Contraception
Abortion care, permanent contraception and inpatient postpartum insertion are out of scope. Perimenopause hormone therapy: Menopause.
Before prescribing
- INSPQ Institut national de santé publique du Québec
- SOGC Society of Obstetricians and Gynaecologists of Canada
| Decision | Guideline |
|---|---|
| Pregnancy | Be reasonably certain the person is not pregnant before inserting an IUD, at any point in the cycle. |
| Eligibility | Category 4: absolute contraindication; no prescriber may prescribe the method.
Category 3: relative contraindication; a physician or IPS may prescribe it after counselling, with closer follow-up. PCQ 2024, p. 13 opens in a new tabPCQ annex VI opens in a new tab |
| Start or continue | A category can differ for starting and continuing.Acute PID: do not insert an IUD (category 4). IUD already in place: treat the PID; removal depends on the response (category 2). |
| Unexplained bleeding or amenorrhea | Investigate before starting CHC or a progestin-only pill.Neither is a contraindication to those methods.
Unexplained vaginal bleeding: investigate before inserting an LNG-IUD (category 4 for insertion). PCQ 2024, p. 129 opens in a new tabPCQ 2024, p. 155 opens in a new tabPCQ 2024, p. 58 opens in a new tab |
| STI before an IUD | Insert without waiting for results if there is no mucopurulent cervicitis.Treat a positive result; the IUD stays in place.
Mucopurulent cervicitis or current chlamydia or gonorrhea: do not insert (category 4).
Who to screen: Sexually transmitted infections. PCQ 2024, p. 12 opens in a new tabPCQ 2024, p. 59 opens in a new tabSOGC CCC 329, ch. 7, recommendation 9 opens in a new tab |
Treat
- INSPQ Institut national de santé publique du Québec
- SOGC Society of Obstetricians and Gynaecologists of Canada
| Decision | Guideline |
|---|---|
| Long-acting | Offer an IUD as a first-line method to nulliparous and multiparous people.Heavy menstrual bleeding or dysmenorrhea: consider the LNG-IUD 52 mg over other IUDs. SOGC CCC 329, ch. 7, recommendation 1 opens in a new tabSOGC CCC 329, ch. 7, recommendation 2 opens in a new tab |
| Switching | No need to wait for the next period.Overlap the methods so there is no gap. Example: start a pill, patch, ring or injection 7 days before an IUD or implant comes out (norethindrone pill: 2 days). Every pair of methods: annex III opens in a new tab. |
| Combined pill, patch or ring (CHC) | |
| Works at once | Started within 5 days of the start of the last period.Or the same day or within 5 days after an abortion, a miscarriage or an ectopic pregnancy. Starting on day 1 of the period is best for the patch. |
| Quick Start | Any other day, check for unprotected sex since the last period.None: start today, condom for 7 days, pregnancy test 2–4 weeks after the start. Unprotected sex: offer emergency contraception first. Full steps: PCQ table 2 opens in a new tab. |
| Do not start (category 4) | Any of:
Age 35 or older and 15 or more cigarettes a day;
Systolic 160 or diastolic 100 mm Hg or higher;
Migraine with aura;
Ischemic heart disease or stroke, current or past;
Past VTE with a high risk of recurrence, without anticoagulation;
Known thrombogenic mutation;
Current breast cancer;
Under 21 days postpartum.
Full list: annex VI opens in a new tab. PCQ 2024, p. 124-126 opens in a new tabPCQ annex VI opens in a new tab |
| Category 3 | Physician or IPS only, after counselling:
Age 35 or older and under 15 cigarettes a day;
Adequately controlled hypertension;
Systolic 140–159 or diastolic 90–99 mm Hg. PCQ 2024, p. 13 opens in a new tabPCQ 2024, p. 124-125 opens in a new tab |
| Interactions | Suggest another method with: Ritonavir-boosted protease inhibitors or fosamprenavir; Carbamazepine, eslicarbazepine, oxcarbazepine, perampanel, phenobarbital and other barbiturates, phenytoin, primidone, rufinamide, or topiramate over 200 mg/day; Rifampin or rifabutin; Bosentan, St John's wort, modafinil, aprepitant, or lumacaftor-ivacaftor. CHC lower lamotrigine and valproic acid levels: monitor serum levels; lamotrigine is category 3. Full list: PCQ table 3 opens in a new tab. |
| Progestin-only and long-acting methods | |
| LNG-IUD, implant or injection | Works at once if placed within 5 days of the start of the last period.Or within 21 days after delivery, or within 5 days after an abortion, a miscarriage or an ectopic pregnancy.
Otherwise: check for unprotected sex since the last period and follow PCQ table 2. PCQ 2024, p. 37 opens in a new tabPCQ 2024, p. 60 opens in a new tabPCQ 2024, p. 104 opens in a new tab |
| Copper IUD | Works at once, whatever the timing of insertion.Outside the same windows, still check for unprotected sex since the last period. PCQ 2024, p. 84 opens in a new tabPCQ errata, 6 October 2025 opens in a new tab |
| Drug | Dose | How long | Note |
|---|---|---|---|
| Norethindrone pill | 0.35 mg PO DIE, no hormone-free days | Ongoing | At most 3 h late. Late or missed: backup for 48 h. |
| Drospirenone pill | 4 mg PO DIE, 24 active then 4 placebo, or continuous | Ongoing | At most 24 h late |
| Medroxyprogesterone acetate (DMPA) | 150 mg IM | Every 12–13 weeks | May be given 1–2 weeks early. 14 weeks or more: late-injection tool, annex X. |
| Etonogestrel implant | 68 mg | Up to 5 years | Health Canada label: 3 years. |
| LNG-IUD 52 mg | Device | Up to 8 years for contraception. Inserted at 40 or older: until menopause. | Informed choice on the very small loss of efficacy |
| LNG-IUD 19.5 mg | Device | Up to 5 years | Manufacturer's limit |
| Copper IUD, TCu380A or TCu380S equivalent (Mona Lisa 10, Liberte TT380 Standard) | Device | Up to 12 years. Any 380 mm² copper IUD inserted at 35 or older: until menopause. | Other copper IUDs: manufacturer's limit |
Emergency contraception
- INSPQ Institut national de santé publique du Québec
- SOGC Society of Obstetricians and Gynaecologists of Canada
| Decision | Guideline |
|---|---|
| Most effective | Copper IUD, up to 7 days after unprotected sex, at any BMI.Negative urine pregnancy test the day of insertion. PCQ 2024, p. 20-22 opens in a new tabSOGC CCC 329, part 1, statement 12 opens in a new tabSOGC CCC 329, part 1, statement 13 opens in a new tab |
| Over 72 h, up to 120 h | Favour UPA.After 120 h, pill efficacy is unknown;
the copper IUD still works up to day 7. PCQ 2024, p. 22 opens in a new tabINSPQ emergency contraception tool 2024 opens in a new tab |
| Higher BMI | Favour UPA at BMI 30 or more, or the copper IUD.Do not double the LNG dose: two recent studies found it ineffective. UPA first-line from BMI 25, where access and cost allow.Above BMI 30: recommend the copper IUD.
Do not withhold hormonal emergency contraception because of BMI. |
| Hormonal contraception in the past 7 days | Do not use UPA.Use LNG, up to 5 days after unprotected sex,
or the copper IUD, up to 7 days.
Missed doses: give LNG and restart the method at once, with backup for 7 days. PCQ errata, 6 October 2025 opens in a new tabPCQ 2024, p. 24 opens in a new tab |
| Enzyme inducer | Still give a pill, but its efficacy may be lower.The copper IUD gives full efficacy and may be preferable. PCQ 2024, p. 23 opens in a new tabINSPQ emergency contraception tool 2024 opens in a new tab |
| Vomited within 3 h | Give another dose.An antiemetic may be considered. |
| Again in the same cycle | The same pill is preferable.LNG not before day 6 after UPA. UPA not before day 8 after LNG. Do not give LNG and UPA together. Pregnancy risk rises with further unprotected sex in the same cycle. |
| Start a method after LNG | Same day or next day.Condom for 7 days. PCQ 2024, p. 24 opens in a new tabINSPQ emergency contraception tool 2024 opens in a new tabSOGC CCC 329, part 1, statement 19 opens in a new tab |
| Start a method after UPA | Start on day 6 after UPA.Backup for 21 days from the unprotected sex. PCQ 2024, p. 24 opens in a new tabINSPQ emergency contraception tool 2024 opens in a new tab |
| After any pill | Backup until the next period if no method is started.Pregnancy test 2–4 weeks after the pill if there is no period. |
| Drug | Dose | Window |
|---|---|---|
| Copper IUD | 300–380 mm² of copper | Up to 7 days |
| Levonorgestrel | 1.5 mg PO, 1 dose | Up to 120 h; UPA favoured after 72 h |
| Ulipristal acetate | 30 mg PO, 1 dose | Up to 120 h |
Follow-up
- INSPQ Institut national de santé publique du Québec
- SOGC Society of Obstetricians and Gynaecologists of Canada
| Decision | Guideline |
|---|---|
| CHC | No early visit required.If one is done: within 3 months, mainly when adherence may be a problem. |
| IUD | No early visit required.If one is done: after the first period.
People can check the strings themselves. PCQ 2024, p. 72 opens in a new tabPCQ 2024, p. 93 opens in a new tab |
| Pregnancy test after an IUD | 2–4 weeks after insertion if the IUD went in outside a period or an immediate-efficacy window. |
| Missed pills, patch or ring | Combined or drospirenone pill: Week 1, 1 pill or more missed: take one now, condom for 7 days, emergency pill if unprotected sex in the past 5 days; Weeks 2–3, under 3 pills: take one now, finish the pack and skip the hormone-free days; Weeks 2–3, 3 pills or more: same, plus condom for 7 days. Patch, ring and norethindrone pill: annex X opens in a new tab. |
| Stopping | Offer another method and a safe switch.See annex III opens in a new tab. PCQ 2024, p. 145 opens in a new tabPCQ 2024, p. 72 opens in a new tabPCQ annex III opens in a new tab |
| Pregnancy with an IUD | Exclude ectopic pregnancy as early as possible.15% to 50% of pregnancies with an IUD in place are ectopic.
Once ectopic is excluded, remove the IUD without an invasive procedure. SOGC CCC 329, ch. 7, statement 7 opens in a new tabSOGC CCC 329, ch. 7, recommendation 7 opens in a new tab |
| PID with an IUD | Leave the IUD in and start antibiotics.Remove it only if there is no improvement after 48–72 h of treatment.
Treatment: Sexually transmitted infections. PCQ 2024, p. 72 opens in a new tabPCQ 2024, p. 92 opens in a new tabSOGC CCC 329, ch. 7, recommendation 8 opens in a new tab |
| Vomiting or diarrhea | Repeated episodes can lower pill efficacy.Backup during the episodes and for 7 days after. The patch and ring are not affected. |
Postpartum and breastfeeding
- INSPQ Institut national de santé publique du Québec
| Decision | Guideline |
|---|---|
| CHC, under 21 days | Category 4, breastfeeding or not. |
| CHC, not breastfeeding | May start from 21 days if there is no VTE risk factor.21–42 days with a VTE risk factor: category 3. |
| CHC, breastfeeding | May start from 30 days if there is no VTE risk factor.21 to under 30 days: category 3. 30–42 days with a VTE risk factor: category 3. |
| VTE risk factors | Age 35 or older, past VTE, thrombophilia, immobility, transfusion at delivery, peripartum cardiomyopathy, BMI 30 or more, postpartum hemorrhage, cesarean delivery, preeclampsia, smoking. Some, such as past VTE or thrombophilia, raise the category to 4. |
| LNG-IUD and implant | Work at once if placed within 21 days of delivery.Or up to 6 months after delivery if all lactational amenorrhea criteria hold:
Full or nearly full breastfeeding;
No menstrual bleeding. PCQ 2024, p. 37 opens in a new tabPCQ 2024, p. 60 opens in a new tab |
| Emergency contraception | LNG first, with no break in breastfeeding.Over 72 h or BMI 30 or more: UPA, still with no break. PCQ 2024, p. 23 opens in a new tabINSPQ emergency contraception tool 2024 opens in a new tab |
Reviewed 17 October 2026 against the official sources below.
Sources
Blue square: Québec · red round: Canada. The code names the body; each section's key gives its full name.