What physical exam and review of systems (ROS) are required prior to initiating contraceptive use?

Physical Examination and Review of Systems Required Prior to Contraceptive Initiation

For most healthy women seeking contraception, only blood pressure measurement is essential before initiating hormonal contraceptives, while no specific examinations or tests are required before initiating progestin-only methods. 1

Essential Examinations by Contraceptive Method Type

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Blood pressure measurement - Class A (essential and mandatory) 1
  • Can be obtained in non-clinical settings (e.g., pharmacy) if access to healthcare is limited 1
  • Essential because women with severe hypertension (≥160/100 mmHg) should not use combined hormonal contraceptives (U.S. MEC 4) 1
• Weight/BMI - Not essential for determining eligibility but useful for baseline monitoring 1

Progestin-Only Methods (Pills, Implant, Injection)

• No examinations are essential before initiation 1
• Weight/BMI measurement is optional but may be useful for monitoring changes over time 1

Intrauterine Devices (Copper and Hormonal)

• Bimanual examination and cervical inspection are needed before IUD placement 1

Non-Essential Examinations (Class C)

The following examinations and tests do NOT contribute substantially to safe and effective contraceptive use for healthy women and should not be required barriers to access 1:

• Clinical breast examination
• Bimanual examination and cervical inspection (except for IUD placement)
• Glucose testing
• Lipid panel
• Liver enzyme tests
• Hemoglobin measurement
• Thrombogenic mutation screening
• Cervical cytology (Pap smear)
• STD screening with laboratory tests
• HIV screening with laboratory tests

Review of Systems Considerations

While no specific review of systems is mandated by guidelines, clinicians should assess:

• Cardiovascular symptoms - Particularly important for combined hormonal methods due to thrombotic risk 1, 2
• Headache history - Especially migraines with aura, which are contraindications for estrogen-containing methods 2, 3
• Menstrual patterns - To establish baseline and identify potential benefits of hormonal methods for menstrual disorders 3

Common Pitfalls to Avoid

• Requiring unnecessary examinations - 16-23% of providers still require unnecessary pelvic examinations before non-IUD hormonal method initiation 4
• Delaying contraception initiation - Unnecessary examinations can create barriers to access and increase unintended pregnancy risk 5
• Omitting blood pressure measurement - The only essential examination for combined hormonal contraceptives 1
• Failing to perform bimanual examination before IUD placement - Up to 48% of providers don't require this recommended examination 4

Clinical Algorithm for Pre-Contraception Assessment

1. For all methods: Take medical history focusing on U.S. MEC conditions
2. For combined hormonal methods: Measure blood pressure (essential)
3. For IUD placement: Perform bimanual examination and cervical inspection
4. Optional for all methods: Measure weight/BMI for baseline monitoring
5. Consider individual risk factors: Additional examinations or tests may be needed for women with known medical problems 1

The evidence clearly shows that requiring extensive examinations before contraception creates unnecessary barriers to effective contraception 5. The CDC's Selected Practice Recommendations emphasize minimizing these barriers while ensuring safe provision 6.