What is the most suitable birth control method for a healthy female of reproductive age with no significant medical history?

Questions to Ask When Starting Birth Control

Essential Medical History Questions

For a healthy woman of reproductive age with no significant medical history, focus your assessment on identifying contraindications to specific methods rather than performing extensive examinations. 1, 2

Cardiovascular Risk Screening

• Smoking status and age: Combined hormonal contraceptives (CHCs) are absolutely contraindicated (Category 4) in smokers aged ≥35 years 3, 4
• Blood pressure: Measurement is mandatory before initiating CHCs, though it can be obtained at a pharmacy or fire station and self-reported if clinic access is limited 1, 2
• History of blood clots: Any history of deep vein thrombosis, pulmonary embolism, or known thrombophilia is an absolute contraindication to CHCs 2, 4
• Migraine characteristics: Migraines with aura or focal neurologic symptoms contraindicate CHC use 4

Reproductive History

• Last menstrual period: Helps determine if "quick start" initiation is appropriate 1
• Current pregnancy status: Can be reasonably excluded if the woman is ≤7 days after menses start, has not had intercourse since last menses, or has been using reliable contraception 1
• Breastfeeding status: Affects method selection, as CHCs can reduce milk production 5
• Menstrual pattern regularity: Irregular bleeding complicates fertility awareness-based methods 1

Sexual Health Assessment

• STI risk factors: Screen for multiple partners, new partners, or symptoms, though this should not delay IUD placement 1, 2
• Need for STI protection: Hormonal methods and IUDs do not protect against STIs; condom counseling is essential 1, 3

Medical Conditions to Exclude

• Liver disease: Active or chronic liver dysfunction contraindicates CHC use 5
• Uncontrolled hypertension: Category 4 contraindication for CHCs 4
• Current medications: Certain anticonvulsants and rifampin reduce hormonal contraceptive effectiveness 3

Examinations NOT Required Before Initiation

Most contraceptive methods require minimal to no physical examination for healthy women. 1

• Pelvic examination: Not needed for pills, patch, ring, injection, or implant (Class C - does not contribute substantially to safe use) 1
• Breast examination: Not required for any method (Class C) 1
• Cervical cancer screening: Not needed before contraception initiation (Class C) 1
• Laboratory tests: Glucose, lipids, liver enzymes, hemoglobin, and thrombogenic mutation testing are all Class C (not needed) for healthy women 1

Exception for IUD Placement

• Bimanual examination and cervical inspection: Required only for IUD insertion (Class A - essential) 1, 2

Method Selection Guidance

Long-acting reversible contraceptives (LARCs) offer the highest effectiveness with failure rates <1% and should be presented as first-line options. 1, 3

Most Effective Options (Perfect Use Failure Rate)

• Implant: 0.05% failure rate, lasts 3 years, no user action required 1
• Levonorgestrel IUD: 0.2% failure rate, lasts 3-8 years, can reduce menstrual bleeding 1, 3
• Copper IUD: 0.6% failure rate, lasts 10 years, hormone-free option 1, 3

Highly Effective Hormonal Methods

• Injectable (Depo-Provera): 0.3% perfect use failure rate, given every 3 months 1
• Combined hormonal contraceptives (pill/patch/ring): 0.3% perfect use failure rate, but 8% typical use failure rate due to user error 1

User-Dependent Methods (Higher Typical Use Failure)

• Male condoms: 2% perfect use vs. 15% typical use failure rate 1
• Diaphragm: 6% perfect use vs. 16% typical use failure rate 1
• Fertility awareness methods: 3-5% perfect use vs. 25% typical use failure rate 1

Counseling Points for Informed Decision-Making

Voluntary informed choice is an essential guiding principle; effectiveness, availability, and acceptability all factor into the best choice for each individual. 1

Benefits Beyond Contraception

• Menstrual management: LNG-IUD and CHCs can reduce cramping and blood loss 4
• Cancer protection: Long-term CHC use (>3 years) reduces endometrial and ovarian cancer risk 4
• Acne improvement: CHCs with anti-androgenic properties can improve skin 4

Common Reasons Women Value Contraception

• Financial stability: 56% report contraception allows them to support themselves financially 6
• Educational completion: 51% report it enabled them to complete their education 6
• Career maintenance: 50% report it helped them keep or get a job 6
• Family planning: 63% report it allowed better care of themselves or existing families 6

Practical Implementation Strategy

Provide onsite dispensing and "quick start" initiation at the visit rather than waiting for next menses, if pregnancy can be reasonably excluded. 1

• Prescribe extended supplies: Provide or prescribe up to one year of pills/patch/ring to reduce barriers 1, 4
• No waiting period needed: Most methods can be started immediately without waiting for menses 1
• Referral system: Have referrals ready for methods not available onsite 1

Critical Pitfall to Avoid

Do not refuse contraception even when contraindications exist for certain methods—alternatives always exist. 2 For example, if CHCs are contraindicated due to cardiovascular risk, progestin-only methods (pills, implant, injection) or copper IUD remain safe options (Category 1-2) 3, 2.