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Long-acting reversible contraception

Please refer to appendix A for key features of IUDs to discuss with women, and appendix B, which summarises issues affecting choice for specific groups and women with medical conditions.

Contraception and principles of care

Contraceptive provision

  • Women requiring contraception should be given information about and offered a choice of all methods, including long-acting reversible contraception (LARC) methods
  • Women should be provided with the method of contraception that is most acceptable to them, provided it is not contraindicated
  • Contraceptive service providers should be aware that:
    • all currently available LARC methods (intrauterine devices [IUDs], the intrauterine system [IUS], injectable contraceptives and implants) are more cost effective than the combined oral contraceptive pill even at 1 year of use
    • IUDs, the IUS and implants are more cost effective than the injectable contraceptives
    • increasing the uptake of LARC methods will reduce the numbers of unintended pregnancies

Provision of information and informed choice

  • Women considering LARC methods should receive detailed information—both verbal and written—that will enable them to choose a method and use it effectively. This information should take into consideration their individual needs and should include:
    • contraceptive efficacy
    • duration of use
    • risks and possible side-effects
    • non-contraceptive benefits
    • the procedure for initiation and removal/discontinuation
    • when to seek help while using the method
  • Counselling about contraception should be sensitive to cultural differences and religious beliefs

Contraceptive prescribing

  • A medical history should be taken as part of the routine assessment
  • Healthcare professionals should be familiar with nationally agreed guidance on medical eligibility and recommendations for contraceptive use
  • When considering choice of LARC methods for specific groups of women and women with medical conditions, healthcare professionals should be aware of and discuss with each woman any issues that might affect her choice
  • Healthcare professionals should exclude pregnancy before initiating any contraceptive methods
  • Healthcare professionals should supply an interim method of contraception at first appointment if required
  • Healthcare professionals should ensure that informed consent is obtained from the woman whenever any method of LARC is being used outside the terms of the UK Marketing Authorisation. This should be discussed and documented in the notes
  • Women who have a current venous thromboembolism (VTE) and need hormonal contraception while having treatment for the VTE should be referred to a specialist in contraceptive care

Contraception for special groups

  • Healthcare professionals should be aware of the law relating to the provision of advice and contraception for young people and for people with learning disabilities. Child protection issues and the Fraser guidelines should be considered when providing contraception for women younger than 16 years*
  • Women with learning and/or physical disabilities should be supported in making their own decisions about contraception
  • Contraception should be seen in terms of the needs of the individual rather than in terms of relieving the anxieties of carers or relatives
  • When a woman with a learning disability is unable to 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

Copper intrauterine devices

Decision making

  • Women should be given the following information:
    • contraceptive efficacy:
      • IUDs act by preventing fertilisation and inhibiting implantation
      • the licensed duration of use for IUDs containing 380 mm2 copper ranges from 5 to 10 years, depending on the type of device
      • the pregnancy rate associated with the use of IUDs containing 380 mm2 copper is very low (fewer than 20 in 1000 over 5 years)
      • there is no evidence of a delay in the return of fertility following removal or expulsion of IUDs
    • effect on periods:
      • heavier bleeding and/or dysmenorrhoea are likely with IUD use
    • risks and possible side-effects:
      • up to 50% of women stop using IUDs within 5 years; the most common reasons are unacceptable vaginal bleeding and pain
      • there is no evidence that IUD use affects weight
      • any changes in mood and libido are similar whether using IUDs or the IUS, and the changes are small
      • the risk of uterine perforation at the time of IUD insertion is very low (less than 1 in 1000)
      • the risk of developing pelvic inflammatory disease following IUD insertion is very low (less than 1 in 100) in women who are at low risk of STIs
      • IUDs may be expelled but this occurs in fewer than 1 in 20 women in 5 years
      • the risk of ectopic pregnancy when using IUDs is lower than when using no contraception
      • the overall risk of ectopic pregnancy when using the IUD is very low, at about 1 in 1000 in 5 years
      • if a woman becomes pregnant with the IUD in situ, the risk of ectopic pregnancy is about 1 in 20, and she should seek advice to exclude ectopic pregnancy

Other issues to consider before fitting an IUD

  • Women who are aged 40 years or older at the time of IUD insertion may retain the device until they no longer require contraception, even if this is beyond the duration of the UK Marketing Authorisation
  • Contraceptive care providers should be aware that the risk of perforation is related to the skill of the healthcare professional inserting the IUD
  • Testing for the following infections should be undertaken before IUD insertion:
    • Chlamydia trachomatis in women at risk of STIs
    • Neisseria gonorrhoeaein women from areas where the disease is prevalent and who are at risk of STIs
    • any STIs in women who request it
  • If testing for STIs is not possible, or has not been completed, prophylactic antibiotics should be given before IUD insertion in women at increased risk of STIs
  • Women with identified risks associated with uterine or systemic infection should have investigations, and appropriate prophylaxis or treatment before insertion of an IUD
  • Specific groups, medical conditions, and contraindications:
    • IUDs may be used by adolescents, but STI risk should be considered where relevant
    • healthcare professionals should be aware that:
      • IUD use is not contraindicated in nulliparous women of any age
      • women of all ages may use IUDs
      • IUDs can safely be used by women who are breastfeeding
      • IUD use is not contraindicated in women with diabetes
      • IUD use is a safe and effective method of contraception for women who are HIV positive or have AIDS (safer sex using condoms should be encouraged in this group)

Practical details of fitting IUDs

  • The most effective IUDs contain at least 380 mm2 of copper and have banded copper on the arms. This, together with the licensed duration of use, should be considered when deciding which IUD to use
  • Provided that it is reasonably certain that the woman is not pregnant, IUDs may be inserted:
    • at any time during the menstrual cycle
    • immediately after first- or second-trimester abortion, or at any time thereafter
    • from 4 weeks post-partum, irrespective of the mode of delivery
  • Emergency drugs, including anti-epileptic medication, should be available at the time of IUD insertion in a woman with epilepsy because there may be an increased risk of a seizure at the time of cervical dilation
  • Advice for women at time of fitting—women should be informed:
    • about symptoms of uterine perforation or infection that would warrant an early review of IUD use
    • that insertion of an IUD may cause pain and discomfort for a few hours and light bleeding for a few days, and they should be informed about appropriate pain relief
    • about how to check for the presence of IUD threads and encouraged to do this regularly with the aim of recognising expulsion

Follow-up and managing problems

  • A follow-up visit should be recommended after the first menses, or 3–6 weeks after insertion, to exclude infection, perforation, or expulsion. Thereafter, a woman should be strongly encouraged to return at any time to discuss problems, if she wants to change her method of contraception, or if it is time to have the IUD removed
  • Heavier and/or prolonged bleeding associated with IUD use can be treated with non-steroidal anti-inflammatory drugs and tranexamic acid
  • Women who find heavy bleeding associated with IUD use unacceptable may consider changing to a levonorgestrel intrauterine system (LNG-IUS)
  • The presence of Actinomyces-like organisms on a cervical smear in a woman with a current IUD requires an assessment to exclude pelvic infection. Routine removal is not indicated in women without signs of pelvic infection
  • Women who have an intrauterine pregnancy with an IUD in situ should be advised to have the IUD removed before 12 completed weeks’ gestation, whether or not they intend to continue the pregnancy

Intrauterine system

Decision making

  • Women should be given the following information:
    • contraceptive efficacy:
      • the IUS may act predominantly by preventing implantation and sometimes by preventing fertilisation
      • the pregnancy rate associated with the use of the IUS is very low (fewer than 10 in 1000 over 5 years)
      • the licensed duration of use for the IUS is 5 years for contraception
      • there is no evidence of a delay in the return of fertility following removal or expulsion of the IUS
    • effects on periods:
      • irregular bleeding and spotting are common during the first 6 months following IUS insertion
      • oligomenorrhoea or amenorrhoea is likely by the end of the first year of IUS use
    • risks and possible side-effects:
      • up to 60% of women stop using the IUS within 5 years. The most common reasons are unacceptable vaginal bleeding and pain; a less common reason is hormonal (non-bleeding) problems
      • there is no evidence that IUS use causes weight gain
      • any changes in mood and libido are similar whether using the IUS or IUDs, and the changes are small
      • there may be an increased likelihood of developing acne as a result of absorption of progestogen, but few women discontinue IUS use for this reason
      • the risk of uterine perforation at the time of IUS insertion is very low (less than 1 in 1000)
      • the risk of developing pelvic inflammatory disease following IUS insertion is very low (less than 1 in 100) in women who are at low risk of STIs
      • the IUS may be expelled, but this occurs in fewer than 1 in 20 women in 5 years
      • the risk of ectopic pregnancy when using the IUS is lower than when using no contraception
      • the overall risk of ectopic pregnancy when using the IUS is very low, at about 1 in 1000 in 5 years
      • if a woman becomes pregnant with the IUS in situ, the risk of ectopic pregnancy is about 1 in 20, and she should seek advice to exclude ectopic pregnancy

Other issues to consider before fitting an IUS

  • Women who are aged 45 years or older at the time of IUS insertion and who are amenorrhoeic may retain the device until they no longer require contraception, even if this is beyond the duration of UK Marketing Authorisation
  • Contraceptive care providers should be aware that the risk of perforation is related to the skill of the healthcare professional inserting the IUS
  • Testing for the following infections should be undertaken before IUS insertion:
    • Chlamydia trachomatis in women at risk of STIs
    • Neisseria gonorrhoeae in women from areas where the disease is prevalent and who are at risk of STIs
    • any STIs in women who request it
  • If testing for STIs is not possible, or has not been completed, prophylactic antibiotics should be given before IUS insertion in women at increased risks of STIs
  • Women with identified risks associated with uterine or systemic infection should have investigations, and appropriate prophylaxis or treatment before insertion of the IUS
  • Specific groups, medical conditions, and contraindications:
    • the IUS may be used by adolescents, but STI risk should be considered where appropriate
    • healthcare professionals should be aware that:
      • IUS use is not contraindicated in nulliparous women of any age
      • women of all ages may use the IUS
      • the IUS can safely be used by women who are breastfeeding
      • there is no evidence that the effectiveness of the IUS is reduced when taking any other medication
      • IUS use is not contraindicated in women with diabetes
      • IUS is a safe and effective method of contraception for women who are HIV positive or have AIDS (safer sex using condoms should be encouraged in this group)
      • all progestogen-only methods, including the IUS, may be used by women who have migraine with or without aura
      • women with a history of VTE may use the IUS
      • IUS is medically safe for women to use if oestrogen is contraindicated

Practical details of fitting the IUS

  • Provided that it is reasonably certain that the woman is not pregnant, the IUS may be inserted:
    • at any time during the menstrual cycle (but if the woman is amenorrhoeic or it has been more than 5 days since menstrual bleeding started, additional barrier contraception should be used for the first 7 days after insertion)
    • immediately after first- or second-trimester abortion or at any time thereafter
    • from 4 weeks post-partum, irrespective of the mode of delivery
  • Emergency drugs including anti-epileptic medication should be available at the time of IUS insertion in a woman with epilepsy because there may be an increased risk of a seizure at the time of cervical dilation
  • Advice for women at time of fitting—women should be informed:
    • about symptoms of uterine perforation or infection that would warrant an early review of IUS use
    • that insertion of an IUS may cause pain and discomfort for a few hours and light bleeding for a few days, and they should be informed about appropriate pain relief
    • about how to check for the presence of IUS threads, and encouraged to do this regularly with the aim of recognising expulsion

Follow-up and managing problems

  • A follow-up visit should be recommended after the first menses, or 3–6 weeks after insertion, to exclude infection, perforation, or expulsion. Thereafter, a woman should be strongly encouraged to return at any time to discuss problems, if she wants to change her method of contraception, or if it is time to have the IUS removed
  • The presence of Actinomyces -like organisms on a cervical smear in a woman with a current IUS requires an assessment to exclude pelvic infection. Routine removal is not indicated in women without signs of pelvic infection
  • Women with an intrauterine pregnancy with an IUS in situ should be advised to have the IUS removed before 12 completed weeks’ gestation whether or not they intend to continue the pregnancy

Progestogen-only injectable contraceptives

Decision making

  • Women should be given the following information:
    • contraceptive efficacy:
      • progestogen-only injectable contraceptives act primarily by preventing ovulation
      • the pregnancy rate associated with injectable contraceptives, when given at the recommended intervals, is very low (fewer than 4 in 1000 over 2 years) and the pregnancy rate with depo medroxyprogesterone acetate (DMPA) is lower than that with norethisterone enantate (NET-EN)
      • DMPA should be repeated every 12 weeks and NET-EN every 8 weeks
      • there could be a delay of up to 1 year in the return of fertility after stopping the use of injectable contraceptives
      • if a woman stops using injectable contraceptives but does not wish to conceive, she should start using a different contraceptive method immediately even if amenorrhoea persists
    • effects on periods:
      • amenorrhoea is likely during use of injectable contraceptives; this is:
      • more likely with DMPA than NET-EN
      • more likely as time goes by
      • not harmful
      • up to 50% of women stop using DMPA by 1 year; the most common reason is an altered bleeding pattern, such as persistent bleeding
    • risks and possible side-effects:
      • DMPA use may be associated with an increase of up to 2–3 kg in weight over 1 year
      • DMPA use is not associated with acne, depression or headaches
      • DMPA use is associated with a small loss of bone mineral density, which is largely recovered when DMPA is discontinued
      • there is no evidence that DMPA use increases the risk of fracture

Other issues to consider before giving injectable contraceptives

  • Specific groups, medical conditions and contraindications:
    • because of the possible effect on bone mineral density, care should be taken in recommending DMPA to:
      • adolescents, but it may be given if other methods are not suitable or acceptable§
      • women older than 40 years, but in general the benefits outweigh the risks, and it may be given if other methods are not suitable or acceptable§
    • healthcare professionals should be aware that:
      • women with a body mass index over 30 can safely use DMPA and NET-EN
      • women who are breastfeeding can consider using injectable contraceptives
      • all progestogen-only methods, including injectable contraceptives, may be used by women who have migraine with or without aura
      • DMPA is medically safe for women to use if oestrogen is contraindicated
      • injectable contraceptives are not contraindicated in women with diabetes
      • DMPA use may be associated with a reduction in the frequency of seizures in women with epilepsy
      • there is no evidence that DMPA use increases the risk of STI or HIV acquisition
      • DMPA is a safe and effective method of contraception for women with STIs, including HIV/AIDS (safer sex using condoms should be encouraged in this group)
      • women taking liver enzyme-inducing medication may use DMPA and the dose interval does not need to be reduced

Practical details of giving injectable contraceptives

  • Injectable contraceptives should be given by deep intramuscular injection into the gluteal or deltoid muscle or the lateral thigh
  • Provided that it is reasonably certain that the woman is not pregnant, the use of injectable contraceptives may be started:
    • up to and including the fifth day of the menstrual cycle without the need for additional contraceptive protection
    • at any other time in the menstrual cycle, but additional barrier contraception should be used for the first 7 days after the injection
    • immediately after first- or second-trimester abortion, or at any time thereafter
    • at any time post-partum

Follow-up and managing problems

  • Women attending up to 2 weeks late for repeat injection of DMPA may be given the injection without the need for additional contraceptives
  • A pattern of persistent bleeding associated with DMPA use can be treated with mefenamic acid or ethinylestradiol
  • Women who wish to continue DMPA use beyond 2 years should have their individual clinical situations reviewed, the balance between the benefits and potential risks discussed, and be supported in their choice of whether or not to continue
  • Healthcare professionals should be aware that if pregnancy occurs during DMPA use there is no evidence of congenital malformation to the fetus

Progestogen-only subdermal implants

  • Inform women that etonogestrel implants have a very low failure rate (less than 1 pregnancy per 1000 implants fitted over 3 years)
  • Inform women that vaginal bleeding patterns are likely to change while using an etonogestrel implant. Vaginal bleeding may stop, become more or less frequent, or be prolonged during implant use
  • Inform women that dysmenorrhoea may reduce during etonogestrel implant use
  • Inform women that there is no evidence showing a delay in return to fertility after an etonogestrel implant is removed
  • Inform women that complications with etonogestrel implant insertion and removal are uncommon. (Possible complications are listed in the summary of product characteristics.)

†Check the Summary of Product Characteristics of individual devices for current licensed indications. Informed consent is needed when using outside the licensed indications. This should be discussed and documented in the notes.

 

‡At the time of original publication (October 2005), use before 6 weeks post-partum is outside the UK Marketing Authorisation for the IUS. Check the Summary of Product Characteristics for current licensed indications. Informed consent is needed when using outside the licensed indications. This should be discussed and documented in the notes.

 

§Refer to CSM advice issued in November 2004. Search for Depo Provera.

 

¶At the time of publication (September, 2014), Nexplanon was the only subdermal implant licensed in the UK and did not have UK marketing authorisation for use outside of the age range 18-40 years. Outside of this age range, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See theGeneral Medical Council'sGood practice in prescribing medicines­—guidance for doctors and theNursing and Midwifery Council'sStandards of proficiency for nurse and midwife prescribers for further information.

© NICE 2014. Long-acting reversible contraception (update). Available from: www.nice.org.uk/guidance/CG30. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: February 2006, updated September 2014.