What is the most appropriate initial investigation for a patient with no complaints who presents to the clinic and requests contraception?

Most Appropriate Investigation Before Prescribing Contraception

For a healthy patient requesting contraception with no complaints, blood pressure measurement is the only investigation needed if considering combined hormonal contraceptives; otherwise, no investigations are required before prescribing most contraceptive methods. 1

Investigation Requirements by Contraceptive Method

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Blood pressure measurement is the only essential examination (Class A - mandatory) before initiating combined hormonal contraceptives 1
• Blood pressure can be obtained in non-clinical settings (pharmacy, fire station) and self-reported if access to healthcare is limited 1
• No pelvic examination, breast examination, or laboratory tests are needed 1

Progestin-Only Methods (Pills, Implants, Injectables)

• No examinations or tests are required before initiating these methods 1
• These can be started immediately without any investigations 1

Intrauterine Devices (IUDs)

• Bimanual examination and cervical inspection are required (Class A - mandatory) for IUD insertion 1
• Most patients do not require additional STI screening at the time of IUD placement 1
• If the patient has risk factors for STIs and has not been screened according to CDC guidelines, screening can be performed at the time of placement, but insertion should not be delayed 1

Barrier Methods (Condoms, Diaphragm)

• No examination needed for condoms 1
• Bimanual examination required for diaphragm fitting 1, 2

Investigations That Are NOT Needed

The following are Class C examinations (do not contribute substantially to safe contraceptive use) and should not be required as they create unnecessary barriers to contraceptive access 1:

• Pelvic examination (except for IUD insertion or diaphragm fitting) 1, 2
• Cervical cytology (Pap smear) 1, 2
• Clinical breast examination 1
• Laboratory tests including:
  • Glucose 1
  • Lipids 1
  • Liver enzymes 1
  • Hemoglobin 1
  • Thrombogenic mutations 1
• HIV screening 1
• STI screening (unless clinically indicated for other reasons) 1

Weight/BMI Measurement

• Weight and BMI measurement are not needed to determine medical eligibility for any contraceptive method 1
• All methods can be used or generally can be used among patients with obesity 1
• However, baseline weight/BMI may be helpful for monitoring changes and counseling patients concerned about weight changes related to their contraceptive method 1

Key Clinical Pitfalls to Avoid

Do not delay contraceptive provision by requiring unnecessary examinations. The most recent CDC guidelines (2024) emphasize that requiring prerequisite preventive services creates logistical, emotional, and economic barriers to contraceptive access, particularly for adolescents and low-income patients who have high rates of unintended pregnancies 1

Do not confuse contraceptive eligibility screening with general preventive health services. While Pap smears, breast exams, and STI screening are important for overall health, they are not necessary to safely prescribe contraception and should not be barriers to access 1, 2

The American Academy of Family Physicians' Choosing Wisely recommendation explicitly states: "Do not require a pelvic exam or other physical exam to prescribe oral contraceptive medications" 1