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Family Planning

Last updated 1 Jun 2026 · Women's Health

📋 Key Information Summary

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  • Long-acting reversible contraception (LARC) — IUDs and subdermal implants — are the most effective reversible methods, with failure rates <1% per year in typical use.
  • The combined oral contraceptive pill (COCP) has a typical-use failure rate of approximately 7–9% per year; perfect use achieves <1%.
  • The etonogestrel subdermal implant (Implanon NXT®) provides ≥3 years of contraception and is PBS-listed as an Authority Required item.
  • Levonorgestrel-releasing intrauterine systems (Mirena® 52 mg, Kyleena® 19.5 mg) are effective for 5–8 years depending on product and indication.
  • Depot medroxyprogesterone acetate 150 mg IM (Depo-Provera®) is given every 12 weeks; counsel regarding potential bone mineral density reduction.
  • The COCP is contraindicated with combined hormonal contraceptive use in women aged ≥35 years who smoke ≥15 cigarettes/day, or with BMI ≥35 kg/m² with additional risk factors for VTE.
  • Emergency contraception with levonorgestrel 1.5 mg (Postinor-1®) is most effective within 72 hours; ulipristal acetate 30 mg (ellaOne®) extends efficacy to 120 hours.
  • A copper intrauterine device (IUD) inserted within 5 days of unprotected intercourse is the most effective form of emergency contraception (failure rate <1%).
  • All contraceptive methods require a shared decision-making approach considering efficacy, side-effects, reversibility, patient preference, and medical eligibility.
  • Use the UKMEC or Australian-adapted eligibility criteria when prescribing combined hormonal contraception, particularly regarding VTE risk, migraine with aura, and hypertension.
  • Aboriginal and Torres Strait Islander women experience higher rates of teenage pregnancy and reduced access to LARC in remote settings; culturally safe counselling is essential.
  • Document contraceptive counselling including discussion of LARC in all women of reproductive age presenting for routine care or antenatal booking.

Introduction & Australian Epidemiology

Contraception is a core component of general practice and reproductive health care in Australia. Effective family planning reduces unintended pregnancies, supports reproductive autonomy, and improves maternal and perinatal outcomes. Australian general practitioners (GPs) play a central role in contraceptive counselling, prescribing, insertion of long-acting reversible contraception (LARC), and follow-up.

According to the Australian Institute of Health and Welfare (AIHW), approximately 4.0 million Australian women aged 15–49 use some form of contraception. The most commonly used methods are the combined oral contraceptive pill (COCP) and condoms, though uptake of LARC methods — particularly the levonorgestrel intrauterine system (LNG-IUS) and the etonogestrel subdermal implant — has increased significantly over the past decade, supported by GP training initiatives and PBS subsidies.

The national rate of induced abortions is estimated at approximately 15–20 per 1,000 women aged 15–44 years, with a significant proportion associated with contraceptive failure or non-use. The Royal Australian College of General Practitioners (RACGP) and Family Planning Australia recommend that discussions about contraception should be proactive, patient-centred, and inclusive of all available methods, with particular emphasis on LARC as first-line for most women.

This guideline provides Australian GPs and primary care clinicians with an evidence-based approach to contraceptive prescribing, including effectiveness comparisons, combined hormonal contraception, progestogen-only and LARC methods, and emergency contraception.

Effectiveness of Contraceptive Methods

Contraceptive effectiveness is best understood through both perfect-use and typical-use failure rates. Typical use reflects real-world adherence and includes user error. LARC methods (implants, IUDs, injectables) have the highest effectiveness because they remove the need for user action after initiation.

Method Perfect-Use Failure Rate (%/yr) Typical-Use Failure Rate (%/yr) Duration of Action Reversibility
Etonogestrel implant (Implanon NXT®) 0.05% 0.05% 3 years Rapid (within days)
Copper IUD (Multiload® / Copper T) 0.6% 0.8% 5–10 years Immediate on removal
Levonorgestrel IUS — Mirena® 52 mg 0.2% 0.2% 5 years (contraception); 8 years (if aged ≥45 at insertion) Immediate on removal
Levonorgestrel IUS — Kyleena® 19.5 mg 0.3% 0.3% 5 years Immediate on removal
Depot medroxyprogesterone IM (Depo-Provera®) 0.2% 6% 12 weeks per injection Delayed (up to 6–12 months)
Combined oral contraceptive pill 0.3% 7–9% Daily (continuous use possible) Rapid (1–3 months)
Progestogen-only pill (desogestrel) 0.3% 7% Daily Rapid
Vaginal ring (NuvaRing®) 0.3% 7% 21 days in / 7 days out Rapid
Transdermal patch (Evra®) 0.3% 7% Weekly × 3 / 1 week off Rapid
Male condom 2% 13% Per act N/A
Female condom 5% 21% Per act N/A
Fertility awareness methods 1–5% 12–24% Ongoing Immediate
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Clinical pearl: The difference between perfect and typical use for LARC methods is negligible, making them the most reliable reversible options. The Contraceptive CHOICE project demonstrated that when cost and access barriers are removed, uptake of LARC increases dramatically and unintended pregnancy rates fall substantially.

Contraceptive Efficacy Tiers

Tier 1 — Most Effective
Failure rate <1%
Implant (Implanon NXT®), LNG-IUS (Mirena®, Kyleena®), copper IUD, sterilisation (tubal ligation, vasectomy)
LARC — set and forget
Tier 2 — Moderately Effective
Failure rate 6–12%
COCP, POP, vaginal ring, transdermal patch, DMPA injectable
Requires adherence — daily, weekly, or 12-weekly
Tier 3 — Less Effective
Failure rate 12–24%
Male and female condoms, diaphragm, fertility awareness, withdrawal, spermicides alone
Per-act or cycle-dependent use

Combined Oral Contraceptive Pill — Formulations & Prescribing

The combined oral contraceptive pill (COCP) contains an oestrogen (usually ethinyloestradiol or, in newer formulations, oestradiol valerate or estetrol) combined with a progestogen. It is one of the most widely prescribed medications in Australian general practice. The COCP works primarily by suppressing ovulation through inhibition of the hypothalamic–pituitary–ovarian (HPO) axis, as well as by thickening cervical mucus and thinning the endometrium.

Common Australian COCP Formulations

Brand Oestrogen Progestogen EE Dose (µg) PBS Status Notes
Levlen® ED EE 30 µg Levonorgestrel 150 µg 30 ✔ PBS General Benefit Common first-line; standard 21/7 or continuous
Monofeme® EE 30 µg Levonorgestrel 150 µg 30 ✔ PBS General Benefit Generic alternative to Levlen ED
Microgynon® 30 ED EE 30 µg Levonorgestrel 150 µg 30 ✔ PBS General Benefit Widely prescribed
Brenda-35 ED® / Diane-35 ED® EE 35 µg Cyproterone acetate 2 mg 35 ✔ PBS General Benefit Second-line; for acne/hirsutism. Higher VTE risk
Yasmin® EE 30 µg Drospirenone 3 mg 30 ✔ PBS General Benefit Anti-androgenic; PMDD benefit; monitor potassium with other potassium-sparing drugs
Yaz® EE 20 µg Drospirenone 3 mg 20 ⚑ PBS Authority Required 24/4 regimen; PMDD indication
Zoely® Oestradiol 1.5 mg Nomegestrol acetate 2.5 mg ~Equivalent to EE 30 µg ✔ PBS General Benefit 24/4 regimen; native oestrogen; may suit women intolerant of EE
Nextstellis® Estetrol 14.2 mg Drospirenone 3 mg ~Equivalent to EE 20–30 µg ⚑ PBS Authority Required 24/4 regimen; novel plant-derived oestrogen; lower hepatic impact

Prescribing Principles

  • Standard regimen: 21 active pills followed by a 7-day hormone-free interval (HFI). Pills are taken at the same time daily.
  • Extended/continuous use: Running packs together (skipping the HFI) is safe and effective for reducing menstrual symptoms, dysmenorrhoea, and endometriosis-related pain. Counsel that breakthrough bleeding is common in the first 3–6 months.
  • Starting the COCP: May be started on day 1 of the menstrual cycle (immediate protection) or on the "quick start" method (any day of the cycle, provided pregnancy is reasonably excluded and condoms are used for 7 days). The Sunday start method is rarely used in Australia.
  • Missed pills: If one active pill is missed (<48 hours late), take it as soon as remembered and continue normally. If ≥2 active pills are missed or the pill is >48 hours late, take the most recent missed pill, discard earlier missed pills, use condoms for 7 days, and consider emergency contraception if unprotected intercourse occurred in the pill-free interval or first week of the missed pills.
  • Low-dose formulations (EE 20 µg): Consider for women with oestrogen-related side-effects (nausea, breast tenderness, headache). Equivalent contraceptive efficacy; may have slightly higher rates of breakthrough bleeding.

Medical Eligibility — Key Contraindications (UKMEC Category 4)

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Do NOT prescribe the COCP (combined hormonal contraception) in:
  • Current or past VTE (deep vein thrombosis, pulmonary embolism)
  • Migraine with aura (at any age — significantly increased stroke risk)
  • Smoker aged ≥35 years (≥15 cigarettes/day) — MEC Category 3–4
  • Current breast cancer
  • SLE with positive antiphospholipid antibodies
  • Uncontrolled hypertension (≥160/100 mmHg)
  • History of ischaemic heart disease or stroke
  • Known thrombogenic mutations (Factor V Leiden homozygous, protein C/S deficiency)
  • Undiagnosed abnormal uterine bleeding
  • Major surgery with prolonged immobilisation (until 4 weeks post-mobilisation)

Common Side-Effects & Management

Side-Effect Management Strategy
Nausea Take pill at bedtime with food; switch to lower-dose EE; consider progestogen-only or non-oral method
Breast tenderness Usually resolves within 3 cycles; consider lower oestrogen dose
Headache Assess for migraine with aura (UKMEC 4); consider continuous use to eliminate HFI headaches
Breakthrough bleeding Reassure (common in first 3 months); ensure adherence; consider switching progestogen type
Mood changes / depression Assess severity; consider progestogen-only or non-hormonal method; switch formulation
Reduced libido Consider switching to androgen-neutral preparation or non-hormonal method
Weight gain (perceived) Evidence does not support significant weight gain from COCP; reassure; address lifestyle factors

Drug Interactions of Note

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Enzyme-inducing medications reduce COCP efficacy: Rifampicin, rifabutin, carbamazepine, phenytoin, phenobarbitone, topiramate (≥200 mg/day), St John's wort, and some antiretrovirals (e.g. efavirenz). In these situations, the COCP is not reliable — switch to a LARC method, progestogen-only injection, or use additional barrier contraception. Note: Most commonly used antibiotics (amoxicillin, doxycycline, metronidazole) do NOT significantly reduce COCP efficacy.

Contraceptive Counselling Checklist

  • Discuss all methods including LARC as first-line options
  • Assess medical history, smoking status, migraine history, VTE risk, BMI
  • Provide written information (Family Planning Australia fact sheets)
  • Discuss STI prevention (condoms in addition to contraception for new/multiple partners)
  • Document discussion and patient's chosen method
  • Arrange follow-up at 3 months and annually

Progestogen-Only & Long-Acting Reversible Contraception (LARC)

LARC methods — including the subdermal implant, intrauterine systems (both hormonal and copper), and the progestogen-only injectable — are the most effective reversible contraceptive options available in Australia. The RACGP and Faculty of Sexual and Reproductive Healthcare (FSRH) recommend LARC as first-line contraception for most women, including nulliparous women and adolescents. LARC methods have very high continuation rates at 12 months compared with user-dependent methods.

1. Etonogestrel Subdermal Implant — Implanon NXT®

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Etonogestrel Implant
Implanon NXT® · MSD · Progestogen-only subdermal
Mechanism Suppresses ovulation; thickens cervical mucus; thins endometrium
Active agent Etonogestrel 68 mg in single-rod ethylene vinyl acetate implant
Duration 3 years (up to 4 years per emerging evidence; 3 years is Australian-approved standard)
Insertion site Inner upper arm (non-dominant), subdermal plane, ~8–10 cm above medial epicondyle
Efficacy Failure rate <0.1% — among the most effective reversible contraceptives available
Common side-effects Unpredictable bleeding patterns (most common reason for removal); headache; weight gain; acne
Renal / Hepatic adjustment No specific dose adjustment; use with caution in severe hepatic impairment
PBS status ⚑ PBS Authority Required — Implant only (insertion/removal is MBS item 14222/14224)
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Insertion & removal training: GPs must complete an accredited training programme (e.g. SHFPACT, Family Planning NSW/VIC/QLD/SA/WA) before inserting or removing Implanon NXT®. The procedure uses a preloaded applicator with a trocar. Insertion takes ~1 minute under local anaesthetic. MBS items for insertion (14222) and removal (14224) are available.

Managing Unscheduled Bleeding on Implanon NXT®

  • Reassure that irregular bleeding is the most common side-effect and often improves after 6–12 months
  • Short courses of hormonal manipulation may help: ethinyloestradiol 20–30 µg daily for 20 days, or COCP for 1–3 months
  • Tranexamic acid 1 g PO TDS during heavy bleeding episodes
  • Mefenamic acid 500 mg PO TDS may reduce bleeding
  • If persistent and unacceptable, consider removal and switching to an alternative LARC (e.g. LNG-IUS)

2. Levonorgestrel Intrauterine Systems (LNG-IUS)

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Levonorgestrel IUS 52 mg
Mirena® · Bayer · LNG-IUS 52 mg
Mechanism Local progestogenic effect: thickens cervical mucus, thins endometrium; suppresses ovulation in some users
Duration 5 years for contraception (up to 8 years if inserted at age ≥45 per FSRH/Australian practice); 5 years for HMB/menorrhagia; 5 years for endometrial protection with HRT
Efficacy Failure rate 0.1–0.2%
Additional benefits First-line for heavy menstrual bleeding (HMB); endometrial protection in HRT; management of endometriosis/adenomyosis
Common side-effects Irregular bleeding first 3–6 months; amenorrhoea (40–50% at 12 months); ovarian cysts (usually self-resolving); acne
PBS status ✔ PBS General Benefit (contraception); ⚑ PBS Authority Required (HMB/endometrial protection) — MBS item 35620 for insertion
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Levonorgestrel IUS 19.5 mg
Kyleena® · Bayer · LNG-IUS 19.5 mg
Duration 5 years for contraception
Suitability Smaller frame — particularly suited to nulliparous women and adolescents
Efficacy Failure rate 0.2–0.3%
Note Lower LNG dose — less likely to cause amenorrhoea; NOT approved for HMB or endometrial protection
PBS status ✔ PBS General Benefit
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Levonorgestrel IUS 13.5 mg
Jaydess® · Bayer · LNG-IUS 13.5 mg
Duration 3 years for contraception
Suitability Smallest LNG-IUS; suited to nulliparous women and young people
PBS status ✔ PBS General Benefit

IUS Insertion Counselling Points

  • Timing: Ideally during menstruation (open cervical os, excludes pregnancy) or at any time with negative pregnancy test and reliable contraception in preceding 7 days
  • Nulliparous women: IUS insertion is safe and appropriate. Consider paracervical block or intracervical local anaesthetic. Jaydess® and Kyleena® have smaller insertion tubes
  • Pain management: Consider ibuprofen 400 mg PO 1 hour pre-insertion; intracervical lignocaine 1% (2 mL) block for nulliparous patients; oral misoprostol is NOT routinely recommended
  • Follow-up: Check threads at 4–6 weeks post-insertion (post-menstruation); annual review; ultrasound if threads not visible
  • Expulsion rate: ~2–10% in the first year, higher in the first 3 months. Check threads after each period

3. Copper Intrauterine Device (Cu-IUD)

The copper IUD (Multiload Cu375®, Copper T 380A) is a non-hormonal option effective for 5–10 years (depending on device). It is the most effective form of emergency contraception when inserted within 5 days of unprotected intercourse. The copper IUD is particularly suitable for women who prefer non-hormonal contraception or have contraindications to hormonal methods.

  • Failure rate: 0.6–0.8% per year
  • Side-effects: Heavier, longer, more painful periods (most common reason for removal); rare risk of perforation (~1:1,000)
  • PBS status: ✔ PBS General Benefit — MBS item 35620 for insertion
  • Contraindications: Wilson's disease, copper allergy, current pelvic infection, unexplained uterine bleeding, distorted uterine cavity

4. Depot Medroxyprogesterone Acetate (DMPA)

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Depot Medroxyprogesterone Acetate
Depo-Provera® 150 mg/mL · Pfizer · Progestogen-only injectable
Adult dose 150 mg IM (deep gluteal or deltoid) every 12 weeks (±2 weeks window)
Subcutaneous option Depo-SubQ Provera 104® — 104 mg SC every 12–13 weeks (not currently PBS-listed in Australia)
Efficacy Perfect use 0.2%; typical use ~6% (largely due to late injections)
Side-effects Irregular bleeding / amenorrhoea; weight gain (mean 2–3 kg in year 1); headache; mood changes
Bone mineral density Use associated with reduced BMD (reversible on discontinuation); TGA recommends review after 2 years of continuous use; avoid as first-line in adolescents unless other methods unsuitable
Return to fertility Delayed — median 10 months after last injection; counsel that return to fertility may take up to 18 months
Renal / Hepatic Use with caution in severe hepatic impairment; no renal dose adjustment
PBS status ✔ PBS General Benefit
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DMPA and bone health: DMPA causes dose-dependent, reversible reduction in bone mineral density. The TGA and FDA have issued warnings. Review ongoing DMPA use at 2-yearly intervals and consider a "drug holiday" or switching to an alternative LARC. Adequate calcium and vitamin D intake should be advised. DMPA is MEC Category 2 for adolescents — not contraindicated, but a less preferred first-line option.

5. Progestogen-Only Pill (POP) — Desogestrel

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Desogestrel 75 µg
Cerazette® · MSD · Progestogen-only pill
Adult dose 75 µg PO once daily, taken continuously (no hormone-free interval)
Mechanism Suppresses ovulation in ~97% of cycles (unlike older POPs); thickens cervical mucus
Missed pill window 12 hours (if >12 hours late, take immediately, use condoms for 48 hours)
Advantages Safe with VTE history, migraine with aura, hypertension, smoker ≥35; oestrogen-free
Side-effects Irregular bleeding; headache; acne; mood changes
PBS status ✔ PBS General Benefit

Quick Reference — LARC Comparison

Implanon NXT®
Etonogestrel 68 mg
3 years
Most effective; 15-min GP visit; irregular bleeding common
Mirena®
LNG 52 mg
5–8 years
HMB benefit; amenorrhoea common; nulliparous insertion safe
Kyleena®
LNG 19.5 mg
5 years
Smaller; suited to nulliparous; lower systemic absorption
Cu-IUD
Copper 380 mm²
5–10 years
Non-hormonal; EC option; heavier periods
Depo-Provera®
DMPA 150 mg IM
12-weekly
Discreet; delayed fertility; BMD concerns

Emergency Contraception

Emergency contraception (EC) is used after unprotected sexual intercourse or contraceptive failure to prevent pregnancy. Three methods are available in Australia: levonorgestrel oral EC, ulipristal acetate oral EC, and the copper IUD. The copper IUD is the most effective method and should be offered wherever possible, particularly for women presenting within 120 hours of unprotected intercourse.

Emergency Contraceptive Methods

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Levonorgestrel EC
Postinor-1® · Gedeon Richter · Progestogen-only EC
Dose 1.5 mg PO as a single dose (or 750 µg × 2 tablets taken together)
Timing As soon as possible within 72 hours of UPSI; may be used up to 96 hours with reduced efficacy
Efficacy Reduces pregnancy risk by ~85% if taken within 72 hours; effectiveness decreases with time and increasing BMI
Mechanism Delays or inhibits ovulation; may impair fertilisation; does NOT cause abortion of an established pregnancy
BMI considerations Reduced efficacy at BMI ≥30 kg/m²; consider ulipristal acetate or Cu-IUD for obese women
Side-effects Nausea (20%); vomiting (3%); irregular bleeding; headache
If vomiting If vomiting within 2 hours of dose, repeat dose; consider antiemetic (ondansetron 4 mg ODT prior)
Availability Pharmacist-supplied (Schedule 3 — no prescription required); also available from GPs
PBS status ✔ PBS General Benefit (prescription supply); private purchase from pharmacies ~–30
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Ulipristal Acetate EC
ellaOne® · Laboratoire HRA Pharma · Selective progesterone receptor modulator
Dose 30 mg PO as a single dose
Timing Up to 120 hours (5 days) after UPSI — no reduction in efficacy over this window
Efficacy Approximately 2× more effective than levonorgestrel EC; better efficacy than LNG in overweight/obese women
Mechanism Delays ovulation even when taken close to the LH surge; selective progesterone receptor modulator
Important interactions Avoid with hormonal contraception for 5 days after use; enzyme inducers (rifampicin, phenytoin, carbamazepine) may reduce efficacy
Contraception after ellaOne® Commence or resume hormonal contraception 5 days after ellaOne®; use condoms in the interim
Pregnancy Not an abortifacient; if pregnancy occurs after inadvertent use, evidence suggests no teratogenic effect but counsel accordingly
Availability Prescription-only in Australia (Schedule 4); NOT available over-the-counter
PBS status ✘ Not PBS-listed — private prescription; ~–50
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Copper IUD for EC
Multiload Cu375® / Copper T 380A · Most effective EC method
Timing Insertion within 5 days (120 hours) of UPSI; can also be inserted up to 5 days after estimated ovulation
Efficacy Failure rate <1% — the most effective EC method; 99%+ effective at preventing pregnancy
Advantage Provides ongoing highly effective contraception for 5–10 years after insertion
Suitability All women including nulliparous; especially recommended for obese women where oral EC less effective
Access Requires trained inserter — GP with IUD skills, Family Planning clinic, sexual health clinic, or gynaecology service
PBS status ✔ PBS General Benefit

Emergency Contraception Decision Algorithm

1
Assess timing
Within 72 hours → LNG EC or UPA; within 120 hours → UPA or Cu-IUD preferred
2
Assess BMI
BMI ≥30 → UPA or Cu-IUD preferred (LNG EC less effective)
3
Assess access to IUD insertion
If Cu-IUD insertion feasible within 5 days → offer Cu-IUD (most effective + ongoing contraception)
4
Consider ongoing contraception
Discuss LARC initiation; if starting COCP/POP after EC, use condoms for 7 days; consider quick-start method
5
Follow-up
Pregnancy test at 3 weeks (or if period >7 days late); STI screen if indicated; ongoing contraception plan
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Key safety points for emergency contraception:
  • Emergency contraception is NOT an abortifacient — it prevents fertilisation/ovulation, not implantation of an established pregnancy.
  • Efficacy decreases with delay — administer as soon as possible regardless of method chosen.
  • Repeat dosing of levonorgestrel EC is safe if further UPSI occurs in the same cycle, but counsel regarding efficacy limitations.
  • Do NOT combine levonorgestrel EC and ulipristal acetate — ulipristal acetate may be less effective if taken after levonorgestrel.
  • Always discuss ongoing contraception after EC and provide a supply or prescription if appropriate.

Special Populations

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Pregnancy

Hormonal contraception is contraindicated in established pregnancy, though inadvertent exposure is not an indication for termination — evidence shows no teratogenic risk from COCP, POP, LNG-IUS, or implant exposure.
If LNG-IUS or Cu-IUD is in situ when pregnancy is confirmed: remove if threads are accessible (risk of infection/miscarriage if left in place); if not accessible, pregnancy may continue with monitoring.
Postpartum contraception: LARC can be inserted immediately after vaginal delivery or at caesarean section (with consent). COCP is safe from 6 weeks postpartum in breastfeeding women (UKMEC 2 if fully breastfeeding <6 months; UKMEC 1 from 6 weeks if not fully breastfeeding). DMPA may be given from 6 weeks postpartum.
Post-termination contraception: LARC insertion immediately after surgical or medical termination is safe and effective (immediate post-placental insertion).
Note: Lactational amenorrhoea method (LAM) is ~98% effective only if: fully breastfeeding (day and night), amenorrhoeic, and infant <6 months old.
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Adolescents & Young People

LARC methods (implant, IUS, IUD) are recommended as first-line for adolescents due to high efficacy, privacy, and no need for daily adherence.
Implanon NXT® is safe from menarche; no minimum age or parity requirement.
Kyleena® 19.5 mg and Jaydess® 13.5 mg are preferred IUS for nulliparous adolescents; paracervical block recommended.
DMPA is MEC Category 2 for adolescents (bone health concerns) — should not be first-line unless other methods declined or unsuitable. Review at 2 years.
Confidentiality: Minors who are deemed competent (Gillick competence) can consent to contraception without parental involvement. Assess capacity using mature minor principles.
Emergency contraception: LNG EC available without prescription from pharmacies for any age; counsel regarding LARC initiation.
Note: Engage with adolescent-friendly services (headspace, Family Planning clinics). Address peer pressure, relationship dynamics, and STI risk in a non-judgemental manner.
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Women Aged >40 Years

Contraception is needed until 1 year after last menstrual period if aged ≥50; until 2 years after last period if aged <50.
LARC is ideal — Mirena® 52 mg may be used up to 8 years if inserted at age ≥45 for contraception.
COCP is UKMEC 2 from age ≥40 (VTE risk increases with age). Consider switching to POP, LARC, or non-hormonal methods.
COCP has additional non-contraceptive benefits in the perimenopause: cycle regulation, menorrhoea management, bone protection.
FSH testing is unreliable as a contraceptive guide while hormonal contraception is in use.
Note: Mirena® is PBS-listed for endometrial protection during HRT — allows women to use systemic oestrogen HRT with the Mirena® providing the progestogenic component.
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Renal Impairment

LARC methods (implant, IUS, IUD, DMPA) are preferred — no renal dose adjustments required.
COCP and POP may be used in mild–moderate CKD (eGFR >30 mL/min) with monitoring; avoid in severe CKD with hypertension or proteinuria (VTE risk).
Drospirenone-containing COCP (Yasmin®, Yaz®): caution with potassium-sparing diuretics and in CKD (hyperkalaemia risk).
Women on dialysis: LARC (particularly Cu-IUD or implant) is suitable; COCP is relatively contraindicated due to VTE risk.
Note: Renal transplant recipients on immunosuppression — LARC preferred; COCP may interact with tacrolimus; discuss with transplant team.
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Hepatic Impairment

COCP is UKMEC 4 in active viral hepatitis, severe cirrhosis (Child-Pugh C), hepatocellular adenoma, and active liver tumour.
LARC methods (implant, IUS, IUD) are safe in hepatic impairment — progestogen-only methods have minimal hepatic metabolism.
DMPA is an acceptable alternative as it is not subject to significant first-pass hepatic metabolism.
Note: For women with a history of pregnancy-related cholestasis, COCP is generally safe but monitor LFTs if symptomatic.
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Immunocompromised / HIV

All contraceptive methods are generally safe in women living with HIV on stable antiretroviral therapy (ART).
Drug interactions: Enzyme-inducing ART (efavirenz, nevirapine) may reduce efficacy of hormonal methods. LNG-IUS and Cu-IUD are not affected by ART interactions — preferred for women on enzyme-inducing regimens.
IUD insertion in women with HIV: safe if CD4 count >200 cells/µL and no active pelvic infection. WHO MEC Category 1–2.
Women on immunosuppressive therapy (post-transplant, autoimmune disease): LARC preferred; COCP may be used if no contraindications.
Note: Discuss dual protection (condoms + contraception) for STI/HIV prevention in all at-risk populations.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health — Family Planning

Aboriginal and Torres Strait Islander women experience significantly higher rates of teenage pregnancy, higher total fertility rates, and greater burden of sexually transmitted infections compared with non-Indigenous Australians. The AIHW reports that the teenage birth rate among Aboriginal and Torres Strait Islander women is approximately 4–5 times higher than non-Indigenous rates. Access to the full range of contraceptive options — particularly LARC — is reduced in remote and very remote communities due to workforce shortages, limited specialist and GP availability, and cultural barriers.

Culturally safe contraceptive counselling requires recognition of the social determinants of health, avoidance of judgemental language, and understanding of historical and ongoing impacts of colonisation, including forced sterilisation and child removal policies that may affect trust in reproductive health services.

Key Considerations for Practice

Access to LARC
Remote communities often lack trained LARC inserters. Support telehealth contraceptive counselling with local health worker-assisted insertion. Plan LARC insertion during specialist outreach visits (e.g. visiting gynaecologist, sexual health physician). Mobile health clinics can provide Implanon NXT® and IUD insertion in community settings.
Supply continuity
Ensure adequate COCP and condom stock in remote clinic pharmacy. Cold-chain requirements for DMPA may limit availability. Mail-order PBS supply via Remote Area Aboriginal Health Services (RAAHS) can assist. Implanon NXT® does not require refrigeration after supply.
STI co-screening
Offer chlamydia, gonorrhoea, syphilis, HIV, and hepatitis B screening at every contraceptive visit, per the Australian STI Guidelines. STI rates are significantly higher in Aboriginal and Torres Strait Islander populations, particularly in remote Northern Territory, Western Australia, and Queensland communities.
Cultural safety
Use Aboriginal Health Workers and Aboriginal Community Controlled Health Organisation (ACCHO) staff as key intermediaries. Acknowledge family and kinship structures. Use plain language, visual resources, and interpreter services where required. Recognise that discussing contraception may require trust-building across multiple consultations.
Young women and adolescents
Early and proactive contraceptive education in schools and community settings, co-designed with Aboriginal community leaders. Encourage Implanon NXT® or LNG-IUS as first-line for young Aboriginal women — discreet, long-acting, no daily adherence required. Confidentiality is essential — ensure young women feel safe to access services independently.
Menstrual health
Heavy menstrual bleeding and dysmenorrhoea may be under-reported. LNG-IUS (Mirena®) offers dual benefit of contraception and menstrual management. Screen for iron deficiency anaemia — high prevalence in remote communities.
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Referral pathways: Family Planning Australia (state-based services), Sexual Health Quarters (WA), SHFPACT (ACT), North Queensland Primary Health Network reproductive health programs, and ACCHO-led women's health programs. The Australian Government's Closing the Gap initiative includes improved access to reproductive health services as a priority area.

📚 References

  1. 1. Faculty of Sexual and Reproductive Healthcare (FSRH). FSRH Clinical Guideline: Intrauterine Contraception. London: FSRH; 2023 (amended 2024).
  2. 2. Faculty of Sexual and Reproductive Healthcare (FSRH). FSRH Clinical Guideline: Combined Hormonal Contraception. London: FSRH; 2019 (amended 2023).
  3. 3. World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 5th ed. Geneva: WHO; 2015.
  4. 4. Australian Institute of Health and Welfare (AIHW). Contraception and Reproductive Health in Australia. Cat. no. PER 106. Canberra: AIHW; 2023.
  5. 5. Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105-1113. doi:10.1097/AOG.0b013e31821188ad
  6. 6. Royal Australian College of General Practitioners (RACGP). Prescribing Drugs of Dependence in General Practice, Part C2: The Role of Drugs in Contraception. Melbourne: RACGP; 2020.
  7. 7. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404. doi:10.1016/j.contraception.2011.01.021
  8. 8. Glasier A, Cameron ST, Blithe D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011;84(4):363-367. doi:10.1016/j.contraception.2011.02.009
  9. 9. Family Planning Alliance Australia. National Contraceptive Guidelines for Australian General Practice. Sydney: FPAA; 2023.
  10. 10. Department of Health and Aged Care, Australian Government. Closing the Gap: National Agreement on Closing the Gap — Target 2: Increase in proportion of Aboriginal and Torres Strait Islander babies with a healthy birthweight. Canberra: Commonwealth of Australia; 2020.
  11. 11. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
  12. 12. Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod. 2012;27(7):1994-2000. doi:10.1093/humrep/des140
  13. 13. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Contraception and the Perimenopause — C-Gyn 35. Melbourne: RANZCOG; 2022.
  14. 14. Pharmaceutical Benefits Scheme (PBS). Schedule of Pharmaceutical Benefits for Approved Pharmacists and Medical Practitioners. Australian Government Department of Health; effective 1 March 2025.
  15. 15. Australian STI Management Guidelines for Use in Primary Care. STI Screening in Priority Populations. Sydney: ASHM; updated 2024. Available at: https://www.sti.guidelines.org.au/
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).