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 most contraceptive methods. 1, 2, 3

Essential Investigations by Method Type

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Blood pressure measurement is mandatory (Class A: essential and mandatory) before initiating combined hormonal contraceptives 1, 2, 3
• 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, 3

Progestin-Only Methods (Pills, Implants, Injectables)

• No examinations or laboratory tests are required before initiating progestin-only pills, implants, or injectable contraceptives 1, 3
• All examinations 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, 3
• Most women do not require additional STI screening at the time of IUD insertion if already screened according to CDC guidelines 1, 3

Investigations That Are NOT Required

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

• Pelvic examination (except for IUD placement or diaphragm fitting) 1
• Cervical cytology (Pap smear) 1, 2, 3
• Clinical breast examination 1, 3
• Laboratory tests: glucose, lipids, liver enzymes, hemoglobin, thrombogenic mutations 1, 2, 3
• HIV screening (unless indicated by risk factors) 1, 3
• STI screening (unless indicated by risk factors or CDC screening guidelines) 1, 2, 3

Clinical Approach

Step 1: Take Focused Medical History

• Review medical history focusing on U.S. Medical Eligibility Criteria (MEC) conditions 1, 2, 3
• Assess for contraindications such as history of venous thromboembolism, stroke, cardiovascular disease, or current pregnancy 4

Step 2: Measure Blood Pressure (for Combined Hormonal Methods Only)

• This single measurement can be obtained in non-clinical settings (pharmacy, fire station) and self-reported if access to healthcare is limited 1

Step 3: Assess Pregnancy Status

• Use detailed history rather than routine pregnancy testing 1
• A provider can be reasonably certain a woman is not pregnant if she has no symptoms/signs of pregnancy AND meets one of these criteria: ≤7 days after menses started, no intercourse since last menses, using reliable contraception correctly, ≤7 days post-abortion, within 4 weeks postpartum, or exclusively breastfeeding with amenorrhea <6 months postpartum 1

Step 4: Provide Same-Day Contraception

• Begin contraception at the visit ("quick start") rather than waiting for next menses 1
• Provide or prescribe a full year's supply when possible 1

Critical Pitfalls to Avoid

Requiring unnecessary examinations creates barriers to contraceptive access, particularly for adolescents and low-income women who have high rates of unintended pregnancy 1. The widespread but incorrect perception that hormonal contraceptives are dangerous is reinforced by requiring unnecessary testing 5.

Do not require pelvic examination for hormonal methods (except IUDs), as this is the most common unnecessary barrier imposed by providers—16-23% of providers incorrectly require pelvic examination before non-intrauterine hormonal method initiation 6.

Women with known medical conditions may require additional evaluation based on specific contraindications, but for healthy women presenting without complaints, the assessment should remain minimal 1, 2, 3.