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Contraception (non-emergency)

FSRH UK Medical Eligibility Criteria For Contraceptive Use UKMEC 2016 (Amended Sep 2019) FSRH CEU Guidance: Recommended Actions after incorrect Use of Combined Hormonal Contraception (e.g. late or missed pills, ring and patch) (Mar 2020, amended Jul 2021)

How To Use This Article

This is a concise study aid article for non-emergency contraception:

  • It lists only the most common or clinically significant UK MEC category 3 and 4 conditions for each contraceptive method.
    • Conditions that are UK MEC category 1 or 2 (generally safe to use) are not shown.
 
  • It lists only the most common or clinically significant adverse effects for each contraceptive method.

This article organises everything important on non-emergency contraceptives into 2 main categories:
  • By contraceptive method - information is grouped under each type of contraceptive method.
  • By common clinical scenarios - information on various contraceptive methods is grouped under each clinical theme.

Note that there are significant overlaps between these 2 categories, but both should be read and studied to cover most of contraception.

Background Information

The following data is extracted from the FSRH UKMEC and arranged in ascending order of failure rate (from most effective to least effective), by perfect use rate.
 
Method Typical Use Failure Rate Perfect Use Failure Rate
Implant 0.05% 0.05%
Levonorgestrel intrauterine system 0.2% 0.2%
Copper intrauterine device 0.6% 0.6%
DMPA injection 6% 0.2%
COCP 9% 0.3%
POP 9% 0.3%
Patch / Ring 9% 0.3%
Fertility awareness methods 24% 0.4%–5%
Male condom 18% 2%
Female condom 21% 5%
Diaphragm 12% 6%
Withdrawal 22% 4%
 

Contraception by Method

This section covers:
  • Combined oral contraceptive pill (COCP)
  • Transdermal patch 
  • Vaginal ring 
  

Primary action: inhibition of ovulation (by suppressing mid-cycle LH surge)

Secondary action:
  • Thickening of cervical mucus (from the progesterone component)
  • Endometrial thinning 

There are 3 main regimens:
 
Regimen Description
Standard cyclic regimen 2 cyclic regimens:
  • 21/7: each cycle is made up of 21 days of active pill, followed by a 7-day hormone-free break
  • 24/4: each cycle is made up of 24 days of active pill, followed by a 4-day hormone-free break (offers less hormonal fluctuation and more consistent ovarian suppression)

The patient would experience withdrawal bleeding during the hormone-free interval.
Extended regimen Each cycle is made up of 63 days (3 packs) of active pill, followed by a 4-7 day hormone-free break

The patient would experience withdrawal bleeding during the hormone-free interval.
Continuous regimen No scheduled hormone-free break

Withdrawal bleeding is not expected, although some users may experience light breakthrough bleeding or spotting over time..
 

The extended and continuous COCP regimens offer no extra contraceptive benefits, but have extra therapeutic benefits in dysmenorrhoea and heavy menstrual bleeding.

Standard cyclic regimen: one patch changed every week for 3 weeks, followed by 1 patch-free week.

Just like COCP, extended and continuous use is possible.

Standard cyclic regimen: inserted for 3 weeks, then removed for 1 week.

Just like COCP, extended and continuous use is possible.

  • If started on day 1-5 of the menstrual cycle → immediately effective (no additional protection needed)
 
  • If started on any other days → use additional contraception (e.g. condoms) for 7 days (only effective after taking 7 consecutive pills)

Less serious adverse effects:
  • Breakthrough bleeding  - common in the first month of use
  • Mood changes
  • Weight gain
  • Nausea
  • Breast tenderness

Serious adverse effects:
  • Venous thromboembolism
  • Arterial events (stroke, myocardial infarction)
  • Hypertension
  • Breast cancer
  • Cervical cancer (small increase)
 

Importantly, CHC reduces the risk of endometrial and ovarian cancer.

 

COCP is shown to improve:

  • Heavy menstrual bleeding
  • Irregular bleeding
  • Dysmenorrhoea

UKMEC 4 (unacceptable health risk of CHC is used), grouped according to its rationale:
 
Rationale Conditions
Hormone-sensitive tumour risk
  • Current breast cancer
  • Hepatocellular adenoma or carcinoma
Thrombosis risk
  • Current or past VTE
  • +ve Antiphospholipid antibodies
  • Thrombogenic mutation
  • Major surgery with prolonged immobilisation
  • Postpartum <3 weeks with additional risk factors (not breastfeeding)
Cardiovascular disease risk
  • Migraine with aura (↑ risk of stroke)
  • ≥35 y/o + smoke ≥15 cigarettes / day
  • Uncontrolled hypertension (≥160/110 mmHg)
  • Atrial fibrillation
Oestrogen impact on infant Breastfeeding <6 weeks postpartum
Liver function risk Severe cirrhosis

Selected important UKMEC 3 (risk usually outweigh benefits, specialist input needed):
  • Past breast cancer
  • ≥35 y/o + migraine without aura
  • Smoking ≥35 y/o + smoke <15 cigarettes / day
  • Hypertension 
  • BMI ≥35 kg/m2
  • Diabetes with vascular complications 
  • Gallbladder disease 
  • Cholestasis (past COC-related)
  • Use of liver enzyme-inducing drugs

Note this section applies only to CHC being used in the standard cyclic regimen:
  • COCP: 21/7 regimen without placebo pills
  • Combined vaginal ring: 21 days of ring in place, followed by 7 day ring-free interval
  • Combined transdermal patch: patch replaced weekly for 3 weeks, followed by 7 day patch-free interval

The management depends on how many doses are missed and at what time of the cycle the dose is missed.

 

The following information assumes that prior to the missed dose, there was correct use in the previous 7 consecutive days. 

The management depends on how many pills are missed and at what time of the cycle the dose is missed.
 

ALL patients (regardless of what week the pill is missed):
  • Take the missed pill as soon as possible (2 pills would be taken on the same day: 1 missed pill + 1 scheduled pill)
  • Continue the remaining pills at the usual time
 
  • No additional contraception needed
  • Emergency contraception is NOT required

ALL patients:
  • Take the most recent missed pill as soon as possible (2 pills would be taken on the same day: 1 missed pill + 1 scheduled pill. But do not take both missed pills)
  • Continue the remaining pills at the usual time
  • Use condoms / avoid sex until pills have been taken for 7 consecutive days

Additional action, depending on which week the pills are missed:
  • Week 1 → consider emergency contraception if UPSI has taken place during hormone-free interval or week 1
  • Week 2 → nothing else (emergency contraception not required)
  • Week 3 → omit hormone-free interval and start new pack immediately at week 4
 

If >7 consecutive pills missed at any time:

  • Manage as new start contraception
  • Consider emergency contraception and pregnancy test
  • Use condoms or avoid sex until pills have been taken for 7 consecutive days
  • Start new COCP packet

Defined by ≥9 days since last active pill was taken:
  • Take the most recent missed pill as soon as possible
  • Continue the remaining pills at the usual time
 
  • Use condoms / avoid sex until pills have been taken for 7 consecutive days
  • Consider emergency contraception if UPSI has taken place during or after hormone-free interval
 

For pills, the hormone-free interval is considered to start 24 hours after the last pill is taken. Therefore the cut-off for additional action is 9 days.

If a woman took her last pill before a hormone-free interval at 9am on Monday, so long as she restarts before 9am on Wednesday of the following week (just less than 9 days later) she does not need to take additional action.

If she starts at or after 9am on the Wednesday of the following week (9 days or more later), additional action is required. 

The management is essentially identical to incorrect use of COCP, the only difference is:
  • Unscheduled ring removal for <48 hours corresponds to 1 missed COCP pill
  • Unscheduled ring removal for ≥48 hours corresponds to 2 or more missed COCP pills
 

ALL patients (regardless of what week it is):
  • Insert the ring as soon as possible
  • Keep the ring in until scheduled ring removal day
 
  • No additional contraception needed
  • Emergency contraception is NOT required 

ALL patients:
  • Insert the ring as soon as possible
  • Keep the ring in until scheduled ring removal day
  • Use condoms / avoid sex until ring has been used for 7 consecutive days

Additional action, depending on which week the ring is removed:
  • Week 1 → consider emergency contraception if UPSI has taken place during hormone-free interval or week 1
  • Week 2 → nothing else (emergency contraception not required)
  • Week 3 → omit hormone-free interval and start new cycle immediately

The management is essentially identical to incorrect use of COCP, the only difference is:
  • Unscheduled patch removed for <48 hours OR <48 hours of delayed schedule removal corresponds to 1 missed COCP pill
  • Unscheduled patch removed for ≥48 hours OR ≥48 hours of delayed schedule removal corresponds to 2 or more missed COCP pills

 

 Delayed schedule removal of the patch means that the same patch has been continuously used for additional hours.

ALL patients (regardless of what week it is):
  • Attach new patch as soon as possible
  • Keep the new patch one until scheduled removal day
 
  • No additional contraception needed
  • Emergency contraception is NOT required 

ALL patients:
  • Attach new patch as soon as possible
  • Keep the new patch one until scheduled removal day
  • Use condoms / avoid sex until ring has been used for 7 consecutive days

Additional action, depending on which week it is:
  • Week 1 → consider emergency contraception if UPSI has taken place during hormone-free interval or week 1
  • Week 2 → nothing else (emergency contraception not required)
  • Week 3 → omit hormone-free interval and start new cycle immediately

The FSRH UKMEC 2019 only included 3 POPs that are licensed in the UK at the time of publication:
  • Norethisterone (1st generation)
  • Levonorgestrel (2nd generation)
  • Desogestrel (3rd generation)
 

Primary action: thicken cervical mucus → impermeable to sperm 

Oral, once daily with no pill-free interval (to be taken continuously every day).
  • Traditional POP (levonorgestrel and norethisterone) must be taken within 3 hours of usual time
  • Desogestrel (3rd generation POP) must be taken within 12 hours of usual time

  • If started on day 1-5 of the menstrual cycle → immediately effective (no additional protection needed)
 
  • If started on any other days → use additional contraception (e.g. condoms) for 2 days (only effective after taking 2 consecutive pills)

  • Menstrual changes
    • Irregular bleeding - most common
    • Spotting
    • Amenorrhoea
  • Breast tenderness
  • Acne
  • Headache 
  • Functional ovarian cysts
 

Unlike COCP, POP does NOT increase risk of venous thromboembolism and cardiovascular disease (e.g. stroke, myocardial infarction).

POP can also be used in migraine with aura (UKMEC 2) (but UKMEC 4 for COCP).

There are very few contraindications for POP, important ones:
  • Current breast cancer (UKMEC 4)
  • Past breast cancer (within the past 5 days)
  • Severe decompensated liver cirrhosis 
  • Use of enzyme-inducing drugs (due to reduced efficacy)
  • Unexplained vaginal bleeding (before evaluation)
 
 

POP are suitable for most women, including those with a higher risk of thrombosis.

The cut-off to guide management differs slightly depending on the POP, but the management concept is the same:
  • Traditional POP (levonorgestrel and norethisterone): 3 hour window
  • Desogestrel POP: 12 hour window


Approach:

  • If the pill is <3 hours late (levonorgestrel and norethisterone) or <12 hours late (desogestrel) → take the missed pill ASAP and no further action
 
  • If the pill is >3 hours late (levonorgestrel and norethisterone) or >12 hours late (desogestrel) →
    • Take the missed pill ASAP
    • Use condoms or avoid sex for the next 48 hours
    • Consider emergency contraception if UPSI occurred 

The only contraceptive implant licensed in the UK is the etonogestrel implant (Nexplanon®)

Etonogestrel is a progesterone-only hormone.
 

Primary action: inhibit ovulation

Subdermal implant in the upper non-dominant arm.

Inserted once and remains effective for 3 years.

  • If inserted on day 1-5 of the menstrual cycle → immediately effective (no additional protection needed)
 
  • If started on any other days → use additional contraception (e.g. condoms) for 7 days (only effective after 7 consecutive days)

Adverse effects of the contraceptive implant are largely same as those of POP:
  • Menstrual changes
    • Irregular bleeding - most common
    • Spotting
    • Amenorrhoea
  • Breast tenderness
  • Acne
  • Headache 

Contraindications of the contraceptive implant are largely same as those of POP:
  • Current breast cancer (UKMEC 4)
  • Past breast cancer (within the past 5 days)
  • Severe decompensated liver cirrhosis 
  • Use of enzyme-inducing drugs (due to reduced efficacy)
  • Unexplained vaginal bleeding (before evaluation)

Injectable contraception contains depo-medroxyprogesterone acetate (DMPA)
 

Primary action: inhibit ovulation

There are 2 preparations of DMPA:
  • Intramuscular DMPA: every 12 weeks
  • Subcutaneous DMPA: every 12-13 weeks

  • If inserted on day 1-5 of the menstrual cycle → immediately effective (no additional protection needed)
 
  • If started on any other days → use additional contraception (e.g. condoms) for 7 days

  • Menstrual changes
    • Irregular bleeding - most common
    • Amenorrhoea
  • Headache
  • Acne

Important adverse effects that are significant in DMPA but not in other contraceptive methods:
  • Weight gain - common (well-documented and more significant compared to other contraceptive methods)
  • Delay in return to fertility (median 7-8 months after last injection)
  • Reduction in bone mineral density (mostly reversible on discontinuation)

Important contraindications:
  • Current breast cancer (UKMEC 4)
  • Past breast cancer (within the past 5 days)
  • Severe decompensated liver cirrhosis 
  • Unexplained vaginal bleeding (before evaluation)
 
  • Known osteoporosis / significant fracture risk
  • Current / history of ischaemic heart disease or stroke
  • Current or recent VTE (not on anticoagulation)
  • Multiple cardiovascular disease risk factors (e.g. smoking, diabetes, hypertension, dyslipidemia)

 Levonorgestrel is a progesterone-only hormone.
 

Primary action: cervical mucus thickening

Intrauterine placement.

Inserted once and remains in place for:
  • Up to 8 years (Mirena®)
  • 6 years (Levosert®)
  • 5 years (Kyleena®)
  • 3 years (Jaydess®)

  • If inserted on day 1-5 of the menstrual cycle → immediately effective (no additional protection needed)
 
  • If started on any other days → use additional contraception (e.g. condoms) for 7 days

LNG-IUS specific adverse effects
  • Irregular bleeding and spotting - especially in the first 6 months
  • Possible amenorrhea

 

LNG-IUS reduces bleeding, while copper IUD makes bleeding worse.

 
Other shared adverse effects as copper IUD:
  • Risk of expulsion (1 in 20), more likely in first 3 months
  • Risk of uterine perforation (rare, up to 2 in 1000)
  • Risk of ectopic pregnancy (overall risk of ectopic pregnancy is reduced but if pregnancy does occur while using an LNG-IUS, there is a higher relative risk of it being ectopic)
  • Risk of PID in first 20 days (after 20 days, risk of PID returns to baseline population levels)
 

LNG-IUS have therapeutic benefits in heavy menstrual bleeding. It is 1st line for the management of heavy menstrual bleeding in those who do not want to conceive. 

Important contraindications:
  • Breast cancer (current is UKMEC 4 and past 5 years is UKMEC 3)
  • Cervical or endometrial cancer (UKMEC 4)
  • Unexpalined vaginal bleeding (prior to evaluation) (UKMEC 4)
 
  • Distorted uterine cavity (UKMEC 4)
  • Current PID (UKMEC 4)
  • Postpartum sepsis (UKMEC 4)

Primary action: copper ions are toxic to sperm → prevents fertilisation by reducing sperm motility and viability

Secondary action: inhibit implantation if fertilisation occurs

Intrauterine placement.

Various copper IUDs are available, they differ in shape, copper surface area and licensed duration of use:
  • TCu380A: up to 10 years
  • TT380 Slimline: up to 10 years
  • Multi-load Cu375: up to 5 years

Immediate effect upon insertion, no need for additional contraception​​​​​​.

Copper IUD specific adverse effects
  • Menstrual bleeding may become heavier, longer or more painful - especially in the first few months

 

LNG-IUS reduces bleeding, while copper IUD makes bleeding worse.

 
Other shared adverse effects as copper IUD:
  • Risk of expulsion (1 in 20), more likely in first 3 months
  • Risk of uterine perforation (rare, up to 2 in 1000)
  • Risk of ectopic pregnancy (overall risk of ectopic pregnancy is reduced but if pregnancy does occur while using an LNG-IUS, there is a higher relative risk of it being ectopic)
  • Risk of PID in first 20 days (after 20 days, risk of PID returns to baseline population levels)
 

LNG-IUS have therapeutic benefits in heavy menstrual bleeding. It is 1st line for the management of heavy menstrual bleeding in those who do not want to conceive. 

UKMEC 4:
  • Current PID
  • Current purulent cervicitis or chlamydial / gonococcal infection
 
  • Distorted uterine cavity
 
  • Cervical or endometrial cancer
  • Unexpalined vaginal bleeding (before evaluation)

UKMEC 3:
  • Increased risk of STIs
  • History of PID in the past 3 months
 
  • Severe thrombocytopenia or bleeding disorder
  • Copper allergy or Wilson's disease

Contraception by Clinical Scenarios

Contraception is needed after 21 days postpartum.
 
Type of contraception Description
Combined hormonal contraception (including COCP) Breastfeeding postpartum:
  • <6 weeks postpartum: contraindicated (UKMEC 4)

Not breastfeeding postpartum:
  • <3 weeks postpartum: contraindicated (UKMEC 4 if with VTE risk factors, 3 without risk factors)
  • 3-6 weeks postpartum + VTE risk factors: UKMEC 3
POP Can be started immediately postpartum

(always UKMEC 1)
Contraceptive implant Can be started immediately postpartum

(always UKMEC 1)
DMPA Can be used safely postpartum

(no UKMEC 3 / 4)
LNG-IUS and copper IUD Can be safely inserted (UKMEC 1) if:
  • <48 hours postpartum, OR
  • ≥4 weeks postpartum

Contraindicated if:
  • Postpartum sepsis (UKMEC 4)
  • 48 hours - 4 weeks postpartum (UKMEC 3)
 

The only precaution is with CHC:

  • Age ≥35 y/o + smoke ≥15 cigarettes / day: UKMEC 4 
  • Age ≥35 y/o + smoke <15 cigarettes / day: UKMEC 3
  • Age ≥35 y/o + stopped smoking <1 year: UKMEC 3

UKMEC 1 for all other contraceptive methods, regardless of age and quantity of smoking.

The only precaution is with CHC:
  • BMI  ≥35 kg/m2: UKMEC 3
  • BMI 30-34 kg/m2: UKMEC 2

UKMEC 1 for all other contraceptive methods, regardless of BMI.

All hormonal methods are UKMEC 4 (for current breast cancer) and UKMEC 3 (for past breast cancer).

Only UKMEC 1 is a copper IUD.

The only UKMEC 1s are:
  • LNG-IUS
  • Copper IUD
  • DMPA injection

All other contraceptive methods are UKMEC 3.

The 2 implicated contraceptive methods are CHC and DMPA.

CHC contraindications:
  • UKMEC 4: BP ≥160/100 mmHg and presence of vascular disease
  • UKMEC 3: BP ≥140/90 mmHg (even if adequately controlled)

DMPA contraindications:
  • UKMEC 3 if there is vascular disease

The only precaution is with CHC:

  • UKMEC 4 if
    • History or current VTE
    • Major surgery with prolonged immobilisation
 
  • UKMEC 3 if
    • 1st degree relative <45 y/o with VTE
    • Immobility (unrelated to surgery) (e.g. wheelchair use, debilitating illness)

All other contraceptive methods are UKMEC 1 or 2.

References

Author: Adams Lau
Reviewer:
Last edited: 14/05/25