What are the guidelines for giving and using contraception?

Guidelines for Contraceptive Provision and Use

Initial Assessment and Eligibility

Most women can safely initiate contraception with minimal pre-screening examinations or laboratory tests. 1

Required Pre-Initiation Assessments

• Blood pressure measurement is mandatory only for combined hormonal contraceptives (CHCs) before initiation 1
• Bimanual examination and cervical inspection are required only for IUD placement 1, 2
• No other routine examinations are needed for most contraceptive methods, including pelvic exams, cervical cytology, breast exams, HIV screening, or laboratory tests for lipids, glucose, liver enzymes, hemoglobin, or thrombogenic mutations 1
• Weight measurement (BMI) is not required to determine medical eligibility for any contraceptive method, though baseline measurement may help address future concerns about weight changes 1

Pregnancy Exclusion

• A detailed medical history provides the most accurate pregnancy assessment in most cases 1
• Routine pregnancy testing is not necessary for every woman initiating contraception 1
• If uncertainty exists about pregnancy status, the benefits of starting contraception likely exceed any risk, so initiation should be considered with follow-up pregnancy testing in 2-4 weeks 1

Timing of Contraceptive Initiation

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Can be started anytime if reasonably certain the patient is not pregnant 1
• No backup contraception needed if started within 5 days of menstrual bleeding 1
• Backup contraception (abstinence or barrier methods) required for 7 days if started >5 days after menses 1

Progestin-Only Pills

• Norethindrone/norgestrel: Backup contraception needed for 2 days if started >5 days after menses 1
• Drospirenone: Backup contraception needed for 7 days if started >1 day after menses 1

Long-Acting Reversible Contraception (LARC)

Copper IUD:

• Can be inserted anytime with no backup contraception needed 1

Levonorgestrel IUD:

• Backup contraception needed for 7 days if inserted >7 days after menses 1, 3

Implant:

• Backup contraception needed for 7 days if inserted >5 days after menses 1

DMPA injection:

• Backup contraception needed for 7 days if given >7 days after menses 1

Contraindications to Specific Methods

Absolute Contraindications to Combined Hormonal Contraceptives (Category 4)

• Current or history of thrombophlebitis or thromboembolic disorders 4
• History of deep vein thrombosis or pulmonary embolism 2, 4
• Cerebrovascular or coronary artery disease 4
• Current or history of breast cancer 4
• Undiagnosed abnormal genital bleeding 4
• Cholestatic jaundice of pregnancy or with prior pill use 4
• Hepatic adenomas or carcinomas 4
• Concurrent use with certain hepatitis C drug combinations (ombitasvir/paritaprevir/ritonavir ± dasabuvir) 4

Important Clarifications

• Smoking is NOT a contraindication to CHCs in women <35 years old 3
• Progestin-only methods (pills, implants, DMPA) are generally safe (Category 1-2) even with thromboembolic risk factors 2, 5
• Copper IUDs are non-hormonal with no systemic effects, making them suitable when hormonal methods are contraindicated 2

Drug Interactions Requiring Alternative Methods or Caution

• Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine): Category 3 for CHCs and POPs 1
• Rifampin or rifabutin: Category 3 for CHCs and POPs 1
• Lamotrigine: Category 3 for CHCs (CHCs reduce lamotrigine levels) 1
• St. John's wort: Category 2 for CHCs, POPs, and implants 1
• Broad-spectrum antibiotics, antifungals, and antiparasitics: No interaction (Category 1) 1

Follow-Up and Monitoring

General Follow-Up for All Methods

No routine follow-up visit is required 1, 3

• Advise women to return anytime for side effects, concerns, or desire to change methods 1
• Inform users of IUDs, implants, or injectables when removal or reinjection is needed 1

Routine Visit Components (When They Occur)

• Assess satisfaction with current method and any concerns 1
• Assess health status changes or new medications that would affect method safety (Category 3-4 conditions per U.S. MEC) 1
• Consider checking IUD strings 1
• Consider assessing weight changes and counseling if concerned 1
• Measure blood pressure for CHC users 1, 3

Management of Breakthrough Bleeding

Copper IUD Users

• For spotting, light bleeding, or heavy/prolonged bleeding: NSAIDs for 5-7 days 1

LNG-IUD Users

• NSAIDs for 5-7 days 1
• Hormonal treatment (if medically eligible) with COCs or estrogen for 10-20 days 1

Implant Users

• NSAIDs for 5-7 days 1

DMPA Users

• NSAIDs for 5-7 days 1, 3
• Hormonal treatment (if medically eligible) with COCs or estrogen for 10-20 days 1

Extended/Continuous CHC Users

• Not recommended during first 21 days of use 1, 3
• Hormone-free interval of 3-4 consecutive days for heavy/prolonged bleeding (but not more than once per month as effectiveness may be reduced) 1, 3
• NSAIDs for 5-7 days 1

Critical Caveat

Before treating breakthrough bleeding, evaluate for underlying conditions if clinically warranted: pregnancy, STIs, medication interactions, or new pathologic uterine conditions (polyps, fibroids) 1, 3, 6

If bleeding persists or is unacceptable to the patient, counsel on alternative methods and offer another method if desired 1, 6

Special Populations

Postpartum (Breastfeeding)

• Implants can be inserted anytime (U.S. MEC 2 if <1 month postpartum, U.S. MEC 1 if ≥1 month) 1
• If <6 months postpartum, amenorrheic, and fully/nearly fully breastfeeding, no backup contraception needed 1

Postpartum (Not Breastfeeding)

• Implants can be inserted anytime, including immediately postpartum (U.S. MEC 1) 1
• Contraception can be initiated 4 weeks postpartum, though increased thromboembolic risk must be considered for estrogen-containing methods 4
• If ≥21 days postpartum without return of menses, backup contraception needed for 7 days 1

Postabortion

• Implants can be inserted within first 7 days, including immediately (U.S. MEC 1) 1
• Backup contraception needed for 7 days unless placed at time of surgical abortion 1

Adolescents

• All methods appropriate for adolescents 1
• Confidential discussion of family planning needs is essential, as adolescents are significantly less likely to use services without confidentiality assurances 3
• Consistent condom use should be encouraged for STI protection regardless of contraceptive method 3

Switching Between Methods

• Can switch immediately if reasonably certain patient is not pregnant 1
• Waiting for next menstrual period is unnecessary 1
• If >5 days since menstrual bleeding started, backup contraception needed for 7 days 1

Special Consideration When Switching from IUD

If sexual intercourse occurred since current menstrual cycle started and >5 days since bleeding began, consider: 1

• Retain IUD for at least 7 days after new method insertion, then return for removal
• Abstain or use barrier contraception for 7 days before IUD removal
• Use emergency contraception at time of IUD removal

Counseling Priorities

• Discuss expected bleeding pattern changes before initiating any hormonal method 3
• Reassure that amenorrhea with hormonal contraceptives does not require treatment and is generally not harmful 3
• Unscheduled bleeding is common during first 3-6 months of hormonal methods and generally decreases with continued use 3, 6
• Provide instructions on missed pill management: take most recently missed pill as soon as possible; 7 consecutive hormone pills needed to prevent ovulation 3
• Promote adherence strategies: cell phone alarms, family member support 3

Key Clinical Pitfalls to Avoid

• Do not delay contraception initiation for unnecessary examinations (pelvic exam, Pap smear, breast exam) 1
• Do not delay IUD insertion for STI screening results if no visible purulent cervicitis 2
• Do not refuse contraception even with contraindications to certain methods, as alternatives always exist 2
• Do not prescribe CHCs to women ≥35 years who smoke 5
• Remember that the risk of unintended pregnancy may exceed contraceptive risks in many situations 2