Contraception in Australia: LARC first-line, hormonal options and emergency

What contraception options are available in Australia

About 70% of Australian women aged 15–49 use contraception, with the combined oral contraceptive pill historically most common. But the guideline emphasis has shifted markedly: RANZCOG’s Long-Acting Reversible Contraception position statement and Family Planning Australia both recommend presenting LARC — long-acting reversible contraception — as the first-line conversation, not as a fallback after the pill.

Unintended pregnancy affects approximately 25% of all pregnancies in Australia. That figure reflects the gap between method efficacy under perfect use versus typical real-world use. LARC closes that gap almost entirely because it removes user dependency. The combined pill fails in roughly 9 per 100 typical users per year — not because the pill doesn’t work, but because missed doses happen.

The role of general practice is to take a structured eligibility history, apply the WHO Medical Eligibility Criteria (MEC) framework, identify contraindications, present options honestly, and support the patient’s reproductive goals and values through shared decision-making.

A. Core clinical — the AU general-practice framework

History

A contraception consultation is an eligibility assessment as much as a prescription conversation. Therapeutic Guidelines — Reproductive health frames the key domains:

• Reproductive goals — completed family, planning pregnancy within 1–5 years, or undecided; the answer informs duration and reversibility preference
• Menstrual pattern — regularity, volume, dysmenorrhoea; heavy menstrual bleeding or endometriosis may make the Mirena LNG-IUD a therapeutic first choice, not just a contraceptive one
• VTE history or thrombophilia — absolute contraindication to combined oestrogen-containing methods; LARC and progestogen-only options remain safe
• Migraine — migraine with aura contraindicates combined hormonal methods due to increased stroke risk; migraine without aura is not a contraindication
• Cardiovascular risk — hypertension, smoking (especially age ≥35), BMI, diabetes, dyslipidaemia
• Hepatic disease — severe hepatic impairment contraindicates most hormonal methods; copper IUD remains safe
• Breast cancer history — all hormonal methods contraindicated; copper IUD is the safe option
• Postpartum and breastfeeding status — combined oestrogen-containing methods avoided for at least 6 weeks postpartum and longer during breastfeeding
• Drug interactions — enzyme inducers (rifampicin, carbamazepine, phenytoin, topiramate, St John’s wort) reduce efficacy of combined hormonal pills; LARC is unaffected by all drug interactions
• Sexual history and STI risk — STI screen recommended before IUD insertion if at-risk; condoms remain the only STI-protective contraceptive method
• Coercive control or intimate partner violence — method visibility has safety implications; covert options such as the Implanon implant or Mirena IUD can be safer than visible pill packets or condoms

Physical assessment

• Blood pressure — essential before prescribing combined hormonal methods; sustained hypertension with other cardiovascular risk factors shifts preference toward LARC
• BMI — BMI ≥35 with additional risk factors contraindicates combined oestrogen-containing methods per WHO MEC; all LARC options maintain full efficacy regardless of body weight
• Pelvic examination is not routinely required for contraceptive prescribing but is needed for IUD insertion procedures

Investigations

• Pregnancy test — before LARC insertion, or insert within 5 days of onset of menses
• STI screen (chlamydia and gonorrhoea NAAT) — before IUD insertion if at-risk; active cervicitis should be treated before insertion
• Cervical screening — contraception consultations are efficient opportunities to check that 5-yearly HPV-based cervical screening is current (women aged 25–74)
• Haemoglobin and iron studies — if significant menorrhagia is present before Mirena insertion
• Lipids and fasting glucose — selective, based on individual cardiovascular risk profile

B. LARC and hormonal contraception — options and evidence

Long-acting reversible contraception

RANZCOG’s LARC position statement and Family Planning Australia are unambiguous: LARC should be offered first to most women, including adolescents and nulliparous women. The “LARC is for women who’ve already had children” framing is outdated and not supported by evidence.

Mirena (levonorgestrel 52 mg IUD, licensed 8 years) releases levonorgestrel locally, producing endometrial atrophy and cervical mucus thickening with minimal systemic progestogen absorption. Typical-use efficacy exceeds 99%. It reduces menstrual blood loss by approximately 90% and is first-line for both contraception and heavy menstrual bleeding — a PBS Authority is available for the menorrhagia indication. The licensed duration was extended to 8 years in recent years. Cost: approximately $30 with a concession card, $40 general patient.

Kyleena (levonorgestrel 19.5 mg IUD, 5 years) — smaller frame suitable for smaller or nulliparous uteri; produces less amenorrhoea than Mirena and less bleeding reduction. PBS-subsidised.

Copper IUD (5–10 years) — non-hormonal; acts through direct sperm toxicity and endometrial inflammation. Does not alter the hormonal milieu. Periods may become heavier and more painful. Also the most effective form of emergency contraception when inserted within 5 days of unprotected sex.

Implanon NXT (etonogestrel 68 mg implant, 3 years) — a small flexible rod inserted subdermally into the upper inner arm under local anaesthetic by a trained provider. Suppresses ovulation and thickens cervical mucus. Over 99% typical-use efficacy. PBS-subsidised. Irregular bleeding affects approximately 50% of users; about 20% experience amenorrhoea; approximately 25% have prolonged spotting. Fertility returns promptly after removal.

Combined hormonal methods

Combined oral contraceptive pills (COC) combine oestrogen with a progestogen. Per Australian Medicines Handbook and eTG Reproductive health:

Method	Notes
Levonorgestrel COC (Microgynon 30, Levlen ED)	Lowest VTE risk in class; first-line for eligible patients
Drospirenone COC (Yaz, Yasmin)	Anti-androgenic; useful for acne and PMDD; higher VTE than levonorgestrel formulations
Cyproterone (Diane-35, Brenda-35)	PBS Authority for severe acne only; not first-line for contraception alone; highest VTE in class
NuvaRing (monthly vaginal ring)	Consistent hormone delivery; comparable efficacy to COC
Evra patch (weekly)	Higher oestrogen exposure than oral COC; applied to skin

VTE risk with COC is 3–5 times background — approximately 5–12 per 10,000 woman-years versus 2 per 10,000 without hormonal contraception. WHO MEC absolute contraindications include VTE history, known thrombophilia, migraine with aura, smoker aged ≥35, BMI ≥35 with additional risk factors, severe hypertension, ischaemic heart disease, stroke, breast cancer, and severe liver disease.

Progestogen-only options

Standard progestogen-only pill (POP) — Cerazette (desogestrel), Microlut (levonorgestrel): strict 3-hour missed-dose window. Useful when combined hormonal methods are contraindicated.

Slynd (drospirenone-only POP) — 24-hour missed-dose window; anti-androgenic effect; PBS general schedule. A practical choice for women who cannot take combined hormonal contraceptives — VTE history, migraine with aura, breastfeeding, age ≥35 smokers.

DMPA (Depo-Provera 150 mg IM 3-monthly) — 94% typical-use efficacy; ovulation suppression; useful where daily pill adherence is difficult. The average delay to fertility return after the last injection is 9 months, occasionally longer. Bone mineral density reduction occurs with long-term use — calcium, vitamin D, and weight-bearing exercise are recommended; reassess in adolescents after 2 continuous years.

Emergency contraception

Per TGA prescribing data and eTG Reproductive health, three options exist:

• Levonorgestrel 1.5 mg (Postinor-2, NorLevo) — pharmacy OTC; effective within 72 hours; efficacy declines by 96 hours; less effective with BMI ≥30
• Ulipristal acetate 30 mg (EllaOne) — pharmacy without prescription; up to 120 hours; maintains efficacy better across the full window; preferred if more than 72 hours have elapsed
• Copper IUD — within 5 days of unprotected sex; most effective emergency contraception; also provides ongoing contraception for up to 10 years

C. Shared decision-making and safety in practice

The consultation framework

A structured consultation works through:

1. Reproductive goals — completed vs future plans inform urgency of highly effective contraception and method duration preference
2. WHO MEC eligibility — identify absolute and relative contraindications before prescribing any hormonal method
3. LARC as the opening conversation — present IUDs and implant as the most effective, least user-dependent options; not as a second-line fallback after pill failure
4. Patient priorities — efficacy, presence of hormones vs non-hormonal, ease of use, fertility return timeline, cost, STI protection, cultural or religious considerations
5. Side-effect counselling — bleeding pattern changes are the most common driver of method discontinuation; proactive counselling about expected changes reduces unexpected stopping
6. STI prevention — hormonal methods provide no STI protection; recommend dual use (hormonal method plus condoms) for any new or casual partner
7. Ongoing review — review at 3 months for new combined hormonal starters, then annually; 6-week review post-LARC insertion for string check and symptom assessment

Drug interactions with combined hormonal methods

Enzyme inducers reduce combined hormonal contraceptive efficacy. Clinically important interactions per AMH: rifampicin, rifabutin, carbamazepine, phenytoin, topiramate at antiepileptic doses, some HIV antiretrovirals, and St John’s wort. For women on these agents, LARC is the preferred contraceptive. The widespread belief that routine antibiotics reduce COC efficacy is a clinical myth — only rifampicin and rifabutin have clinical significance; standard antibiotics such as amoxycillin and doxycycline do not require additional contraceptive precautions.

Safety-netting

Patients should know to return urgently for: missed periods with any uncertainty (test and contact GP), severe pelvic pain in the days following IUD insertion (possible perforation), severe unilateral leg swelling or pleuritic chest pain on combined hormonal methods (VTE or PE), or new neurological symptoms on combined hormonal contraception.

D. Australian operations

PBS-subsidised options

PBS covers the major LARC options and most hormonal methods:

• Mirena (52 mg LNG-IUD) — approximately $30 concession, $40 general patient; PBS Authority required for the menorrhagia indication
• Kyleena (19.5 mg LNG-IUD) — PBS general schedule
• Implanon NXT — PBS general schedule
• Copper IUD — not PBS-subsidised in most settings; state family planning services may reduce cost
• COC, POP (including Slynd), DMPA, NuvaRing, Evra — most formulations PBS-subsidised; some newer formulations at private cost
• Levonorgestrel EC, Ulipristal EC (EllaOne) — pharmacy OTC; private cost; no PBS subsidy

MBS item numbers

Standard consultations bill general practice items 23, 36, or 44 by duration. Key procedural items from MBS Online:

• IUD insertion — item 35503
• IUD removal — item 35506
• Implanon NXT insertion — item 14206
• Implanon NXT removal — item 14209

GPCCMP (items 965/967) applies when contraception overlaps chronic comorbidity management — heavy menstrual bleeding, endometriosis, or perimenopause where Mirena provides endometrial protection alongside systemic oestrogen HRT.

Family planning and sexual health services

State-based organisations offer trained-provider LARC insertion, STI services, and counselling beyond what is routinely available in general practice: Family Planning Australia, Sexual Health Quarters (WA), SHINE SA, and True Relationships and Reproductive Health (Queensland). These services are a resource when a GP is not trained for LARC procedures or when complex comorbidities require specialist input.

E. Special populations

Adolescents. RANZCOG explicitly supports LARC in adolescents and nulliparous women — insert this into the standard conversation, not as a late fallback. For those under 16, assess Gillick competence, document the assessment, and maintain confidentiality unless specific safeguarding concerns are present. HPV vaccination and STI prevention are co-priorities at any contraception consultation for young people.

Postpartum women. Combined oestrogen-containing methods are avoided for at least 6 weeks postpartum due to elevated VTE risk. Implanon and LNG-IUDs can be inserted from 4–6 weeks postpartum. Copper IUD from 6 weeks. Lactational amenorrhoea (LAM) provides effective contraception for up to 6 months only when all three criteria are simultaneously met: exclusive breastfeeding, no return of periods, and infant age under 6 months. When any criterion lapses, transition to another method promptly.

Breastfeeding. Progestogen-only methods and copper IUD are safe while breastfeeding. Combined oestrogen-containing methods should be avoided for at least 6 weeks postpartum — many guidelines extend this to 6 months during exclusive breastfeeding due to potential effects on milk supply.

Women with VTE or thrombophilia. Combined hormonal methods are absolutely contraindicated. LNG-IUDs do not increase systemic progestogen to a clinically significant level and are safe. Progestogen-only pills, Implanon, and copper IUD are all appropriate. Complex thrombophilia warrants haematology input before prescribing.

Women with endometriosis or heavy menstrual bleeding. Mirena LNG-IUD is first-line — reducing menstrual blood loss by approximately 90% and suppressing endometrial activity. PBS Authority for the menorrhagia indication. This is a therapeutic choice as well as a contraceptive one.

Women in coercive or controlling relationships. Method visibility has direct safety implications. Implanon (subdermal, not visible) and Mirena (no packaging needed after insertion) are safer choices. 1800RESPECT (1800 737 732) provides 24/7 support. Document thoughtfully and preserve confidentiality.

Perimenopause. LARC remains an excellent choice. For women who also need HRT for perimenopausal symptoms, Mirena provides the progestogen component for endometrial protection alongside systemic oestrogen — a convenient single-device solution.

When to escalate

Refer urgently:

• Suspected ectopic pregnancy on LARC — positive pregnancy test with an in-situ LARC warrants urgent assessment; ectopic risk is proportionally higher if conception occurs on a LARC because LARC is so effective at preventing intrauterine pregnancy
• Suspected IUD perforation — severe pelvic pain immediately post-insertion, missing strings with no evidence of expulsion on ultrasound, or imaging showing IUD outside uterine cavity

Routine referral:

• Failed or difficult IUD insertion — uterine anomaly, stenosed or scarred cervix; refer to family planning specialist or gynaecology
• String issue — suspected expulsion or malposition; ultrasound first, then refer if confirmed
• Sterilisation counselling — vasectomy (urology), tubal ligation or bilateral salpingectomy (gynaecology); document counselling about permanence and the limited success of reversal
• Fertility concerns after DMPA — if no return of menses by 12 months post-last-injection, investigation and potentially gynaecology referral

What this article is and is not

This is general health information drawn from current Australian guidelines — RANZCOG, Family Planning Australia, Therapeutic Guidelines, Australian Medicines Handbook, TGA, and WHO Medical Eligibility Criteria. It is not personal medical advice and does not create a doctor–patient relationship. Contraceptive choices are made through shared decision-making with your own GP, taking your complete medical history, current medications, values, and reproductive goals into account.

For consumer-facing information: HealthDirect — Contraception, Better Health Channel — Contraception, Family Planning Australia.

If safety in a relationship is a concern: 1800RESPECT 1800 737 732 (24/7).

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Sources cited

1. RANZCOG — LARC position statement
2. Family Planning Australia
3. Therapeutic Guidelines (eTG) — Reproductive health
4. Australian Medicines Handbook
5. WHO Medical Eligibility Criteria for Contraceptive Use
6. TGA
7. PBS
8. MBS Online
9. HealthDirect — Contraception
10. Better Health Channel — Contraception
11. Sexual Health Quarters (WA)
12. 1800RESPECT