What checklist should be performed before initiating contraceptive therapy?

Pre-Contraceptive Therapy Checklist

The essential checklist before starting contraceptive therapy is minimal and method-specific: blood pressure measurement is required only for combined hormonal contraceptives (CHC), and bimanual examination with cervical inspection is required only for IUD insertion 1.

Core Assessment Requirements

Mandatory Examinations by Method Type

The 2024 CDC guidelines clearly delineate what is actually needed 1:

Combined Hormonal Contraceptives (CHC):

• Blood pressure measurement (Class A - essential)
• No pelvic examination required
• No laboratory tests required

Intrauterine Devices (both Cu-IUD and LNG-IUD):

• Bimanual examination and cervical inspection at time of insertion
• No blood pressure measurement required
• No laboratory tests required

Implants, DMPA, and Progestin-Only Pills:

• No examination required
• No blood pressure measurement required
• No laboratory tests required

Critical Medical History Screening

While extensive physical examination is unnecessary, you must systematically assess medical eligibility using the U.S. MEC categories 1. The most clinically important contraindications to identify include:

For CHC specifically:

• Current or history of venous thromboembolism (VTE)
• Smoking status if age ≥35 years
• Migraine with aura
• Current breast cancer
• Severe cirrhosis or liver tumors
• Uncontrolled hypertension
• Multiple cardiovascular risk factors
• Prolonged immobilization after major surgery

For IUDs specifically:

• Current purulent cervicitis (U.S. MEC 4 - do not place)
• Current chlamydial or gonococcal infection (U.S. MEC 4 - do not place)
• Current pregnancy

For all hormonal methods:

• Current pregnancy status
• Drug interactions (particularly enzyme-inducing anticonvulsants, rifampin/rifabutin) 1

Pregnancy Exclusion Strategy

You can initiate any contraceptive method immediately if you are "reasonably certain" the patient is not pregnant 1. This determination does not require a pregnancy test if the patient meets specific timing criteria (e.g., within 7 days of menses onset for most methods).

When uncertainty exists, the 2024 guidelines explicitly state that the benefits of starting implants, DMPA, CHC, and POPs likely exceed any risk, so initiation should proceed with follow-up pregnancy testing in 2-4 weeks 1. For IUDs, if pregnancy cannot be excluded, bridge with another method until confirmation.

A validated six-item pregnancy checklist has 99.8% negative predictive value when combined with a negative urine pregnancy test, supporting same-day LARC initiation 2.

Common Pitfalls to Avoid

Do not delay contraception for unnecessary testing:

• Weight/BMI measurement is not required for medical eligibility determination, though it may be helpful for baseline documentation 1
• Pelvic examination is not needed before starting pills, patches, rings, injections, or implants
• Cervical cancer screening is not required before contraception initiation
• STI screening should be offered but acceptance is not mandatory for contraception provision 3

Do not require multiple visits:

• Same-day initiation is appropriate for all methods when pregnancy can be reasonably excluded 1
• Quick-start protocols improve contraceptive uptake without compromising safety

Do not overlook drug interactions:

• Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine) reduce effectiveness of CHC and POPs (U.S. MEC 3) 1
• Lamotrigine levels decrease with CHC use (U.S. MEC 3 for CHC with lamotrigine) 1
• Rifampin/rifabutin significantly reduce hormonal contraceptive effectiveness 1

Practical Implementation

The structured approach involves 3:

1. Assess pregnancy intentions and contraceptive preferences through patient-centered discussion
2. Apply method-specific requirements (BP for CHC, pelvic exam for IUD only)
3. Screen medical history using U.S. MEC categories to identify contraindications
4. Exclude pregnancy using clinical criteria or testing
5. Initiate method immediately when appropriate, with backup contraception as specified by timing 1

Research demonstrates that checklist-based approaches increase appropriate contraceptive provision and improve uptake of highly effective methods 4, 5, 6. However, the 2024 CDC guidelines have deliberately minimized mandatory requirements to reduce barriers to access while maintaining safety 1, 3.

Prescribe a 1-year supply of short-acting or injectable contraceptives at initiation to reduce barriers 3, and consider advance provision of emergency contraception 3.