Contraception: which option for which patient (2025)

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, includingadolescents
• Combined oral contraceptive regimens can be tailored: advise patients that withdrawal bleeds are not necessary andextended use is safe and effective
• Clinicians should ensure that people of all ages recognise the need for condoms to protect against STIs, even whenother 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 orawkward topic, as it touches on issues such as their sexuality and sexual practices, as well as relationship issues andtheir future plans for children. In addition, their views and behaviours can be influenced by social, family, religiousor cultural factors. However, there is much to be gained and little to be lost when patients and healthcare providers haveopen discussions about contraception and prevention of STIs. The goal of counselling patients about contraception is toensure they are using a safe, effective option which is the most appropriate for their clinical needs and preferences. Cliniciansshould 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 contraceptiveoptions 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 needfor condoms to protect against STIs, even when other forms of contraception are used⁵
• Long-acting reversible contraceptives (LARCs); progestogen implants, copper and levonorgestrel (progestogen) intrauterinecontraceptives (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 contraceptiveas 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 toa high risk of adverse effects (Table 1).

Patients may base their preference for a contraceptive method on factors such as effectiveness (Table2), 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, whileothers 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 continuemenstruating.⁷ Some patients may discontinue contraceptives earlier if menopause has occurred.⁷ Aclinical diagnosis of menopause can be made after one year of amenorrhoea; contraception can be ceased at this time forpatients aged over 50 years, but is recommended for an additional year in patients aged 40 – 50 years, i.e. for two yearsafter 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-termform of contraception. There was some resistance to the idea that an IUC could be an appropriate contraceptive option foryounger women and those who had not yet given birth, due to concerns such as ease of insertion. However, there is no clinicalbasis for this concern, and an IUC should be considered as an appropriate option for almost anyone.⁶ The levonorgestrelimplant (inserted in the arm) has been funded in New Zealand since 2010, and is the most effective method of contraceptionavailable (Table 2). Some clinicians may be less familiar with this method as they do not have experiencein 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, ratesof abortion have been declining since the mid-2000s and research suggests that this is due in partto an increased use of LARCs.^2,8 Reductions have been particularly pronounced in people aged 15 – 19 years, however, rates of abortion are stillhighest 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 LARCcan be a barrier to patients in terms of convenience and cost.^{9, 10} Consider whether there are ways yourpractice could simplify the process for patients, e.g. by having a clinical staff member trainedin insertion and removal techniques, and having a supply of LARCs at the practice (implants and copperintrauterine devices [IUDs] are available on PSO; levonorgestrel intrauterine systems [IUSs] arenot). If offering these services at your practice is not possible, patients can be referred to FamilyPlanning or Sexual Health Clinics, if locally available; these services may offer contraception services at a lowercost or for free^*.Some PHOs may also offer funding for sexual health or contraception-related consultations; enquirewith your PHO.

^*Appointments at Family Planning are free for people aged under 22 years. Appointments cost $5for 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 mimicthe natural menstrual cycle, with three weeks of active hormone tablets followed by one week of placebo tablets at whichtime a withdrawal bleed usually occurs. However, there is no medical basis for this withdrawal bleed and people taking COCscan be reassured that skipping the hormone-free interval is safe, and is in fact now recommended.⁶ Continuoususe of hormone pills, rather than stopping and starting, may improve contraceptive effectiveness by reducing the likelihoodof missing pills, as well as lessening the consequences of missed pills, e.g. compared with missing pills in the first weekof a conventional regimen, thereby extending the hormone-free interval. In addition, bleeding-related adverse effects, suchas headache, bloating and abdominal pain, can be avoided, which is likely to improve satisfaction and adherence with thismethod 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, includingCOCs;⁶ progestogen-only pills, injections or implants can be used prior to six weeks and IUCs can either be insertedimmediately 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 potentialsuppressive 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 supplementalfeeding, 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 initiatedat three weeks post-partum in those who are not breastfeeding, provided they do not have additional risk factors for venousthromboembolism.⁶

The lactational amenorrhoea method is an effective form of contraception if fewer than six months post-partum, amenorrhoeicand 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 timesper 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 typesof contraception may be the most appropriate for them; detailed information on each option is available in the accompanyingarticles 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

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}

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

	Number of pregnancies per 1,000 females of reproductive age after one year		Funding status	For further information, see:
	Perfect Use*	Typical Use*
No contraception	850
Barrier and short-term options:
Male condoms	20	130 - 180		“Condoms: advising on the options”
Female condoms	50	210
Diaphragm†	60	120
Spermicide†	180	280
Oral contraceptives:				“Oral contraceptives: selecting a pill”
Combined oral contraceptive (COC)	3	90
Progestogen-only contraceptive (POP)	2	90
Injectable options:				“Depot medroxyprogesterone acetate injections: an intermediate option”
Depot medroxyprogesterone acetate injections (DMPA)	2-6	60
Long-acting reversible contraceptives:				“Long-acting contraceptives: implants and IUDs”
Levonorgestrel implants	< 1
Levonorgestrel IUDs	2 – 6
Copper IUD	6 – 8
Non-pharmacological options:				“Natural family planning” below
Fertility awareness methods	Varies with method: See Table 3
Permanent contraceptive methods:				“Sterilisation methods” below
Tubal occlusion/ligation	5		**
Vasectomy	1 – 2		**

Fully funded options available

^* Perfect use refers to using the contraceptive exactly as recommended. Typical use is when contraception is not always used consistently or correctly, e.g. forgetting to take a dose of medicine, condom applied incorrectly.

^† Diaphragms and spermicide have not been available on prescription in New Zealand for some time. Diaphragms may be available unsubsidised at some pharmacies. If patients already have a diaphragm they wish to keep using, support is available from Family Planning: www.familyplanning.org.nz/advice/contraception/diaphragms

^** Some patients may qualify for a tubal ligation or vasectomy performed in the public health system, depending on local eligibility criteria

Natural family planning

The use of fertility awareness to prevent conception may be preferred by people who wish to avoid other methods of contraceptionfor religious or personal reasons. When adhered to strictly these methods can have good efficacy rates (Table3). However, with typical use, approximately 2 – 23% of people become pregnant within one year, depending on the methodused.^{6, 17}

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

Table 3: Effectiveness of fertility awareness methods.⁶

^* 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

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 methodused
• 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) unlessthey 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 aneducator 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 shouldnot 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 insteadof 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 menstrualcycle
• 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 > 24hours 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 copperIUD 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 withouta prescription.

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

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

N.B. Emergency contraception providers must be familiar with the Contraception, Sterilisation and Abortion Act 1977 andthe Abortion Legislation Act 2020, e.g. all people wishing to access emergency contraception must be able to do so within48 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-inducingmedicines.⁶ A copper IUD can be inserted either up to five days following unprotected sexual intercourse or upto five days after the expected date of ovulation. The copper IUD can be left in place for ongoing contraception, or removedonce 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 witha BMI greater than 26 kg/m², with rates of pregnancy of up to 5% observed in some, but not all, studies.²¹ Forthese patients, prescribing two 1.5 mg tablets is recommended if a copper IUD is not preferred or accessible, however, thisis an unapproved dose.^{6, 20} The effectiveness of levonorgestrel emergency contraception is also reduced in patientstaking 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 occurringearlier 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 copperIUD is recommended.²⁰ There is limited evidence as to whether taking levonorgestrel emergency contraception withfood, or prior administration of antiemetic medicines, can help reduce nausea.²² However, these approaches arewidely recommended and may benefit some patients. Some evidence suggests that if levonorgestrel emergency contraceptionfails there may be a higher risk of ectopic pregnancy, however, this has not been consistently observed in studies and theabsolute 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; recommenda 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 ensurethat both partners have an opportunity to express any questions or concerns. Information should be provided on other contraceptiveoptions for the female partner that would offer a similar level of effectiveness, such as an implant or IUC; also considerif the patient has a history of menstrual difficulties that may reoccur when their current contraceptive is stopped, andmenstruation resumes after sterilisation.

Sterilisation options include vasectomy and tubal ligation or occlusion. Tubal ligation or occlusion is carried out bylaparoscopy or laparotomy and is typically performed under general anaesthesia. Vasectomy is typically performed with alocal anaesthetic.

Some patients may be eligible for a sterilisation procedure performed in the public health system, however, most patientswill need to seek private treatment. Vasectomies are also performed in some primary care clinics. Some patients may be eligiblefor 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 techniqueused, but are more complex than the initial sterilisation procedure and may not be successful.