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

Blood Pressure Measurement Only

For a patient requesting contraception with no complaints, blood pressure measurement is the only essential investigation required before prescribing most contraceptive methods. 1, 2

Investigation Requirements by Method Type

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Blood pressure measurement is the only Class A (mandatory) examination before initiating combined hormonal contraceptives 1, 2
• Blood pressure can be obtained in non-clinical settings (pharmacy, fire station) and self-reported if healthcare access is limited 1, 2
• No pelvic examination, breast examination, cervical cytology, or laboratory tests (glucose, lipids, liver enzymes, hemoglobin, thrombogenic mutations) are needed 1, 2, 3

Progestin-Only Methods (Pills, Implants, Injectables)

• No examinations or laboratory tests are required before initiating progestin-only contraceptives 1, 2
• This includes Depo-Provera, implants, and progestin-only pills 1

Intrauterine Devices (IUDs)

• Bimanual examination and cervical inspection are Class A (mandatory) only at the time of IUD insertion 1, 2
• No pre-visit examination is required for counseling or method selection 1
• Most patients do not require STI screening at the time of IUD placement unless clinically indicated 2

Barrier Methods

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

Investigations That Should NOT Be Required

The CDC explicitly classifies these as Class C (not contributing substantially to safe contraceptive use): 1, 2

• Pelvic examination (except for IUD insertion or diaphragm fitting) 1, 2, 4
• Cervical cytology (Pap smear) 1, 2, 5
• Clinical breast examination 1, 2, 3
• HIV screening 1, 2
• STI screening (unless clinically indicated by sexual history) 1, 2
• Laboratory tests: glucose, lipids, liver enzymes, hemoglobin, thrombogenic mutations 1, 2

Weight/BMI Considerations

• Weight and BMI measurement are not needed to determine medical eligibility for any contraceptive method 1, 2
• All contraceptive methods can be used among patients with obesity 1, 2
• Baseline weight may be helpful for monitoring changes if patients are concerned about weight-related side effects 2

Critical Pitfall to Avoid

Requiring prerequisite preventive services (pelvic exams, Pap smears, breast exams) creates unnecessary logistical, emotional, and economic barriers to contraceptive access. 2 The American Academy of Family Physicians explicitly recommends not requiring a pelvic exam or other physical exam to prescribe oral contraceptive medications. 2

Clinical Algorithm

1. Measure blood pressure (or obtain self-reported measurement from pharmacy/fire station) 1, 2
2. Take focused medical history assessing contraindications to specific methods (smoking status if age >35, history of venous thromboembolism, cardiovascular disease, migraine with aura) 1, 6
3. Conduct sexual health assessment to determine STI risk and need for dual protection with condoms 1
4. Provide contraceptive counseling using tiered approach (most effective methods first) 1
5. Dispense or prescribe contraception immediately at the visit with "quick start" if reasonably certain patient is not pregnant 1, 5

Delaying contraception to perform unnecessary examinations decreases adherence and increases risk of unintended pregnancy. 5, 3