Is a pregnancy test required before initiating a contraception method?

Pregnancy Testing Before Contraception Initiation

A pregnancy test is not routinely required before initiating most contraceptive methods as long as you can be reasonably certain that the woman is not pregnant based on specific criteria. 1

How to Be Reasonably Certain a Woman is Not Pregnant

A healthcare provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any one of the following criteria:

• Is ≤7 days after the start of normal menses
• Has not had sexual intercourse since the start of last normal menses
• Has been correctly and consistently using a reliable method of contraception
• Is ≤7 days after spontaneous or induced abortion
• Is within 4 weeks postpartum
• Is fully or nearly fully breastfeeding (exclusively breastfeeding or ≥85% of feeds are breastfeeds), amenorrheic, and <6 months postpartum 1

These criteria have a negative predictive value of 99-100% for ruling out pregnancy 1.

Contraceptive Method-Specific Considerations

For Most Contraceptive Methods

For contraceptive methods other than IUDs (including combined hormonal contraceptives, progestin-only pills, implants, and injectables), the benefits of starting contraception likely exceed any risk, even when pregnancy status is uncertain. These methods can be started at any time with a follow-up pregnancy test in 2-4 weeks if there's uncertainty about pregnancy status 1.

For Intrauterine Devices (IUDs)

For women wanting to begin using an IUD (copper or levonorgestrel), if pregnancy status is uncertain, another contraceptive method should be provided until pregnancy can be reasonably excluded before IUD insertion. This is because pregnancies with IUDs in place have higher risk for complications such as spontaneous abortion, septic abortion, preterm delivery, and chorioamnionitis 1.

For Injectable Contraceptives

For injectable contraceptives like medroxyprogesterone acetate, the first injection must be given only during the first 5 days of a normal menstrual period, within the first 5 days postpartum if not breastfeeding, or at the sixth postpartum week if exclusively breastfeeding 2.

When to Consider Pregnancy Testing

Although not routinely required, pregnancy testing may be considered in the following situations:

• When a woman doesn't meet any of the criteria for being reasonably certain she's not pregnant
• Based on clinical judgment, especially if there has been recent unprotected intercourse
• When initiating an IUD and pregnancy status is uncertain
• When more than 13 weeks have passed since the last injection of DMPA 1, 2

Important Considerations About Pregnancy Tests

• Most qualitative urine pregnancy tests have a sensitivity of 20-25 mIU/mL 1, 3
• Pregnancy tests cannot detect a pregnancy resulting from very recent sexual intercourse
• Urine pregnancy tests typically become detectable 10-14 days after conception 3
• Qualitative tests might have positive results for several weeks after termination of pregnancy 1
• A negative pregnancy test alone is insufficient for definitively ruling out pregnancy 1

Practical Approach

1. Assess if the woman meets any of the criteria to be reasonably certain she is not pregnant
2. If criteria are met, initiate the chosen contraceptive method without pregnancy testing
3. If criteria are not met and she desires a non-IUD method, consider starting the method with a follow-up pregnancy test in 2-4 weeks
4. If criteria are not met and she desires an IUD, provide another contraceptive method until pregnancy can be reasonably excluded
5. If recent unprotected intercourse has occurred, consider offering emergency contraception if pregnancy is not desired 1

Common Pitfalls to Avoid

• Unnecessarily delaying contraception initiation while waiting for pregnancy test results
• Relying solely on a negative pregnancy test without considering timing relative to last intercourse
• Failing to provide alternative contraception when IUD insertion must be delayed
• Not considering emergency contraception when appropriate

By following these guidelines, healthcare providers can facilitate timely access to contraception while minimizing risks associated with inadvertent use during pregnancy.