Contraception

❍ At a glance

• Start with the most effective options. LARCs (Jadelle implant, Mirena/Jaydess IUS, copper IUD) have failure rates under 1% per year and are all funded in NZ. Present them first, not as a last resort.
• Copper IUD is the most effective emergency contraception available (<0.1% failure rate if inserted within 5 days of unprotected intercourse). It also provides ongoing contraception. Always offer it alongside oral options.
• COCP typical-use failure rate is 9% - the gap between perfect use (0.3%) and real life. This is the central clinical reality of pill counselling. If reliability matters, discuss LARC.
• WHO MEC category 4 absolute contraindications to COCP include: migraine with aura, personal history of VTE or stroke, current breast cancer, and age over 35 with heavy smoking. Check the full MEC tables - the list is longer than commonly memorised.
• For emergency contraception: ulipristal acetate (EllaOne) outperforms levonorgestrel across the full 120-hour window and in women over 70 kg. Prescribe it preferentially.

❍ Long-acting reversible contraception (LARC)

LARCs are the most effective reversible methods available and should be the starting point of any contraception conversation. All are funded in NZ for eligible patients.

• Jadelle (two-rod levonorgestrel implant, up to 5 years): failure rate approximately 0.05% per year - the most effective contraceptive method available. Inserted subdermally in the upper inner arm under local anaesthetic. Common counselling point: irregular bleeding is expected, particularly in the first 3-6 months, and usually improves over time. Does not affect future fertility. Cannot be felt during intercourse.
• Levonorgestrel IUS (Mirena 52 mg, licensed 8 years; Jaydess 13.5 mg, 3 years): reduces menstrual blood loss significantly. Funded in NZ as contraception and for heavy menstrual bleeding. The Mirena is particularly useful when the patient wants both contraception and HMB management simultaneously. Also provides endometrial protection when used with systemic MHT.
• Copper IUD: the only highly effective non-hormonal LARC. Failure rate under 1% per year for contraception; under 0.1% as emergency contraception within 5 days. Can worsen dysmenorrhoea and menstrual blood loss. Fertility returns immediately on removal. Suitable for women who want to avoid all hormones.

❍ Combined oral contraceptive pill (COCP)

With perfect use, the COCP has a failure rate of 0.3%. With typical use (missed pills, vomiting, enzyme-inducing medications), this rises to around 9%.¹ That gap is the central clinical reality of pill counselling.

Default to levonorgestrel-containing pills (e.g. Levlen ED) as first prescription. They carry lower VTE risk than desogestrel- or drospirenone-containing formulations.³ Reserve anti-androgenic progestogens (drospirenone, cyproterone acetate) for specific indications such as acne or hirsutism.

WHO MEC category 4 (do not use): migraine with aura, personal history of VTE or stroke, current breast cancer, age over 35 with ≥15 cigarettes/day, poorly controlled hypertension (systolic ≥160 or diastolic ≥100). Category 3 (risks generally outweigh benefits) includes controlled hypertension, obesity (BMI ≥35), and postpartum breastfeeding. Always check the full MEC tables - the abbreviated list is not complete.

❍ Progestogen-only options

Progestogen-only pill (POP): suitable for women who cannot use oestrogen - breastfeeding, migraine with aura, elevated VTE risk, age over 35 who smoke. The desogestrel-containing POP (Cerazette) inhibits ovulation in over 97% of cycles and has a 12-hour missed-pill window (versus 3 hours for levonorgestrel POPs). It is funded in NZ.

Depot medroxyprogesterone acetate (DMPA, Depo-Provera, 150 mg IM every 12 weeks): highly effective, useful for patients who struggle with daily adherence. Key counselling points: return to fertility may be delayed 6-12 months after stopping; bone density decreases with long-term use (generally reversible on cessation, but relevant in adolescents and those with existing osteoporosis risk factors). Not the preferred long-term choice in under-18s.

❍ Emergency contraception

Two oral options in NZ:

• Ulipristal acetate 30 mg (EllaOne, prescription required): effective up to 120 hours, maintains efficacy throughout this window and in women over 70 kg. Preferred option where efficacy matters.
• Levonorgestrel 1.5 mg (Postinor, pharmacy OTC): most effective within 72 hours. Reduced efficacy at higher body weight. Available without prescription.

Copper IUD insertion within 5 days remains the gold standard for emergency contraception (<0.1% failure rate) and transitions directly to ongoing contraception. Always offer it as an option alongside oral EC.

Clarify for patients: emergency contraception prevents, rather than terminates, pregnancy. This distinction is worth making explicitly - it is a common source of hesitation.

❍ The consultation: what actually matters

Good contraception counselling is not about recommending the most effective method - it is about helping the patient identify what fits her life. Ask about her priorities, her past experience with contraception and what she thought of it, her plans for having children, and whether her partner is involved in the decision (and whether it is safe to ask). These questions take two minutes and change the outcome.

A woman who understands her options, has her concerns addressed without dismissal, and leaves with a plan she chose is more likely to use contraception effectively than one who leaves with a pamphlet and a prescription she was uncertain about. Document the discussion, the method chosen, and any MEC considerations.

For IUD and implant insertion in general practice: NZ Family Planning and BPAC provide insertion training. The Jadelle implant and IUD insertion are funded procedures in NZ; check current schedule fees. If you do not insert LARCs yourself, know where to refer - Family Planning clin