Overview

This guideline covers long-acting reversible contraception. It aims to increase the use of long-action reversible contraception by improving the information given to women about their contraceptive choices.

In March 2019 we revised our decision on how to implement the recommendations of our October 2017 review. Although no new evidence was identified, we noted significant changes in how we commission and provide contraceptive services in England. We have removed the recommendations in this guideline that no longer fit with current practice. There are also many new LARC products now available. See our long-acting reversible contraception: implementation resource summary for links to the latest information.

Introduction

It is estimated that about 30% of pregnancies are unplanned. The effectiveness of the barrier method and oral contraceptive pills depends on their correct and consistent use. By contrast, the effectiveness of long-acting reversible contraceptive (LARC) methods does not depend on daily concordance. The uptake of LARC is low in Great Britain, at around 12% of women aged 16–49 in 2008–09, compared with 25% for the oral contraceptive pill and 25% for male condoms.

Expert clinical opinion is that LARC methods may have a wider role in contraception and their increased uptake could help to reduce unintended pregnancy. The current limited use of LARC suggests that healthcare professionals need better guidance and training so that they can help women make an informed choice. Health providers and commissioners also need a clear understanding of the relative cost effectiveness of LARC compared with other methods of fertility control. Enabling women to make an informed choice about LARC and addressing women’s preferences is an important objective of this guideline.

LARC is defined in this guideline as contraceptive methods that require administration less than once per cycle or month. Included in the category of LARC are:

• copper intrauterine devices
• progestogen-only intrauterine systems
• progestogen-only injectable contraceptives
• progestogen-only subdermal implants

The guideline offers the best-practice advice for all women of reproductive age who may wish to regulate their fertility by using LARC methods. It covers specific issues for the use of these methods during the menarche and before the menopause, and by particular groups, including women who have HIV, learning disabilities or physical disabilities, or are younger than 16 years.

Woman-centred care

This guideline offers the best-practice advice on the provision of information and care for women who are considering or using LARC. Treatment and care should take into account women’s individual needs and preferences.

Women who are considering using or who use LARC, and healthcare professionals, have rights and responsibilities as set out in the NHS Constitution for England - all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. Women should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the patient is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health’s advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.

NICE has produced guidance on the components of good patient experience in adult NHS services. All healthcare professionals should follow the recommendations in patient experience in adult NHS services.

1. Recommendations

2. Research recommendations

The scarcity of robust evidence to answer important clinical questions on the use of LARC methods by women in the UK posed great challenges to the developers of the original guideline (October, 2005). In the majority of cases, the guideline recommendations were based on extrapolated evidence that is indirect or of poor methodological quality. In 2005, the Guideline Development Group made the following recommendations for research on the basis of its review of the evidence.

In making these recommendations for research, the guideline developers consider it important and relevant that the research should be specific to the UK population because there are cultural differences in the response to side effects and non-contraceptive effects of hormonal contraceptives. In addition, freedom to choose any contraceptive method and the provision of a free contraceptive health service in the UK can influence important outcomes such as continuation rates and patterns of method switching.

Update information

July 2019: In March 2019 we revised our decision on how to implement the recommendations of our October 2017 review. Although no new evidence was identified, we noted significant changes in how we commission and provide contraceptive services in England. We have removed the recommendations in this guideline that no longer fit with current practice. There are also many new LARC products now available. See our Long-acting reversible contraception: implementation resource summary for links to the latest information.

September 2014: We reviewed the evidence for progestogen-only subdermal implants and updated the recommendations in section 1.5.

Footnotes

[1]

The MHRA issued a Drug Safety Update in January 2016 highlighting that levonorgestrel-releasing intrauterine systems should always be prescribed by brand name because products have different indications, durations of use, and introducers.

[2]

See the Department of Health’s Best practice guidance for doctors and other healthcare professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health (July 2004).

Your responsibility: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.