Most Important Pre-Management Step: Pregnancy Test
Before starting oral contraceptive pills in any patient with abnormal uterine bleeding, a pregnancy test (HCG) is absolutely mandatory and must be performed first. 1, 2
Rationale
Pregnancy is a Category 4 contraindication to OCPs, meaning the risks clearly outweigh any benefits, and the CDC explicitly requires that it must be "reasonably certain that the woman is not pregnant" before initiating combined hormonal contraceptives. 1
Among healthy women presenting for contraception, no examinations or tests are needed before OCP initiation except to establish that pregnancy can be reasonably excluded. 1
For a woman with abnormal uterine bleeding specifically, the first priority is to rule out pregnancy with urine or serum HCG before any hormonal treatment is initiated. 1
Why Other Options Are Not the Priority
Pelvic Ultrasound (Option A)
- Pelvic ultrasound is classified as Class C by the CDC, meaning it does not contribute substantially to safe OCP use and is not required for healthy women unless structural pathology is specifically suspected. 1
- While ultrasound may eventually be useful for evaluating the cause of bleeding, it is not the most important step before starting OCPs. 1
CBC (Part of Option C)
- CBC is classified as Class C, meaning it is not required for healthy women before OCP initiation. 1
- While CBC may help assess anemia from prolonged bleeding, it does not affect the safety of starting OCPs and is not mandatory. 3
FSH (Option D)
- FSH testing is not mentioned as necessary for contraceptive initiation and is only relevant for diagnosing conditions like premature ovarian failure or PCOS, not for OCP safety. 1
Clinical Approach
If pregnancy status is uncertain but clinical suspicion is low:
- The benefits of starting OCPs likely exceed any risk, and OCPs can be started with a follow-up pregnancy test in 2-4 weeks. 1, 2
- However, this approach should only be used when pregnancy testing is not immediately available, not as a substitute for proper pre-initiation screening. 2
Common Pitfalls to Avoid
- Never start OCPs without first establishing reasonable certainty that the patient is not pregnant, as this represents a fundamental safety violation. 1
- Do not delay pregnancy testing to perform other evaluations like ultrasound or CBC first. 1
- Remember that abnormal bleeding itself can be a sign of pregnancy complications (threatened abortion, ectopic pregnancy), making pregnancy testing even more critical. 4
Answer: B - Pregnancy test