Contraception - choices

Contraception – also called family planning or birth control – protects you from pregnancy by stopping an egg from being fertilised by sperm. Many options are available, and they vary in how well they work and how they work. It is important to remember that no method is 100% effective against pregnancy.

The main types of contraception are:

• long-acting reversible contraception (LARC) – implants and intrauterine devices (IUDs)
• hormonal injections
• oral contraceptive pills (combined pill and progestogen-only pill)
• vaginal rings
• barrier methods (external and internal condoms, and diaphragms)
• permanent methods (tubal ligation and vasectomy)
• emergency contraception
• natural methods

How to choose a method that suits you#

When choosing a method, it helps to have accurate information and, if you have a partner or partners, to talk openly about your options. Things to weigh up include:

• why you are using contraception – some people also use it for hormonal benefits, such as managing heavy menstrual bleeding, skipping periods, endometriosis or acne
• how well each method works
• possible side effects and ease of use
• the time and effort involved – for example, the pill must be taken every day, while an implant or IUD works for years once inserted
• cost
• your general health, including other conditions and current medications
• your lifestyle and relationships
• your risk of getting a sexually transmissible infection (STI)
• whether you want to get pregnant in future
• whether you can stop the method yourself or need to see a health practitioner

Talk about your options with a doctor or reproductive health nurse, who can help you find what will work for you.

Contraception and protection from STIs#

As well as preventing unintended pregnancy, it is important to practise safer sex. Not all methods protect against STIs. The best way to lower your risk is to use condoms (external or internal), which can be used for vaginal, anal and oral sex to help stop infections.

Long-acting reversible contraception (LARC)#

LARC gives safe, effective contraception over a number of years, with the lifespan depending on the type you use. Implants and IUDs are the most effective methods available (more than 99%) and need replacing less often than any other method. They do not protect you from STIs, so still practise safer sex.

Contraceptive implants#

A contraceptive implant is a small plastic rod (about 4 cm long) placed under the skin of your upper arm. It slowly releases a low dose of the hormone progestogen, which stops your ovaries releasing an egg. You will usually notice a change to your periods, which may become lighter or stop altogether.

The implant lasts for 3 years and is more than 99% effective. It can easily be removed and does not affect your ability to get pregnant in the future. It is safe to use while breastfeeding and can be inserted straight after the birth of your baby.

Contraceptive IUDs#

An IUD is a small device placed in your uterus. It stops sperm from reaching and fertilising an egg and changes the lining of the uterus so a fertilised egg cannot stay there. There are two kinds:

• copper IUD – lasts 5 to 10 years and can also be used as emergency contraception. It may make your periods heavier.
• hormonal IUD – lasts 5 years and usually makes periods lighter or stops them completely.

An IUD can easily be removed by a doctor or nurse and does not affect your future fertility. IUDs are safe during breastfeeding and are not affected by other medications.

Contraceptive injections#

The contraceptive injection contains the hormone progestogen, which is similar to a hormone made by the ovaries. When given on time, each injection is more than 99% effective. It stops ovulation and thickens the fluid at the opening of the uterus so sperm cannot get through.

Each injection lasts about 12 to 14 weeks, so you need to return to a clinic for the next one. Injections tend to make periods less painful, and you may have no bleeding or only very light bleeding. They can be given alongside other medications and can be used while breastfeeding and after birth. They do not protect against STIs, so use condoms for safer sex. After you stop, it may take a while for your fertility to return.

Oral contraceptive pills#

Most contraceptive pills stop ovulation and also thicken the fluid around the cervix to block sperm. They need to be taken around the same time each day and are available on prescription. There are two types: the combined pill and the progestogen-only pill. Vomiting or severe diarrhoea can stop the pill working, and the pill does not protect against STIs.

Combined pill#

The combined pill contains synthetic forms of two hormones, estrogen and progestogen. Taken correctly, it is more than 99% effective; with typical use, where pills are sometimes forgotten or taken late, effectiveness falls to around 93%. Some medications and natural remedies can also reduce how well it works, so use condoms as well.

There are many types of combined pill with different doses and hormones. Most come in a 28-day pack containing hormone pills and inactive (“sugar”) pills; the inactive pills can be skipped if you do not wish to have a period. If you are new to the pill or restarting after a break, it can take up to 12 days to start working, so use another form of contraception during that time.

As well as preventing pregnancy, the combined pill can help treat conditions such as heavy menstrual bleeding, polycystic ovary syndrome (PCOS), endometriosis and acne. It is not suitable for everyone. It is generally not recommended if you:

• smoke and are aged 35 or over
• have a body mass index (BMI) over 35 kg/m²
• are at risk of deep vein thrombosis, heart disease or stroke
• have severe liver disease
• have been treated for breast cancer

If you are breastfeeding, do not use the combined pill until your baby is at least 6 weeks old; after birth it is generally not recommended until 3 to 6 weeks. Check with your doctor, nurse or pharmacist about what will suit you.

Progestogen-only pill#

The progestogen-only pill (sometimes called the “mini pill”) contains only one hormone, progestogen. There are two types:

• the traditional low-dose pill, which mainly thickens the fluid at the opening of the uterus. You usually still ovulate, so it is somewhat less effective (up to 99%) and must be taken strictly at the same time every day.
• the standard-dose pill, which also prevents ovulation.

The progestogen-only pill often suits people who have side effects from estrogen or cannot take it for health reasons. It can be used while breastfeeding and is safe to start after the birth of a baby.

Vaginal ring#

The vaginal ring slowly releases hormones that pass from the vagina into the bloodstream, stopping the ovaries from releasing an egg. It is at least 99% effective when used correctly, although some medications and natural therapies may reduce its effectiveness. It comes in one size and is available on prescription.

You insert the ring yourself (a bit like inserting a tampon), and it usually stays in for 3 weeks. You then remove it and wait 7 days before inserting a new one, getting your period during the break. You can skip your period by inserting a new ring straight away instead of taking the break.

You cannot use the vaginal ring until your baby is 6 weeks old, and after birth it is generally not recommended until 3 to 6 weeks. The ring can also help treat conditions such as heavy menstrual bleeding, acne, PCOS and endometriosis. It does not protect against STIs, so use condoms as well. The same cautions that apply to the combined pill also apply to the vaginal ring.

Barrier methods#

Barrier methods stop sperm from getting into the uterus. Options include the external condom, the internal condom and the diaphragm. To be effective, all barrier methods must be used and stored correctly – follow the instructions on the packet and check the use-by date before any sexual contact.

External condom#

The external condom is up to 98% effective when used correctly, and it also lessens the risk of STIs by blocking the exchange of body fluids. Put a new condom on before there is any contact between the penis and vagina, and use a new one each time you have sex or when switching between types of sex (such as from anal to vaginal).

Condoms are easy to use. Be gentle when putting them on to avoid tears, and use water- or silicone-based lubricant, as oil-based products can make them break. Non-latex versions are available for people with a latex allergy. Condoms can be used with other forms of contraception. They are cheap and available without a prescription from pharmacies, supermarkets, sexual health clinics and some vending machines.

Internal condom#

If used correctly every time, the internal condom is 95% effective. It comes in one size, is stronger than the external condom and can be inserted several hours before sex. Use a new one each time. This method can take some practice, and internal condoms are more expensive than external ones; they are available from some retail outlets and sexual health clinics.

Diaphragm#

A diaphragm is a soft, shallow silicone dome that fits in the vagina and is used with a special gel. You insert it so that it covers the cervix, stopping sperm from getting through. It needs to stay in place for at least 6 hours after sex but no longer than 24 hours.

The diaphragm comes in one size and may not fit everyone (around 1 in 7 people). Used correctly, it is about 86% effective, but it does not protect against STIs. Do not use one that is past its use-by date or has been in use for 2 years or more.

You do not need a prescription for a diaphragm – it is available from some pharmacies, sexual health and family planning clinics and online. Diaphragms can be tricky to insert, so it is recommended that a doctor or nurse checks you can position it correctly before you rely on it. If you have recently had a baby, it is best to wait 6 weeks before using one.

Permanent methods#

Sterilisation is a permanent method of contraception that involves surgery. It is very effective (more than 99%). As with any surgery, there is a small risk of injury, and these methods do not protect against STIs, so still use condoms for safer sex.

• Tubal ligation (sometimes called “having your tubes tied”) is usually done as a keyhole procedure (laparoscopy) under general anaesthetic. A surgeon places a clip on each fallopian tube to stop the sperm and egg meeting; in some cases the tubes are removed rather than clipped. Your ovaries and periods are not affected.
• Vasectomy involves cutting the tubes that carry sperm from the testes. Although highly effective, it can take around 3 months to start working (until no sperm is present in the semen). Use another form of contraception during this time and have sperm tests with your doctor.

Natural methods#

Natural family planning (or fertility awareness) methods are, overall, not as effective as other forms of contraception. They are built on trust between partners and on avoiding sex at times when you could get pregnant.

These methods are based on monitoring your body each day – for example, watching changes in your temperature and vaginal fluid to work out when you are fertile. They include the rhythm (or calendar) method, the temperature method, the symptothermal method, the cervical mucus (or Billings) method, and fertility apps.

Because some of these methods rely on a regular menstrual cycle, you have a higher chance of getting pregnant if your periods are irregular. They do not protect against STIs and are not recommended if you are under stress, have a fever, vaginal infection or PCOS, or regularly travel across time zones. Effectiveness varies depending on which method or combination you use.

Withdrawal method#

With the withdrawal (or “pulling out”) method, the penis is withdrawn from the vagina before ejaculation. It is not recommended as contraception because sperm can be present in the pre-ejaculate, or the penis may not be withdrawn in time.

Emergency contraception#

Emergency contraception can be used after unprotected sex – for example, if you missed a pill, the condom broke, or you did not use any contraception. Get it as quickly as possible to lower the chance of pregnancy. Emergency contraception is not an abortion.

• Copper IUD – the most effective method of emergency contraception (more than 99%). It makes it difficult for a fertilised egg to attach to the lining of the uterus and can be inserted within 5 days of unprotected sex. Once in place, it can provide ongoing contraception for 5 to 10 years.
• Emergency contraceptive pill (the “morning-after pill”) – prevents or delays the ovaries releasing an egg, and is around 85% effective. Take it as soon as possible after unprotected sex. Two types are available from pharmacies without a prescription: levonorgestrel, taken up to 4 days (96 hours) afterwards, and ulipristal acetate, taken up to 5 days (120 hours) afterwards. Ulipristal acetate has been shown to be more effective than levonorgestrel.

The emergency contraceptive pill is not recommended as your usual method of contraception. Ask your doctor or reproductive health nurse for further advice.

Key points#

• It is important to have accurate information when choosing a method that is right for you.
• The contraceptive implant lasts for 3 years and is more than 99% effective.
• Given on time, each contraceptive injection is more than 99% effective.
• Most contraceptive pills work by stopping the ovaries releasing an egg each month.
• Oral contraceptive pills are very effective (up to 99%) when used correctly.

Where to get help and trusted information#

For evidence-based global health guidance, see Source: World Health Organization (WHO).