GPAtlas🧭 When to consider non-hormonal contraception
Non-hormonal contraception prevents pregnancy without exogenous hormones. It is relevant whenever a patient prefers to avoid hormones, has a contraindication to hormonal methods (for example migraine with aura, previous venous thromboembolism (VTE), or current/past breast cancer – all UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) 3 or 4 for combined hormonal contraception (CHC)), is breastfeeding, wants a method they control, or needs protection against sexually transmitted infections (STIs).
The methods divide into three groups: barrier (condoms, diaphragm/cap), fertility awareness (including lactational amenorrhoea), and the copper intrauterine device (Cu-IUD). They differ enormously in effectiveness: the Cu-IUD is the only non-hormonal method that is "fit-and-forget" and over 99% effective, whereas barrier and fertility-awareness methods are user-dependent, so their real-world (typical-use) failure rates are far higher.
The core skill is to match the method to what matters to the patient while being honest about typical-use effectiveness – and to recognise the situations where a low-efficacy method is simply not safe enough (a condition where pregnancy is dangerous, or a teratogenic drug).
| Method | Failure rate / year (perfect → typical use) | Protects against STIs? |
|---|---|---|
| Copper IUD (Cu-IUD) | < 1% → < 1% | No |
| External (male) condom | ~2% → ~18% | Yes |
| Internal (female) condom | ~5% → ~21% | Yes |
| Diaphragm or cap (+ spermicide) | ~6% → ~17% | No |
| Fertility awareness (taught, symptothermal) | < 1% → up to ~25% | No |
| Lactational amenorrhoea (all criteria met) | ~1% → ~2% | No |
| Spermicide alone (not advised as sole method) | ~18% → ~28% | No |
Perfect-use figures are best-case; typical use is what most people actually achieve. Fertility-awareness effectiveness is especially training-dependent – well-taught, motivated couples do far better than the upper typical-use figure suggests.
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⚠️ Common pitfall Treating "no hormones" as "low stakes". A patient who chooses condoms or fertility awareness while taking a teratogen (sodium valproate, isotretinoin) – or who has a condition where pregnancy itself is dangerous (UKMEC 4) – is inadequately protected. These situations need a highly effective method (usually a long-acting reversible contraceptive, LARC), whatever the patient's wish to avoid hormones. Always check the drug chart and UKMEC before agreeing to a low-efficacy method. |
Source: FSRH · UKMEC 2025
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