What is the most appropriate initial evaluation for a patient presenting to the clinic with a request for contraception and no current complaints?

Blood Pressure Measurement Before Combined Hormonal Contraceptives

For a healthy patient requesting contraception with no complaints, blood pressure measurement is the only mandatory investigation before prescribing combined hormonal contraceptives (CHCs), while most other contraceptive methods require no examination at all. 1

Method-Specific Requirements

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Blood pressure measurement is essential and mandatory (Class A) before initiating any combined hormonal contraceptive 1, 2, 3
• No other examinations or laboratory tests are routinely needed 1

Long-Acting Reversible Contraceptives (LARCs)

Intrauterine Devices (IUDs):

• Bimanual examination and cervical inspection are required before insertion 1, 2, 3
• STI screening may be performed at time of placement if risk factors present, but should not delay IUD insertion unless purulent cervicitis is visible 1, 2, 3

Subdermal Implant:

• No examination required before insertion 1, 3

Injectable Contraception (DMPA)

• No examination required before administration 1, 3

Progestin-Only Pills

• No examination required before prescribing 1, 3

What Is NOT Required

The following are explicitly not needed as prerequisites for contraception in healthy patients, though they may address other non-contraceptive health needs: 1, 3

• Pelvic examination (except for IUD insertion or diaphragm fitting)
• Cervical cytology (Pap smear)
• Clinical breast examination
• HIV screening
• Laboratory tests for lipids, glucose, liver enzymes, hemoglobin, or thrombogenic mutations
• Routine pregnancy testing (detailed history is usually sufficient)

Weight/BMI Measurement

• Not required to determine medical eligibility for any contraceptive method 1, 3
• All methods can be used or generally can be used in patients with obesity (BMI ≥30) 1, 2, 3
• May be helpful for baseline monitoring to address future concerns about weight changes 1, 3

Pregnancy Assessment

• Detailed medical history is the most accurate assessment of pregnancy risk 1
• Routine pregnancy testing is not necessary for every patient 1
• Pregnancy testing may help confirm low pregnancy risk in uncertain situations, but is not mandatory 1

Critical Clinical Pitfall

Unnecessary examinations and tests create barriers to contraceptive access, particularly for adolescents and low-income patients who have high rates of unintended pregnancies 1. The CDC explicitly warns against requiring preventive services as prerequisites when they are not medically necessary for safe contraceptive provision 1.

Summary Algorithm

1. Patient requests contraception → Take focused medical history 1
2. Considering CHCs? → Measure blood pressure (mandatory) 1, 2, 3
3. Considering IUD? → Perform bimanual exam and cervical inspection at insertion 1, 2, 3
4. Considering implant, DMPA, or progestin-only pills? → No examination needed 1, 3
5. Initiate method same day if reasonably certain patient is not pregnant 1