What is the most appropriate initial investigation for a healthy female of reproductive age with no complaints who presents to the clinic requesting contraception?

Blood Pressure Measurement Only

For a healthy woman requesting contraception, blood pressure measurement is the only essential investigation required before prescribing combined hormonal contraceptives (pills, patch, ring), while no examinations or tests are needed for progestin-only methods or barrier methods. 1, 2

Essential Requirements by Contraceptive Method

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Blood pressure measurement is the single mandatory (Class A) examination before initiating combined hormonal contraceptives 1, 2
• Women with severe hypertension (≥160/100 mmHg) should not use combined hormonal methods 3
• Weight/BMI measurement is optional but may be useful for baseline monitoring, though it does not determine medical eligibility 1

Progestin-Only Methods (Pills, Implants, Injectables)

• No examinations or laboratory tests are required before initiating progestin-only pills, implants, or injectable contraceptives 1, 2, 3
• All examinations including blood pressure are classified as Class C (not contributing substantially to safe use) for these methods 1

Intrauterine Devices (IUDs)

• Bimanual examination and cervical inspection are required for proper IUD placement 1, 2
• Most women do not require additional STI screening at time of IUD insertion if already screened according to CDC guidelines 1

Examinations and Tests That Are NOT Required

The following are unnecessary barriers to contraceptive access and should not be required for healthy women 1:

• Pelvic examination (except for IUD placement or diaphragm fitting) 1, 4
• Pap smear (cervical cytology) 1, 3, 4
• Clinical breast examination 1, 3, 4
• Laboratory tests including glucose, lipids, liver enzymes, hemoglobin, or thrombogenic mutations 1, 3
• HIV screening (unless indicated by risk factors) 1, 3
• STI screening (unless indicated by risk factors or CDC screening guidelines) 1, 3

Clinical Rationale

Why Medical History Trumps Screening Tests

• A detailed medical history focusing on U.S. Medical Eligibility Criteria (MEC) conditions provides the most accurate assessment for contraceptive safety 1, 2
• Routine pregnancy testing is not necessary; history alone can determine if a provider can be reasonably certain the patient is not pregnant 1
• Hormonal contraception can be safely provided based on medical history and blood pressure measurement alone 1, 4

Avoiding Unnecessary Barriers

• Unnecessary examinations and tests create logistical, emotional, and economic barriers to contraceptive access, particularly for adolescents and low-income women who have high rates of unintended pregnancies 1
• The American Academy of Family Physicians explicitly recommends not requiring pelvic exams or other physical exams to prescribe oral contraceptive medications 1
• These requirements reinforce the incorrect perception that hormonal contraceptives are dangerous 4

Common Pitfalls to Avoid

Over-Testing

• Do not require pelvic examinations for hormonal methods (except IUDs) - this is the most common unnecessary barrier, with 16-23% of providers incorrectly requiring it 5
• Do not require Pap smears before contraception initiation - cervical cancer screening is important but unrelated to contraceptive safety 1
• Do not screen for thrombogenic mutations - family history is sufficient to identify high-risk women 1

Under-Assessment

• Do not forget blood pressure measurement for combined hormonal methods - this is the one essential test that identifies women with severe hypertension who should avoid these methods 1, 2
• Do not skip the bimanual examination before IUD placement - up to 48% of providers fail to perform this necessary examination 5

Special Considerations

• Women with known medical conditions may require additional evaluation based on U.S. Medical Eligibility Criteria, but this should be guided by specific history findings, not routine screening 1, 2
• Contraception can be started immediately ("quick start") if the provider is reasonably certain the patient is not pregnant, with follow-up pregnancy testing in 2-4 weeks if uncertainty exists 1, 3
• Provide or prescribe multiple cycles (ideally a full year's supply) to reduce barriers to continued use 1