No Routine Investigation Required Before Prescribing Contraception
For this asymptomatic 41-year-old woman requesting contraception, none of the listed investigations (FSH, TSH, transvaginal ultrasound, or endometrial biopsy) are appropriate or necessary before prescribing contraception. The only essential pre-prescription assessment depends on the contraceptive method chosen: blood pressure measurement for combined hormonal contraceptives, or no investigation at all for progestin-only methods. 1, 2
Method-Specific Investigation Requirements
Combined Hormonal Contraceptives
- Blood pressure measurement is the only mandatory investigation (Class A - essential and mandatory) before initiating combined hormonal contraceptives 1, 2
- Blood pressure can even be self-reported if healthcare access is limited 2
- No other examinations or laboratory tests are needed 1
Progestin-Only Methods
- No examinations or tests are required before initiating progestin-only pills, implants, or injectables 1, 2
IUDs or Diaphragms
- Bimanual examination and cervical inspection are required only for IUD insertion or diaphragm fitting 1, 2
Why the Listed Options Are Inappropriate
FSH Testing (Option A)
- FSH measurement is not required for contraceptive provision at any age 1, 2
- While this patient is 41 years old and approaching perimenopause, age alone does not contraindicate any contraceptive method 3
- Contraceptive counseling should focus on cardiovascular risk factors and symptoms, not hormonal testing 3
TSH Testing (Option B)
- Thyroid function testing is explicitly listed as unnecessary before contraceptive provision 1, 2
- While oral contraceptives can affect thyroid binding globulin levels, this does not require pre-treatment TSH screening in asymptomatic women 4, 5
- Routine pre-conception TSH screening remains controversial and is not part of contraceptive initiation protocols 6
Transvaginal Ultrasound (Option C)
- Pelvic imaging is not required for contraceptive provision in asymptomatic women 1, 2
- The American College of Physicians found no mortality or morbidity benefit from screening pelvic examinations in asymptomatic women 1, 7
- Requiring unnecessary procedures creates logistical, emotional, and economic barriers to contraceptive access 1, 2
Endometrial Biopsy (Option D)
- Endometrial sampling is not indicated in asymptomatic women without abnormal uterine bleeding 1, 7
- This invasive procedure would be completely inappropriate as a prerequisite for contraception 1, 2
Investigations That Should NOT Be Required
The CDC explicitly identifies these as unnecessary barriers to contraceptive care: 1, 2
- Pelvic examination (except for IUD/diaphragm)
- Cervical cytology (Pap smear)
- Clinical breast examination
- Laboratory tests for glucose, lipids, liver enzymes, hemoglobin, or thrombogenic mutations
- HIV screening
- STI screening (unless clinically indicated for other reasons)
Critical Clinical Pitfall to Avoid
Requiring prerequisite preventive services creates barriers to contraceptive access, particularly for adolescents and low-income women who have the highest rates of unintended pregnancy. 1, 2 The American Academy of Family Physicians specifically recommends against requiring pelvic exams or other physical exams to prescribe oral contraceptives. 2
Approximately 30% of women experience anxiety, discomfort, fear, or embarrassment from pelvic examinations, and fear of examination may lead women to delay or avoid obtaining contraception. 1, 7, 8 This practice adds unnecessary costs ($2.6 billion annually in the United States) and exposes women to psychological harms without evidence of benefit. 7, 8
Correct Clinical Approach
For this patient, the appropriate assessment includes: 1
- Determine pregnancy status through history (usually satisfactory without testing)
- Measure blood pressure if considering combined hormonal contraceptives
- Assess medical eligibility criteria through history
- Provide same-day contraceptive initiation if reasonably certain she is not pregnant
- Prescribe a full year's supply to reduce barriers to care