Contraception: all methods compared

Effectiveness at a glance

Two numbers matter for every method. Perfect use is failure when used exactly as directed. Typical use is failure as people actually use it. The gap between them is the single most useful piece of contraceptive information, and it is why long-acting methods outperform daily and per-act ones so decisively. Figures are pregnancies per 100 users in the first year, from Trussell's analyses and Contraceptive Technology.

The Contraceptive CHOICE Project (Winner et al., 2012, NEJM), following 7,486 participants, found failure rates with pills, patch and ring were roughly 20 times higher than with implants and IUDs, and the gap was widest in under-21s.

Long-acting reversible contraception

Implant — a matchstick-sized progestogen rod in the upper arm. The most effective reversible method available. Irregular bleeding is the main reason for discontinuation and should be discussed before insertion, not after.

Hormonal IUD — releases levonorgestrel locally. Lightens or stops periods in most users and is a first-line treatment for heavy menstrual bleeding. Systemic hormone exposure is low.

Copper IUD — hormone-free, works by copper's spermicidal effect. Periods often become heavier and more painful, especially in the first months. It is also the most effective emergency contraceptive.

Insertion pain is real and has been under-treated. Since 2024 CDC guidance explicitly recommends counselling on pain management options, including lidocaine, for IUD placement. Ask; do not assume nothing is available.

Hormonal methods

Combined hormonal (pill, patch, ring) — oestrogen plus progestogen. Non-contraceptive benefits are substantial and well evidenced: reduced ovarian and endometrial cancer risk persisting for decades after stopping (Collaborative Group analyses; Iversen et al., 2017, following 46,000 women for up to 44 years), lighter periods, acne and endometriosis symptom improvement. Risks: venous thromboembolism increases from roughly 2 per 10,000 women-years to 5–12, higher again with smoking over 35, migraine with aura, obesity, or a thrombophilia — these are contraindications, not cautions. Absolute risk remains lower than in pregnancy.

Progestogen-only pill — suitable when oestrogen is contraindicated, including while breastfeeding. Desogestrel and drospirenone formulations have a 12- or 24-hour missed-pill window; traditional formulations have only 3 hours.

Injection (DMPA) — every 12–13 weeks. Associated with reversible bone mineral density reduction and a return to fertility that can take up to a year after stopping.

Barrier and behavioural

Condoms are the only method that also prevents STIs, and are commonly used alongside a more effective pregnancy method — "dual method" use. Diaphragms and caps require fitting and spermicide. Withdrawal, done perfectly, is more effective than its reputation, but perfect use is rare and pre-ejaculate can contain motile sperm in a substantial minority of samples.

Permanent methods

Vasectomy is a 15-minute local-anaesthetic procedure, lower risk and cheaper than tubal ligation, and requires a semen analysis at around 12 weeks before relying on it. Reversal is possible but not guaranteed; treat both as permanent. Tubal ligation or salpingectomy is abdominal surgery; salpingectomy also reduces ovarian cancer risk.

Emergency options

Copper IUD within 5 days is the most effective and continues as ongoing contraception. Ulipristal acetate up to 120 hours, levonorgestrel up to 72 hours. See the dedicated article.

Choosing

Weigh effectiveness, whether you can use it reliably, side effect tolerance, bleeding pattern preference, whether you want future fertility, medical contraindications, and STI protection. UKMEC and WHO Medical Eligibility Criteria classify every method against every medical condition and are freely available; they are what a good clinician is using. There is no single best method, and switching is normal — most people use several over a lifetime.

Sources

• Trussell J. "Contraceptive failure in the United States." Contraception, 2011; Contraceptive Technology, 21st edition.
• Winner B et al. "Effectiveness of long-acting reversible contraception (Contraceptive CHOICE Project)." NEJM, 2012.
• WHO. Medical Eligibility Criteria for Contraceptive Use, 5th edition; FSRH UKMEC, current edition.
• Iversen L et al. "Lifetime cancer risk and combined oral contraceptives: the Royal College of General Practitioners' Oral Contraception Study." American Journal of Obstetrics and Gynecology, 2017.
• Curtis KM et al. "US Selected Practice Recommendations for Contraceptive Use." MMWR, 2024 (including IUD pain management).
• Faculty of Sexual and Reproductive Healthcare (FSRH). Method-specific clinical guidelines, current editions.

Last reviewed: August 2026.