What is the most common birth control method to start with for a female patient of reproductive age with no significant medical history?

Most Common Birth Control Method to Start

For a healthy woman of reproductive age with no medical contraindications, combined oral contraceptive pills (COCs) are the most commonly initiated reversible contraceptive method in the United States, comprising 21.9% of all contraception in current use. 1

Primary Recommendation: Combined Oral Contraceptives

Start with a low-dose combined oral contraceptive pill containing ≤35 mcg ethinyl estradiol plus levonorgestrel or norethindrone as the first-line option. 2 These formulations offer:

• Proven effectiveness with typical-use failure rates of 4-7% per year 1
• Lowest thrombotic risk profile among combined hormonal methods 2
• Immediate availability and ease of initiation 3
• Cost-effectiveness with widespread insurance coverage 2

Initiation Protocol

Begin COCs at any time if reasonably certain the patient is not pregnant (within 7 days of menses onset, no intercourse since last menses, or currently using reliable contraception correctly). 3

Required Pre-Initiation Assessment:

• Blood pressure measurement only - no pelvic exam, lab work, or Pap smear needed 3
• Screen for contraindications to estrogen (history of VTE, stroke, cardiovascular disease, migraine with aura, current smoking if age >35) 3

Backup Contraception Requirements:

• None needed if started within 5 days of menses 3
• 7 days of barrier methods or abstinence if started >5 days after menses 3

Alternative First-Line Options

When COCs Are Contraindicated:

Progestin-only pills (POPs) are the next most accessible option for women with estrogen contraindications (breastfeeding, VTE risk, migraine with aura). 3, 4 These require:

• Only 2 days of backup contraception if started >5 days after menses 3
• No pre-initiation examination required 3
• Strict daily timing adherence 1

For Maximum Effectiveness:

Long-acting reversible contraceptives (LARCs) - specifically levonorgestrel IUDs or etonogestrel implants - have the highest effectiveness (<1% failure rate) and should be strongly considered despite lower initial uptake. 1, 5 LARC use has increased from 6% (2008) to 17.8% (2016) of contraceptive users. 1

Practical Implementation Strategy

1. Prescribe multiple cycles upfront (ideally 12 months) to improve continuation rates 3
2. Use "quick start" method - begin same-day rather than waiting for next menses 3
3. Counsel on expected bleeding changes - irregular bleeding is common initially and not harmful 3
4. Provide emergency contraception information for missed pills 3

Common Pitfalls to Avoid

• Do not delay initiation for unnecessary pelvic exams, Pap smears, or STI screening 3
• Do not require pregnancy testing if criteria for "reasonably certain not pregnant" are met 3
• Do not restrict to single-month supplies - this increases discontinuation 3
• Do not assume barrier methods alone are adequate for pregnancy prevention (18% typical-use failure rate for condoms) 1

Noncontraceptive Benefits

COCs provide additional health benefits including:

• Reduced ovarian and endometrial cancer risk 6
• Improvement in acne, dysmenorrhea, and premenstrual symptoms 1, 6
• More predictable bleeding patterns 6
• Treatment of endometriosis 1

Risk Considerations

Venous thromboembolism risk increases from 2-10 per 10,000 woman-years to 7-10 per 10,000 woman-years with estrogen-containing methods. 1 This absolute risk remains low in healthy women without additional VTE risk factors. 1

For women with thrombophilia (e.g., protein S deficiency), combined hormonal contraceptives are absolutely contraindicated - use levonorgestrel IUD or copper IUD instead. 5