• 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.
• 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.
• Identify any relevant conditions or medication which could affect choice of contraceptive.

In depth

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.

In depth

• 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 < 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 patch.
• 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.
• For women who have had a recent delivery and are not breastfeeding, see Postpartum (not breastfeeding).

In depth

• 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.

In depth

• 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, valproate, and 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 done with caution.
• Methods that should not usually be used (risks usually outweigh the benefits): combined oral contraceptive, combined contraceptive patch, combined contraceptive vaginal ring, and 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.

In depth

• 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.

In depth

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.

In depth

• 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.

In depth

• 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.

In depth

• 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.

In depth

• 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).

In depth

• 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, 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.

In depth

• Women who are < 35 years of age and are currently smoking, or are >= 35 years of age and stopped smoking >= 12 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 who smoke < 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 who smoke >= 15 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.

In depth

• 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.

In depth