What investigations should be done before prescribing oral contraceptive pills (OCPs) to a 25-year-old female with irregular menses and a normal ultrasound (USG)?

Investigations Required Before Prescribing OCPs for a 25-Year-Old Female with Irregular Menses and Normal USG

No specific examinations or laboratory tests are needed before initiating oral contraceptive pills in a healthy 25-year-old woman with irregular menses and normal ultrasound findings. 1

Essential Assessment Before OCP Initiation

Medical History (Focus on):

• Pregnancy status (rule out pregnancy)
• Menstrual pattern details (frequency, duration, amount of bleeding)
• Smoking status
• History of migraines (with or without aura)
• History of venous thromboembolism (VTE)
• Hypertension history
• Liver disease history
• Current breast cancer history

Only Required Physical Examination:

• Blood pressure measurement 1

Laboratory Tests:

• None required for healthy women 1

Rationale for Limited Testing

The U.S. Selected Practice Recommendations for Contraceptive Use clearly classifies all laboratory tests as "Class C" for OCP initiation, meaning they "do not contribute substantially to safe and effective use of the contraceptive method" 1. This includes:

• Glucose testing
• Lipid profile
• Liver enzymes
• Hemoglobin
• Thrombogenic mutations
• Cervical cytology
• STD screening
• HIV screening

Special Considerations for Irregular Menses

For a 25-year-old with irregular menses and normal ultrasound, consider:

1. Ruling out pregnancy before starting OCPs (can be done with a urine pregnancy test)
2. Thyroid-stimulating hormone (TSH) and prolactin levels may be considered (though not mandatory) to rule out common causes of irregular menses 2
3. Consider PCOS evaluation if clinical signs are present (hirsutism, acne) as it's the most common cause of irregular menses in this age group 2

Common Pitfalls to Avoid

1. Unnecessary pelvic examination: The American Academy of Pediatrics clearly states that "a speculum or bimanual examination is now considered unnecessary before prescribing most forms of contraception" 1

2. Delaying OCP initiation for testing: Delaying contraception for unnecessary testing may increase the risk of unintended pregnancy

3. Over-investigation: Many providers incorrectly believe extensive laboratory testing is required before OCP initiation

4. Ignoring timing of initiation: If starting OCPs >5 days after menses began, advise using backup contraception for 7 days 1

5. Missing medication interactions: Certain medications (rifampin, anticonvulsants, some HIV medications) can reduce OCP effectiveness 3

When Additional Testing May Be Warranted

Additional testing should be considered only in specific situations:

• Blood pressure >140/90 mmHg: Further evaluation needed as hypertension may contraindicate combined OCPs 1
• Signs of hyperandrogenism: Consider testosterone, DHEAS if hirsutism or severe acne present 2
• Symptoms of thyroid dysfunction: Consider thyroid testing
• Symptoms of hyperprolactinemia: Consider prolactin level
• Family history of thrombophilia: Consider thrombogenic mutation testing

Remember that OCPs can be safely started while awaiting test results in most cases, as the benefits of preventing unintended pregnancy typically outweigh potential risks 1.