Contraception: which option for which patient?

Key practice points:

• Appropriate contraceptive options vary depending on the specific needs, preferences and co-morbidities of each patient. A funded option is available for everyone.
• Long-acting reversible contraceptives (LARC) are recommended as a first-line choice for people of all ages, including adolescents
• Combined oral contraceptive regimens can be tailored: advise patients that withdrawal bleeds are not necessary and extended use is safe and effective
• Clinicians should ensure that people of all ages recognise the need for condoms to protect against STIs, even when other forms of contraception are used
• Contraception is needed until patients reach menopause or age 55 years

Counselling patients on contraception: it’s better out in the open

Patients may find discussing contraception and the prevention of sexually transmitted infections (STIs) a sensitive or awkward topic, as it touches on issues such as their sexuality and sexual practices, as well as relationship issues and their future plans for children. In addition, their views and behaviours can be influenced by social, family, religious or cultural factors. However, there is much to be gained and little to be lost when patients and healthcare providers have open discussions about contraception and prevention of STIs. The goal of counselling patients about contraception is to ensure they are using a safe, effective option which is the most appropriate for their clinical needs and preferences. Clinicians should be aware that transgender patients may still require contraception even when using gender affirming hormone treatment (see: “Contraception in transgender patients”).

For further information on discussing sex and contraception with younger people, see:

• “Contraception in early adolescence”: www.bpac.org.nz/bpj/2011/april/contraception.aspx
• “Let’s talk about sex”: www.bpac.org.nz/bpj/2009/april/sexhealth.aspx

Evidence suggests people are interested in hearing more

The most commonly used form of contraception in New Zealand is the oral contraceptive pill.^{1, 2} However, data from international surveys and focus groups in New Zealand show that people are eager to know more about the contraceptive options available to them, and that many would be interested in trying other options, such as long-acting reversible contraceptives, if they had information about them.^{3, 4}

A variety of contraceptive options are available

Methods of contraception available^* in New Zealand include:

• Condoms; external (funded) and internal (not funded) varieties – ensure that patients of all ages recognise the need for condoms to protect against STIs, even when other forms of contraception are used⁵
• Long-acting reversible contraceptives (LARCs); progestogen implants, copper and levonorgestrel (progestogen) intrauterine contraceptives (IUCs)
• Depot medroxyprogesterone acetate (DMPA) injections^†
• Oral contraceptives; combined and progestogen-only formulations
• Sterilisation options; vasectomy or tubal ligation
• Emergency contraception
• Natural family planning

*Diaphragms and vaginal rings are not funded in New Zealand

^†Depot medroxyprogesterone acetate injections are no longer classified as a long-acting contraceptive as they are less effective than IUCs or implants and require patients to return for an injection every 13 weeks⁶

Depending on co-morbidities, other prescribed medicines or recent pregnancy, some options may be inappropriate due to a high risk of adverse effects (Table 1).

Patients may base their preference for a contraceptive method on factors such as effectiveness (Table 2), adverse effects and risks, ease of use, future pregnancy plans, cost or particular symptoms they wish to manage. For example, some people may want greater cycle control, relief from menstrual pain or heavy menstrual bleeding, while others may be concerned about age-related adverse effects, such as venous thromboembolism.

Contraception is needed until age 55 years or menopause

Patients can cease using contraceptives at age 55 years, as pregnancy is very rare beyond this age even if they continue menstruating.⁷ Some patients may discontinue contraceptives earlier if menopause has occurred.⁷ A clinical diagnosis of menopause can be made after one year of amenorrhoea; contraception can be ceased at this time for patients aged over 50 years, but is recommended for an additional year in patients aged 40 – 50 years, i.e. for two years after the onset of amenorrhoea.⁷

Increased use of long-acting contraceptives could help reduce disparities

Conventionally, IUCs were most commonly used by women who had completed their families and wished to have a long-term form of contraception. There was some resistance to the idea that an IUC could be an appropriate contraceptive option for younger women and those who had not yet given birth, due to concerns such as ease of insertion. However, there is no clinical basis for this concern, and an IUC should be considered as an appropriate option for almost anyone.⁶ The levonorgestrel implant (inserted in the arm) has been funded in New Zealand since 2010, and is the most effective method of contraception available (Table 2). Some clinicians may be less familiar with this method as they do not have experience in placing the implants, but the procedure can be easily learned.

Use of a long-acting reversible contraceptive (LARC) is associated with a much lower rate of unintended pregnancy, compared to shorter-acting methods such as oral contraceptives or DMPA injections.⁶ In New Zealand, rates of abortion have been declining since the mid-2000s and research suggests that this is due in part to an increased use of LARCs.^{2, 8} Reductions have been particularly pronounced in people aged 15 – 19 years, however, rates of abortion are still highest amongst people of Māori ethnicity and people aged 20 – 29 years.⁸

The additional appointment time and repeat visits, or visits to another provider, required for initiating a LARC can be a barrier to patients in terms of convenience and cost.^{9, 10} Consider whether there are ways your practice could simplify the process for patients, e.g. by having a clinical staff member trained in insertion and removal techniques, and having a supply of LARCs at the practice (implants and copper intrauterine devices [IUDs] are available on PSO; levonorgestrel intrauterine systems [IUSs] are not). If offering these services at your practice is not possible, patients can be referred to Family Planning or Sexual Health Clinics, if locally available; these services may offer contraception services at a lower cost or for free^*. Some PHOs may also offer funding for sexual health or contraception-related consultations; enquire with your PHO.

^*Appointments at Family Planning are free for people aged under 22 years. Appointments cost $5 for Community Services Card holders.

Funding for insertions may be available for some people through their local DHB or PHO; check your local HealthPathway. Information will be updated as more details emerge or check the Ministry of Health website.

Withdrawal bleeds with combined oral contraceptives are not necessary

Combined oral contraceptive (COC) pills were first introduced in New Zealand in the 1960s. They were formulated to mimic the natural menstrual cycle, with three weeks of active hormone tablets followed by one week of placebo tablets at which time a withdrawal bleed usually occurs. However, there is no medical basis for this withdrawal bleed and people taking COCs can be reassured that skipping the hormone-free interval is safe, and is in fact now recommended.⁶ Continuous use of hormone pills, rather than stopping and starting, may improve contraceptive effectiveness by reducing the likelihood of missing pills, as well as lessening the consequences of missed pills, e.g. compared with missing pills in the first week of a conventional regimen, thereby extending the hormone-free interval. In addition, bleeding-related adverse effects, such as headache, bloating and abdominal pain, can be avoided, which is likely to improve satisfaction and adherence with this method of contraception.

Any contraceptive can be started six weeks post-partum

If contraception is required after childbirth, any of the available options can be given from six weeks post-partum, including COCs;⁶ progestogen-only pills, injections or implants can be used prior to six weeks and IUCs can either be inserted immediately post-partum or after four weeks (Table 1).⁶

It was previously recommended that COCs be avoided for the first six months post-partum if breastfeeding due to potential suppressive effects of ethinylestradiol on milk supply. While the data on COC use and breastfeeding are limited and conflicting, better quality studies investigating breastfeeding performance, i.e. duration, exclusivity and initiation of supplemental feeding, and infant growth, health and development have shown no adverse effects when COCs are started from six weeks post-partum, provided breastfeeding is well established and there are no concerns with the infant’s growth.⁶ COCs can be initiated at three weeks post-partum in those who are not breastfeeding, provided they do not have additional risk factors for venous thromboembolism.⁶

The lactational amenorrhoea method is an effective form of contraception if fewer than six months post-partum, amenorrhoeic and fully breastfeeding^*. This method should not be relied on if the frequency of breastfeeding decreases, e.g. night feeds stopped, supplemental foods started, if menstruation returns or if the patient is more than six months post-partum.⁶

^*Defined as at least 10 – 12 times per day in the first few weeks post-partum, and 8 – 10 times per day thereafter, including at least one night feed.⁶ Daytime feedings should be no more than four hours apart, and night-time feedings no more than six hours apart.⁶

Selecting a contraceptive option

Tables 1 and 2 can be used to decide, together with the patient, which types of contraception may be the most appropriate for them; detailed information on each option is available in the accompanying articles in this series:

• Condoms: advising on the options
• Oral contraceptives: selecting a pill
• Depot medroxyprogesterone acetate injections: an intermediate option
• Long-acting contraceptives: implants and IUDs

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Table 1: Recommendations regarding the likely benefits and risks of different contraceptive options. Adapted from New Zealand Aotearoa’s guidance on contraception (2020) and the Faculty of Sexual and Reproductive Healthcare, United Kingdom.^{6, 11}

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Table 2: Effectiveness of different contraceptive methods after one year. Adapted from the Faculty of Sexual and Reproductive Healthcare, United Kingdom.^{12, 13}

Natural family planning

The use of fertility awareness to prevent conception may be preferred by people who wish to avoid other methods of contraception for religious or personal reasons. When adhered to strictly these methods can have good efficacy rates (Table 3). However, with typical use, approximately 2 – 23% of people become pregnant within one year, depending on the method used.^{6, 17}

Fertility awareness methods rely on monitoring markers of fertility daily, including body temperature, changes in cervical secretions, changes in the cervix and timing of menstruation. Combining multiple markers is more effective than relying on a single marker.¹⁷ Learning the technique can be difficult for some people and may be more complicated for those with irregular cycles.¹⁷ People who have been using hormonal contraception should not rely on fertility markers until they have had a minimum of three regular menstrual cycles.⁶

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Table 3: Effectiveness of fertility awareness methods.⁶

Fertility awareness method	Pregnancies per 100 females over first year of use
	Correct and consistent	Typical
Calendar-based*	5	12
Symptoms-based:
Two-day method†	4	14
Ovulation method†	3	23
Sympto-thermal method**	< 1	2

^* Involves tracking the menstrual cycle to identify the start and end of the fertile period

^† Involves monitoring cervical secretions

^** Combines basal body temperature, cervical secretions and other signs, e.g. breast tenderness, ovulatory pain

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Key practice points for the use of fertility awareness methods include:¹⁷

• They should not be used in patients who are taking potentially teratogenic medicines
• They require a high level of patient engagement and in typical use can have high failure rates depending on the method used
• Menstrual irregularities or recent use of hormonal contraception may make determining the fertile window difficult
• Patients wishing to avoid pregnancy should be advised to use other forms of contraception (e.g. barrier methods) unless they are using the sympto-thermal method
• All patients wanting to use a fertility awareness method should be instructed in this method by an expert, such as an educator from Natural Fertility New Zealand: www.naturalfertility.co.nz
• Caution patients that smartphone apps that aim to assist users with fertility awareness may be unreliable and should not replace education from an expert

Withdrawal method alone not advised for contraception

Withdrawal is not considered a natural family planning method and should not be used on its own for contraception or instead of condom use or abstinence in patients using fertility awareness methods to avoid pregnancy.⁶

Emergency contraception

Emergency contraception should be offered to patients who have had unprotected sex and do not wish to conceive:^{6, 18}

• If no contraceptive method is being used, even if ovulation could be reasonably excluded based on their natural menstrual cycle
• If contraceptive failure occurs, e.g. condom breakage
• If two or more active COC pills have been missed in the first week following the hormone-free interval^*, or eight or more pills have been missed at other times or in a continuous cycle¹⁹
• If a POP is missed and intercourse occurs < 48 hours after restarting^*
• If more than 14 weeks have passed since a DMPA injection
• In the seven-day period prior to expulsion of an IUC or discovering the threads of an IUC are missing

^*Emergency contraception may also be required if patients have vomiting or diarrhoea lasting > 24 hours and have unprotected sex in the following two days if they are taking a POP or seven days if they are taking a COC: see “Oral contraceptives: selecting a pill” for more detail

Two forms of fully funded emergency contraception are available in New Zealand (Table 4). The copper IUD is recommended first-line as it is more effective and has a wider treatment window than the levonorgestrel tablet.⁶ However, the tablet may be preferred by patients as it does not require an insertion procedure and is available at pharmacies without a prescription.

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Table 4: Fully funded emergency contraceptives.^{6, 20}

Emergency contraceptive	Pregnancy rate with correct use	To be used within
Copper IUD	Less than 1%	120 hours (5 days) of unprotected sexual intercourse OR Up to 5 days after expected date of ovulation
Levonorgestrel 1.5 mg tablet	1 – 3%	72 hours (3 days) of unprotected sexual intercourse*

^*Evidence suggests that oral emergency contraceptives are not effective if taken after ovulation has occurred; they may be effective if taken more than 96 hours (four days) after unprotected intercourse, but are not approved for this timeframe

N.B. Emergency contraception providers must be familiar with the Contraception, Sterilisation and Abortion Act 1977 and the Abortion Legislation Act 2020, e.g. all people wishing to access emergency contraception must be able to do so within 48 hours of requesting it.⁶ See: https://www.legislation.govt.nz/act/public/1977/0112/latest/DLM17680.html and https://www.legislation.govt.nz/act/public/2020/0006/latest/LMS237550.html

The copper IUD should be considered as the first-line option whenever emergency contraception is needed, as it is the most effective method of emergency contraception and effectiveness is not altered by BMI or the use of enzyme-inducing medicines.⁶ A copper IUD can be inserted either up to five days following unprotected sexual intercourse or up to five days after the expected date of ovulation. The copper IUD can be left in place for ongoing contraception, or removed once pregnancy is excluded, e.g. at the next menstrual period.⁶

Levonorgestrel emergency contraception may be less effective in patients weighing over 70 kg or with a BMI greater than 26 kg/m², with rates of pregnancy of up to 5% observed in some, but not all, studies.²¹ For these patients, prescribing two 1.5 mg tablets is recommended if a copper IUD is not preferred or accessible, however, this is an unapproved dose.^{6, 20} The effectiveness of levonorgestrel emergency contraception is also reduced in patients taking enzyme-inducing medicines; these people should be offered a copper IUD.

After use of levonorgestrel emergency contraception, patients should expect a change in menstruation, typically occurring earlier and heavier than expected.¹⁸ Other adverse effects include headache, nausea, dizziness and, less commonly, vomiting.²⁰ If vomiting does occur and it is within two hours of administration, a repeat dose or use of a copper IUD is recommended.²⁰ There is limited evidence as to whether taking levonorgestrel emergency contraception with food, or prior administration of antiemetic medicines, can help reduce nausea.²² However, these approaches are widely recommended and may benefit some patients. Some evidence suggests that if levonorgestrel emergency contraception fails there may be a higher risk of ectopic pregnancy, however, this has not been consistently observed in studies and the absolute rate is very low.¹⁸

Offer a pregnancy test 28 days after the last instance of unprotected sexual intercourse.⁶

Review contraception use and discussion options if the patient is not using regular contraception; recommend a more reliable method if adherence is an issue.⁶

Sterilisation methods

Discussion about sterilisation should cover issues such as life stage, future plans and relationship stability and ensure that both partners have an opportunity to express any questions or concerns. Information should be provided on other contraceptive options for the female partner that would offer a similar level of effectiveness, such as an implant or IUC; also consider if the patient has a history of menstrual difficulties that may reoccur when their current contraceptive is stopped, and menstruation resumes after sterilisation.

Sterilisation options include vasectomy and tubal ligation or occlusion. Tubal ligation or occlusion is carried out by laparoscopy or laparotomy and is typically performed under general anaesthesia. Vasectomy is typically performed with a local anaesthetic.

Some patients may be eligible for a sterilisation procedure performed in the public health system, however, most patients will need to seek private treatment. Vasectomies are also performed in some primary care clinics. Some patients may be eligible for assistance from Work and Income (WINZ) to assist with the cost of a vasectomy (see: www.workandincome.govt.nz/eligibility/health-and-disability/vasectomies.html).

Sterilisation options are not intended to be reversed. Reversal procedures may be possible, depending on the technique used, but are more complex than the initial sterilisation procedure and may not be successful.