What are the options for starting contraception and how do I begin?

Contraception Options and How to Start

Start contraception immediately at the visit ("quick start") if you can be reasonably certain the patient is not pregnant—waiting for the next menstrual period is unnecessary and creates barriers to access. 1

Determining Pregnancy Status Before Starting

You can be reasonably certain a woman is not pregnant if she has no symptoms/signs of pregnancy AND meets any one of these criteria: 1

• ≤7 days after start of normal menses
• Has not had sexual intercourse since start of last normal menses
• Has been using reliable contraception correctly and consistently
• ≤7 days after spontaneous or induced abortion
• Within 4 weeks postpartum
• Fully/nearly fully breastfeeding (≥85% of feeds), amenorrheic, and <6 months postpartum

If uncertain about pregnancy status, start the method anyway—the benefits of starting contraception exceed any risk—then follow up with a pregnancy test in 2-4 weeks. 1

Available Contraceptive Methods and Initiation

Long-Acting Reversible Contraception (LARC) - Highest Effectiveness

LARC methods have failure rates <1% per year and should be first-line options due to superior effectiveness. 2, 3

Copper IUD (Cu-IUD)

• Start: Anytime if reasonably certain not pregnant 1
• Back-up needed: None 1
• Exam required: Bimanual examination and cervical inspection 1
• Duration: 10 years of protection 4
• Failure rate: 0.8% with typical use 4

Levonorgestrel IUD (LNG-IUD)

• Start: Anytime if reasonably certain not pregnant 1
• Back-up needed: If >7 days after menses started, use barrier methods (condoms) or abstain for 7 days 1
• Exam required: Bimanual examination and cervical inspection 1
• Failure rate: 0.2% with typical use 4

Etonogestrel Implant (Nexplanon)

• Start: Anytime if reasonably certain not pregnant 1
• Back-up needed: If >5 days after menses started, use barrier methods or abstain for 7 days 1
• Exam required: None 1
• Duration: 3 years of protection 4
• Failure rate: <0.05% with typical use 4

Injectable Contraception

DMPA (Depo-Provera)

• Start: Anytime if reasonably certain not pregnant 1
• Back-up needed: If >7 days after menses started, use barrier methods or abstain for 7 days 1
• Exam required: None 1
• Failure rate: 6% with typical use 4

Combined Hormonal Contraceptives (CHCs)

CHCs include pills, patch, and ring—all have similar effectiveness with 4-7% pregnancy rates per year with typical use. 2

Combined Oral Contraceptives (COCs)

• Start: Anytime if reasonably certain not pregnant 1, 5
• Back-up needed: If >5 days after menses started, use barrier methods or abstain for 7 days 1, 5
• Exam required: Blood pressure measurement only 1
• Most common method: 21.9% of all contraception use in the US 2

Key VTE risk consideration: CHCs increase venous thrombosis risk from 2-10 events per 10,000 women-years to 7-10 events per 10,000 women-years. 2

Contraceptive Patch and Vaginal Ring

• Start: Same timing as COCs 1
• Back-up needed: If >5 days after menses started, use barrier methods or abstain for 7 days 1
• Exam required: Blood pressure measurement only 1

Progestin-Only Pills (POPs)

Traditional POPs (Norethindrone/Norgestrel)

• Start: Anytime if reasonably certain not pregnant 1
• Back-up needed: If >5 days after menses started, use barrier methods or abstain for 2 days 1
• Exam required: None 1

Drospirenone POP

• Start: Anytime if reasonably certain not pregnant 1
• Back-up needed: If >1 day after menses started, use barrier methods or abstain for 7 days 1
• Exam required: None 1

Barrier Methods

Condoms

• Start: Immediately, no restrictions 1
• Exam required: None 1
• Additional benefit: Only method that reduces STD/HIV risk 1

What Examinations Are NOT Needed

These create unnecessary barriers to contraception access and should be avoided: 1

• Pelvic examination (except for IUD insertion or diaphragm fitting) 1
• Cervical cytology (Pap smear) 1
• Clinical breast examination 1
• HIV screening 1
• Laboratory tests for lipids, glucose, liver enzymes, hemoglobin, or thrombogenic mutations 1
• Routine pregnancy testing (history is sufficient in most cases) 1

Weight/BMI measurement is not needed for medical eligibility—all methods can be used in obese women—but may be helpful for monitoring changes over time. 1

Special Populations

Postpartum Women (Not Breastfeeding)

Progestin-only methods and IUDs can start immediately postpartum, but CHCs must be delayed due to VTE risk. 4

• CHCs: Contraindicated (Category 4) for first 3 weeks postpartum due to significantly elevated VTE risk 4
• At 3 weeks: CHCs can start (Category 2) if no additional VTE risk factors 4
• With VTE risk factors: Generally should not use CHCs (Category 3) until after 6 weeks 4
• Progestin-only methods/IUDs: Can start immediately postpartum 1, 4

Common error: Waiting until the 6-week postpartum visit to initiate contraception in low-risk women—COCs can safely start at 3 weeks in women without VTE risk factors. 4

Postpartum Women (Breastfeeding)

• CHCs: Contraindicated (Category 4) for first 3 weeks; generally should not use (Category 3) during week 4 due to lactation concerns; appropriate after 6 weeks 4
• Progestin-only methods: Can start immediately; do not affect milk volume or composition 4

Post-Abortion

• All methods: Can start within first 7 days, including immediately after abortion 1
• Implant: No back-up needed if placed at time of surgical abortion; otherwise 7 days of back-up 1

Switching Between Methods

When switching from another method, start the new method immediately—waiting for next period is unnecessary. 1

• If >5 days since menstrual bleeding started: Use back-up contraception for 7 days (for implants/CHCs) or 2 days (for traditional POPs) 1
• When switching from IUD: If >5 days since bleeding started and patient had intercourse since current cycle started, either: retain IUD for 7 days after new method insertion, abstain/use barriers for 7 days before IUD removal, or use emergency contraception at IUD removal 1

Practical Implementation Strategies

Provide these to maximize contraceptive access and continuation: 1

• Onsite dispensing of methods 1
• Multiple cycles (ideally full year's supply) of pills, patch, or ring 1
• Same-day insertion of LARC methods 1
• Referrals for methods not available onsite 1

Common Pitfalls to Avoid

• Do not delay initiation waiting for "the perfect time" in amenorrheic patients—start after excluding pregnancy. 5
• Do not require unnecessary examinations that create barriers, particularly for adolescents and low-income women who have highest unintended pregnancy rates. 1
• Do not assume contraceptive protection if methods are started after the specified days without back-up contraception. 5
• Do not prescribe CHCs in the first 3 weeks postpartum—this is an absolute contraindication due to VTE risk. 4