What contraception options are suitable for a female patient of reproductive age after suction evacuation for a molar pregnancy?

Contraception After Molar Pregnancy Evacuation

All contraceptive methods except intrauterine devices (IUDs) can be initiated immediately after suction evacuation for molar pregnancy, with hormonal contraception being strongly recommended to maintain reliable β-hCG monitoring during the surveillance period. 1, 2, 3

Recommended Contraceptive Options

First-Line Methods (Start Immediately)

Hormonal contraception is specifically indicated during postmolar follow-up to maintain the reliability of β-hCG as a tumor marker. 3 The following methods can be initiated at the time of or immediately after evacuation:

• Combined oral contraceptives (COCs): Can be started immediately after evacuation, require only blood pressure measurement before initiation 4
• Progestin-only pills: Can be started immediately, no examination required 4
• Depot medroxyprogesterone acetate (DMPA) injection: Can be initiated immediately, provides 3 months of reliable contraception 4
• Etonogestrel implant: Can be inserted immediately, highly effective for 3 years 4
• Contraceptive patch or vaginal ring: Can be started immediately 4

Barrier Methods (Acceptable but Less Preferred)

• Male or female condoms: Can be used immediately, though less reliable than hormonal methods 4
• Diaphragm or cervical cap: Requires fitting examination but can be used 4

Absolute Contraindications

IUD Placement - Critical Timing Restrictions

Never insert an IUD during the post-molar surveillance period when β-hCG monitoring is required. 1, 2 The specific contraindications are:

• Category 4 (unacceptable risk): When β-hCG levels remain persistently elevated or malignant disease is present 1, 2
• Category 3 (risks outweigh benefits): When β-hCG levels are decreasing or undetectable but surveillance is ongoing 1, 2
• Both copper and levonorgestrel IUDs carry these same restrictions 1

When IUDs Become Acceptable

IUDs may only be reconsidered after:

• Complete surveillance period ends (1 month after remission for partial mole, 3-6 months after remission for complete mole) 3
• β-hCG has remained undetectable for the appropriate duration 1, 3
• Confirmed remission with no evidence of gestational trophoblastic neoplasia 1
• At that point, IUDs become Category 1-2 (acceptable for use) 1

Surveillance Requirements During Contraception Use

Weekly β-hCG measurement is essential to confirm remission and identify cases requiring further treatment. 3 The surveillance protocol includes:

• Weekly β-hCG monitoring until normalized (3 consecutive normal assays) 2
• Follow-up testing twice at 3-month intervals after normalization 2
• Total surveillance duration: 1 month after remission for partial mole, 3-6 months after remission for complete mole 3

Clinical Implementation Algorithm

1. At time of evacuation: Counsel patient that pregnancy must be avoided during surveillance period 3
2. Immediate initiation: Start hormonal contraception same day as evacuation or within 7 days 4
3. Quick start protocol: No need to wait for next menses if reasonably certain patient is not pregnant (which is confirmed by the evacuation itself) 4
4. Provide extended supply: Prescribe multiple cycles (ideally full year's supply) of oral contraceptives, patch, or ring 4
5. Avoid IUDs completely until surveillance period is complete and remission confirmed 1, 2

Common Pitfalls to Avoid

• Do not insert an IUD at any point during the post-molar surveillance period, even if β-hCG is decreasing—this represents a Category 3-4 contraindication 1, 2
• Do not delay contraception initiation waiting for the next menstrual period; start immediately 4
• Do not require unnecessary examinations before providing hormonal contraception (pelvic exam, breast exam, cervical cytology are not needed) 4
• Do not use barrier methods alone as the primary recommendation, as their lower efficacy could result in pregnancy that would complicate β-hCG monitoring 3

Rationale for Hormonal Contraception Preference

Hormonal contraception serves dual purposes: preventing pregnancy that would interfere with β-hCG monitoring while maintaining the reliability of this critical tumor marker. 3 Pregnancy during surveillance would make it impossible to distinguish between normal pregnancy β-hCG elevation and gestational trophoblastic neoplasia, potentially delaying diagnosis of malignant disease.