controlled.
• Women taking anticonvulsants that induce liver enzymes (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)
• Methods that can be used without restriction: depot medroxyprogesterone acetate, copper intrauterine devices, the levonorgestrel-releasing intrauterine system, barrier methods, and natural family planning methods.
• Methods that can generally be used (benefits generally outweigh the risks): progestogen-only implant, depot norethisterone enantate.
• Sterilization can be used with caution (with extra preparation, and counselling).
• Methods that should not usually be used (risks usually outweigh the benefits): combined oral contraceptives, combined contraceptive patch, combined contraceptive vaginal ring, progestogen-only pill.
• If combined oral contraceptives are chosen, dose adjustment may be needed. For more information about dose adjustment, see Liver enzyme-inducing drugs.
• Women taking lamotrigine
• Methods that can be used without restriction: progestogen-only pills, injectables and implants, copper intrauterine devices, the levonorgestrel-releasing intrauterine system, barrier methods, and natural family planning methods.
• Methods that should not usually be used (risks usually outweigh the benefits): combined oral contraceptives, combined contraceptive patch, combined contraceptive vaginal ring.
• If combined oral contraception is chosen, dose adjustment may be needed. For more information about dose adjustment, see Lamotrigine and Drug interactions.

• Drugs that induce liver enzymes may reduce the efficacy of hormonal contraception by increasing the metabolism of ethinylestradiol and progestogens.
• For details, see the UK Medical Eligibility Criteria.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Health Care (FFPRHC) [FFPRHC, 2005d; MacGregor, 2007; FSRH, 2009b].

• Women with non-migrainous headaches
• Methods that can be used without restriction: initiation of combined oral contraceptives (COCs), the combined contraceptive patch, combined contraceptive vaginal ring; progestogen-only pill, progestogen-only injectables and implants, copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (IUS), barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh the risks): continuation of COCs, the combined contraceptive patch and combined contraceptive vaginal ring in women who develop non-migrainous headaches while taking combined hormonal contraceptives.
• Women with migraine without aura, at any age
• Methods that can be used without restriction: copper IUDs, initiation of progestogen-only pill, barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh risks): initiation of COCs, the combined contraceptive patch, combined contraceptive vaginal ring; continuation of progestogen-only pills; progestogen-only injectables and implants, the levonorgestrel IUS.
• Methods that should generally not be used (risks usually outweigh advantages): continuation of COCs, the combined contraceptive patch, combined contraceptive vaginal ring.
• Women with migraine with aura, at any age
• Methods that can be used without restriction: copper IUDs, barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh the risks): progestogen-only pill, progestogen-only implants and injectables, and the levonorgestrel-releasing IUS.
• Methods that should not be used (unacceptable risk): COCs, the combined contraceptive patch, and the combined contraceptive vaginal ring.
• Women with a past history (>= 5 years ago) of migraine with aura, at any age
• Methods that can be used without restriction: copper IUDs, barrier methods, and natural family planning.
• Methods that can be used without restriction: initiation of the progestogen-only pill, copper IUDs, barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh the risks): the progestogen-only pill, progestogen-only implants and injectables, and the levonorgestrel-releasing IUS.
• Methods that are not usually recommended (risks usually outweigh the advantages): COCs, the combined contraceptive patch, and combined contraceptive vaginal ring.

• Aura are focal neurological symptoms that start before the headache. Aura are due to cerebral ischaemia, which causes such symptoms as visual disturbances, homonymous hemianopia, unilateral paraesthesia and/or numbness, unilateral weakness, and aphasia, or unclassifiable speech disorder.
• For more information on cautions and contraindications when providing a contraceptive, see the UK Medical Eligibility Criteria.
• Migraine without aura: managing increased frequency/severity of headache on starting combined hormonal contraception.
• The UKMEC recommend that women who are using a combined hormonal contraceptive and have increased frequency or severity of migraine headaches should stop the contraceptive [FFPRHC, 2006a]. Although attacks may increase when combined hormonal contraceptives are initiated, there is usually improvement with continued use. Women can be advised that if headache or migraine increases in the first cycle of use, there is only a one in three chance of experiencing headache in the second cycle and a one in ten chance of experiencing headache in the third cycle [Loder et al, 2005]. There is no evidence that the risk of stroke is increased in these circumstances [MacGregor, 2007].

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Health Care (FFPRHC) [FSRH, 2009b].

• Women with hypertension that is adequately controlled
• Methods that can be used without restriction: progestogen-only pill, progestogen-only implants, copper intrauterine devices (IUDs), levonorgestrel-releasing intrauterine system (IUS), barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh risks): progestogen-only injectables.
• Sterilization can be used with caution (extra preparation, precautions and counselling), with blood pressure controlled before surgery.
• Methods that are not usually recommended (risks usually outweigh the advantages): combined oral contraceptives (COCs), the combined contraceptive patch, and combined contraceptive vaginal ring.
• Women with consistently increased systolic blood pressure of more than 140 mmHg and less than 160 mmHg, or diastolic blood pressure more than 90 mmHg and less than 95 mmHg, without vascular disease:
• Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper intrauterine devices (IUDs), levonorgestrel-releasing intrauterine system (IUS), barrier methods, and natural family planning.
• Sterilization can be used with caution (extra preparation, precautions and counselling), with blood pressure controlled before surgery.
• Methods that are not usually recommended (risks usually outweigh the advantages): combined oral contraceptives (COCs), the combined contraceptive patch, and combined contraceptive vaginal ring.
• Women with consistently increased systolic blood pressure 160 mmHg or more, or diastolic blood pressure 95 mmHg or more, without vascular disease
• Methods that can be used without restriction: progestogen-only pill, progestogen-only implants, copper IUDs, levonorgestrel-releasing IUS, barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh the risks): progestogen-only injectables.
• Sterilization can be used but should be done in a setting with experienced healthcare professionals and medical support. Blood pressure should be controlled before surgery.
• Methods that should not be used (because of unacceptable risk): COCs, the combined contraceptive patch, and combined contraceptive vaginal ring.
• Women with hypertension and vascular disease
• Methods that can be used without restriction: copper IUDs, barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh the risks): progestogen-only pill, progestogen-only implants, and the levonorgestrel-releasing IUS.
• Sterilization can be used but should be done in a setting with experienced healthcare professionals and medical support. Blood pressure should be controlled before surgery.
• Methods that are not usually recommended (risks usually outweigh the advantages): progestogen-only injectables.
• Methods that should not be used (because of unacceptable risk): COCs, the combined contraceptive patch, and combined contraceptive vaginal ring.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Health Care (FFPRHC) [FSRH, 2009b].

• Women with idiopathic menorrhagia
• Methods that can be used without restriction: combined oral contraceptives (COCs), combined contraceptive patch, combined contraceptive vaginal ring, and the levonorgestrel-releasing intrauterine system (IUS) (initiation), which all may reduce menstrual blood loss; sterilization.
• Methods that can generally be used (advantages generally outweigh the risks): progestogen-only pill (POP), progestogen-only injectables and implants, copper intrauterine devices (IUDs), the levonorgestrel-releasing IUS (continuation of use), barrier methods, and natural family planning methods (if the cycle is regular; if the cycle is irregular, a new user would find it more difficult to learn the method).
• Consider:
• The levonorgestrel IUS (Mirena^®) as the first-line contraceptive option (licensed indication).
• The COC as the second line contraceptive option.
• The POP and progestogen-only injectables as third line contraceptive options.
• For information on non-contraceptive treatments, see the CKS topic on Menorrhagia.
• Women with a history of ectopic pregnancy
• All methods can be used without restriction.
• However, methods of contraception that inhibit ovulation (i.e. COCs, progestogen-only injectables and implants) are particularly suitable, as they reduce ectopic pregnancy to a greater degree compared with other methods.
• Women with uterine fibroids
• Without distortion of the uterine cavity: all methods can be used without restriction.
• With distortion of the uterine cavity: copper IUDs and the levonorgestrel-releasing IUS should not be used if they cannot be easily fitted. All other methods can be used without restriction.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Health Care (FFPRHC) [FSRH, 2009b], and the National Institute for Health and Clinical Excellence [NICE, 2007b].
• Pharmacological treatments for heavy menstrual bleeding
• NICE recommends that pharmacological treatments be considered in the following order:
• Levonorgestrel-releasing intrauterine system (IUS) — provided long-term (at least 12 months) use is anticipated.
• Tranexamic acid, or nonsteroidal anti-inflammatory drugs (NSAIDs), or combined oral contraceptives (COCs).
• Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens [NICE, 2007b].

• Women with multiple risk factors for cardiovascular disease (e.g. older age, smoking, diabetes, hypertension, and obesity)
• Methods that can be used without restriction: copper intrauterine devices (IUDs), barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh the risks): progestogen-only pill, progestogen-only implants, and the levonorgestrel-releasing intrauterine system (IUS).
• Sterilization can be used but should be done in a setting with experienced healthcare professionals and back-up medical support.
• Methods that are not usually recommended (risks usually outweigh the advantages): progestogen-only injectables.
• Methods that should not be used (because of unacceptable risk): combined oral contraceptives, combined contraceptive patch, and combined contraceptive vaginal ring.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FSRH, 2009b].

• Body mass index >= 30–34 kg/m²
• Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (IUS), barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh the risks): combined oral contraceptives (COCs), combined contraceptive patch, combined contraceptive vaginal ring.
• Sterilization can be used with caution (i.e. extra preparation, precautions, and counselling).
• There are no methods that should not be used (because of unacceptable risk).
• Body mass index >= 35 kg/m²
• Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper IUDs, the levonorgestrel-releasing IUS, barrier methods, and natural family planning.
• Sterilization can be used with caution (i.e. extra preparation, precautions, and counselling).
• Methods that are not usually recommended (risks usually outweigh the advantages): COCs, combined contraceptive patch, combined contraceptive vaginal ring.
• In addition, note that:
• Weight greater than 70 kg — the desogestrel-only pill, Cerazette^®, should be considered in preference to other progesterone only pills.
• Weight greater than 90 kg — the combined contraceptive patch should not be used.
• 'Heavier women' — the progestogen-only contraceptive implant may need to be removed earlier than the licensed 3 years.

• Obesity
• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FSRH, 2009b] and the Summary of Product Characteristics (SPC) of Evra^® transdermal contraceptive patch [ABPI Medicines Compendium, 2009a].
• For women who are obese and use combined oral contraceptives (COCs), the combined contraceptive patch, or combined contraceptive vaginal ring, there is an increased risk of:
• Venous thromboembolism: compared with non-users, but the absolute risk of thromboembolism is still small. The risk of venous thromboembolism increases with increasing body mass index, and the use of COCs increases this risk further.
• Contraceptive failure: compared with women who are not obese, but the data on the impact of obesity on the effectiveness of COCs are limited.
• Women who are obese are more likely to have complications when undergoing sterilization. There is an increased risk of wound infection and disruption.
• POP and weight greater than 70 kg
• The FFPRHC on reviewing the available evidence concluded that POPs may be less effective in women who weigh more than 70 kg (except for the desogestrel-only pill, Cerazette^®) [FFPRHC, 2007c].
• The progestogen-only contraceptive implant and obesity
• The manufacturer states that the contraceptive effect of Implanon^® is related to the plasma levels of etonogestrel, which are inversely related to body weight, and decrease with time after insertion. The clinical experience with Implanon^® in heavier women in the third year of use is limited. Therefore it cannot be excluded that the contraceptive efficacy in these women during the third year of use may be lower than for women of normal weight. Clinicians may therefore consider earlier replacement of the implant in heavier women [ABPI Medicines Compendium, 2006].

• Contraception is not needed in the first 20 days after delivery, but is required from day 21 if the woman does not want to become pregnant.
• Women who are not breastfeeding and are less than 3 weeks postpartum
• Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, barrier methods, and natural family planning.
• Methods that are not usually recommended (risks usually outweigh the advantages): combined oral contraceptive pill (COC), combined contraceptive patch, combined contraceptive vaginal ring, copper IUDs and the levonorgestrel-releasing IUS (use within 48 hours or from 4 weeks after delivery). Fertility awareness–based methods should be delayed — fertility signs and hormonal changes are unlikely to be detectable before 4 weeks postpartum.
• Sterilization is usually delayed until the woman is 6 weeks or more postpartum.
• Women who are not breastfeeding and are 3 weeks or more postpartum
• Methods that can be used without restriction: COCs, combined contraceptive patch, combined contraceptive vaginal ring, progestogen-only pill, progestogen-only injectables and implants, copper IUDs and the levonorgestrel-releasing IUS (use within 48 hours or from 4 weeks after delivery), and barrier methods.
• Fertility awareness–based methods: a previous user can start, but a new user should delay learning to use the method until her periods start.
• Sterilization is usually delayed until the woman is 6 weeks or more postpartum.
• There are no methods that should not be used (because of unacceptable health risk).

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FSRH, 2009b].
• The National Institute for Health and Clinical Excellence recommends that the IUD and IUS be inserted at least 4 weeks after delivery [National Collaborating Centre for Women's and Children's Health, 2005].

• Women with a history of pelvic inflammatory disease and with no current risk factors for sexually transmitted infection (STI)
• All methods can be used without restriction.
• Women with current pelvic inflammatory disease
• Copper IUDs and the levonorgestrel-releasing IUS should not be inserted. However, there is generally no need for removal if the woman wishes to continue their use.
• All other methods can be used without restriction.
• Women with a current STI
• Chlamydia, or purulent cervicitis or gonorrhoea infection:
• Copper IUDs and the levonorgestrel-releasing IUS should not be inserted. However, there is generally no need for removal if the woman wishes to continue their use.
• All other methods can be used without restriction.
• Vaginitis, other STIs (excluding HIV and hepatitis), and increased risk of STIs:
• Copper IUDs and the levonorgestrel-releasing IUS can generally be used (advantages generally outweigh the risks).
• All other methods can be used without restriction.

• For further information see:
• UK Medical Eligibility Criteria;
• Assessing risk for STI;
• Advice about safer sex and STIs.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Health Care (FFPRHC) [FSRH, 2009b].

• Women less than 35 years of age and are currently smoking, or are 35 years of age or older and stopped smoking 12 or more months ago
• Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (IUS), barrier methods, natural family planning, and sterilization.
• Methods that can generally be used (advantages generally outweigh the risks): combined oral contraceptives (COCs), combined contraceptive patch, and combined contraceptive vaginal ring.
• There are no methods that should not be used (because of unacceptable risk).
• Women 35 years of age or older who smoke less than 15 cigarettes daily, or have stopped smoking in the past 12 months
• Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper IUDs, the levonorgestrel-releasing IUS, barrier methods, natural family planning, and sterilization.
• Methods that are not usually recommended (risks usually outweigh the advantages): COCs, combined contraceptive patch, and combined contraceptive vaginal ring.
• Women 35 years of age or older who smoke 15 or more cigarettes daily
• Methods that can be used without restriction: progestogen-only pill, progestogen-only injectables and implants, copper IUDs, the levonorgestrel-releasing IUS, barrier methods, natural family planning, and sterilization.
• Methods that should not be used (because of unacceptable risk): COCs, combined contraceptive patch, and combined contraceptive vaginal ring.

• Women who use combined oral contraceptives (COCs) and smoke are at increased risk of cardiovascular disease, especially myocardial infarction, compared with women who use COCs and do not smoke.
• The risk of myocardial infarction increases with the number of cigarettes smoked daily.
• Excess mortality from cigarette smoking is apparent from 35 years of age.
• Women who stop smoking reduce their risk of cardiovascular disease:
• After 1 year, the risk can be reduced by as much as 50%.
• It may take up to 10 years to reach the risk level of people who have never smoked.

[FFPRHC, 2006a]

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FSRH, 2009b].
• The guidance on the combined contraceptive vaginal ring is based on epidemiological data from combined oral contraceptives (COCs), as no specific data are currently available on the vaginal route of hormone administration. The warnings for COCs are considered applicable to the use of the combined contraceptive vaginal ring [ABPI Medicines Compendium, 2009b].

• Women with known thrombogenic mutations, history of venous thromboembolism, or taking anticoagulants for current venous thromboembolism
• Methods that can be used without restriction: copper intrauterine devices (IUDs), barrier methods, and natural family planning.
• Methods that can generally be used (advantages generally outweigh the risks): progestogen-only pill, progestogen-only implants and injectables, and the levonorgestrel-releasing intrauterine system (IUS).
• Methods that should not be used (because of unacceptable risk): combined oral contraceptives (COCs), the combined contraceptive patch, and combined contraceptive vaginal ring.

• For details, see the UK Medical Eligibility Criteria.

• These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Health Care (FSRHC), formerly the Faculty of Family Planning and Reproductive Health Care (FFPRHC) [FSRH, 2009b].

The UK Medical Eligibility Criteria are summarised in:

• Table for use of a combined hormonal contraceptive method, i.e. combined oral contraceptive pill, transdermal patch, and vaginal ring.
• Table for use of progestogen-only pills.
• Table for use of progestogen-only injectables.
• Table for use of progestogen-only implants.
• Table for use of a copper intrauterine device (IUD).
• Table for use of the levonorgestrel-releasing intrauterine system (IUS).
• Table for female sterilization.
• Table for male sterilization.
• Table for use of cervical mucus fertility awareness based methods.
• Barrier methods.

The UK Medical Eligibility Criteria (UKMEC) are a set of evidence-based recommendations designed to help women select the most appropriate method of contraception for specific clinical conditions without imposing unnecessary restrictions [FSRH, 2009b]. Each clinical condition has a recommendation for contraceptive use, categorized according to the balance of benefits and harms weighted by their probabilities for the typical user with the condition. The categories are defined in Table 1, and the eligibility criteria in Table 2.

Table 2 summarizes the UK Medical Eligibility Criteria for use of a combined hormonal contraceptive method, i.e. combined oral contraceptive (COC), combined contraceptive patch, and combined contraceptive vaginal ring.

The UK Medical Eligibility Criteria are a set of evidence-based recommendations designed to help women select the most appropriate method of contraception for specific clinical conditions without imposing necessary restrictions [FSRH, 2009b]. Each clinical condition has a recommendation for contraceptive use, categorized according to the balance of benefits and harms weighted by their probabilities for the typical user with the condition. The categories are defined in Table 1. Table 2 describes the UK Medical Eligibility Criteria for use of progestogen-only pills.

The UK Medical Eligibility Criteria are a set of evidence-based recommendations designed to help women select the most appropriate method of contraception for specific clinical conditions without imposing necessary restrictions [FSRH, 2009b]. Each clinical condition has a recommendation for contraceptive use, categorized according to the balance of benefits and harms weighted by their probabilities for the typical user with the condition. The categories are defined in Table 1. Table 2 describes the UK Medical Eligibility Criteria for use of progestogen-only injectables.

The UK Medical Eligibility Criteria are a set of evidence-based recommendations designed to help women select the most appropriate method of contraception for specific clinical conditions without imposing necessary restrictions [FSRH, 2009b]. Each clinical condition has a recommendation for contraceptive use, categorized according to the balance of benefits and harms weighted by their probabilities for the typical user with the condition. The categories are defined in Table 1. Table 2 describes the UK Medical Eligibility Criteria for use of progestogen-only implants.

The UK Medical Eligibility Criteria are a set of evidence-based recommendations designed to help women select the most appropriate method of contraception for specific clinical conditions without imposing necessary restrictions [FSRH, 2009b]. Each clinical condition has a recommendation for contraceptive use, categorized according to the balance of benefits and harms weighted by their probabilities for the typical user with the condition. The categories are defined in Table 1. Table 2 describes the UK Medical Eligibility Criteria for use of a copper-bearing intrauterine device (IUD).

The UK Medical Eligibility Criteria are a set of evidence-based recommendations designed to help women select the most appropriate method of contraception for specific clinical conditions without imposing necessary restrictions [FSRH, 2009b]. Each clinical condition has a recommendation for contraceptive use, categorized according to the balance of benefits and harms weighted by their probabilities for the typical user with the condition. The categories are defined in Table 1. Table 2 describes the UK Medical Eligibility Criteria for use of the levonorgestrel-releasing intrauterine system.

The UK Medical Eligibility Criteria are a set of evidence-based recommendations designed to help women select the most appropriate method of contraception for specific clinical conditions without imposing necessary restrictions [FFPRHC, 2006a]. Each clinical condition has a recommendation for contraceptive use, categorized according to the balance of benefits and harms weighted by their probabilities for the typical user with the condition. The categories are defined in Table 1.

• The UK Medical Eligibility Criteria for male condoms:
• All conditions are categorized as UKMEC 1 (no restriction), except for:
• Latex sensitivity, which is categorized as UKMEC 3.
• The UK Medical Eligibility Criteria for female condoms:
• All conditions are categorized as UKMEC 1.
• The UK Medical Eligibility Criteria for female barrier methods (diaphragm, cervical cap):
• All conditions are categorized as UKMEC 1 (no restriction), except for:
• Parity > 0, which is categorized as UKMEC 2.
• Valvular and congenital heart disease, complicated (e.g. with pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis), which is categorized as UKMEC 2.
• At high risk of HIV. or infected with HIV, or with AIDS, which are categorized as UKMEC 3.
• History of toxic shock syndrome,, which is categorized as UKMEC 3.
• Urinary tract infection, which is categorized as UKMEC 2.
• Latex sensitivity, which is categorized as UKMEC 3.

The UK Medical Eligibility Criteria are a set of evidence-based recommendations designed to help women select the most appropriate method of contraception for specific clinical conditions without imposing necessary restrictions [FFPRHC, 2006a]. Each clinical condition has a recommendation for contraceptive use, categorized according to the balance of benefits and harms weighted by their probabilities for the typical user with the condition. The categories are defined in Table 1. Table 2 describes the UK Medical Eligibility Criteria for female sterilization.

The UK Medical Eligibility Criteria are a set of evidence-based recommendations designed to help women and their partners select the most appropriate method of contraception for specific clinical conditions without imposing necessary restrictions [FFPRHC, 2006a]. Each clinical condition has a recommendation for contraceptive use, categorized according to the balance of benefits and harms weighted by their probabilities for the typical user with the condition. The categories are defined in Table 1. Table 2 describes the UK Medical Eligibility Criteria for male sterilization.