Confirming Non-Pregnancy Before Initiating Birth Control
Use the CDC checklist criteria to establish reasonable certainty of non-pregnancy without requiring a pregnancy test in most cases; routine pregnancy testing is not universally required before starting contraception. 1
CDC Checklist for Reasonable Certainty of Non-Pregnancy
You can be reasonably certain a patient is not pregnant (99-100% negative predictive value) if she has no signs or symptoms of pregnancy AND meets at least one of the following criteria: 1, 2
- ≤7 days after start of normal menses
- Has not had intercourse since the start of last normal menses
- Has been correctly and consistently using reliable contraception
- ≤7 days after spontaneous or induced abortion
- Within 4 weeks postpartum
- Fully or nearly fully breastfeeding (≥85% of feeds), amenorrheic, and <6 months postpartum
When Pregnancy Testing Is Indicated
If the patient does not meet the above criteria, consider: 1, 2
- Immediate testing if unprotected intercourse occurred ≥3 weeks ago (97-98% of pregnancies detectable by standard urine test at this point) 2
- Testing if any pregnancy symptoms are present 2
- Testing if irregular periods or amenorrhea and unprotected intercourse within past 3-4 weeks 2
Quick-Start Approach When Pregnancy Status Is Uncertain
If pregnancy status is uncertain but the patient meets some criteria suggesting low risk, initiate a non-intrauterine contraceptive method immediately and order follow-up pregnancy testing in 2-4 weeks. 1 This approach provides immediate contraceptive coverage while confirming non-pregnancy status, as delaying contraception creates unnecessary barriers and may increase unintended pregnancy risk. 1, 3
Key Clinical Pitfalls to Avoid
- Do not delay contraception waiting for next menses or a pregnancy test result when the patient meets CDC checklist criteria—this creates barriers to effective contraception 1, 3
- Do not assume a single negative pregnancy test definitively rules out pregnancy if taken too early after intercourse, as test results depend on timing since intercourse and test sensitivity 1, 2
- Do not require pelvic examination, Pap smear, or breast examination before prescribing hormonal contraception—these are unnecessary and create access barriers 1, 4, 3, 5
- For women with irregular cycles, do not wait for a "missed period" to test for pregnancy, as this concept is not applicable when cycles are unpredictable 2
Physical Examination Requirements
The only examinations needed before initiating contraception are: 1
- Blood pressure measurement for combined hormonal contraceptives
- Bimanual examination and cervical inspection only for IUD placement
- No other examination required for implants, DMPA, or progestin-only pills
Timing Considerations for Pregnancy Test Accuracy
If testing is performed: 2
- Most urine tests detect pregnancy 3-4 days after implantation (which occurs 6-12 days after fertilization)
- By 3 weeks post-intercourse, 97-98% of pregnancies are detectable on standard urine tests
- Serum testing is more sensitive and can detect earlier if clinical suspicion is high
- Repeat testing in 3-4 days if initial test negative but recent intercourse, or in 1 week if symptoms persist