Initiating Hormonal Contraception

 

Most patients can safely begin using hormonal contraception at any point in their menstrual cycle. An evidence-based, flexible, patient-centered approach to initiating contraception promotes health and enhances patients' reproductive autonomy. A recent Papanicolaou test is not necessary before prescribing hormonal contraception. Most patients can begin using progestin-only contraceptives immediately after childbirth. Patients can begin any appropriate contraceptive method immediately after an abortion or early pregnancy loss, except for an intrauterine device following septic abortion. Delaying contraception to wait for the next menses or for an appointment creates unnecessary barriers for patients. Clinicians can facilitate the use of hormonal contraception by providing anticipatory guidance about common side effects (e.g., spotting, other menstrual cycle changes), giving comprehensive information about available contraceptive choices, honoring patients' preferences, and eliminating office-related barriers. Prescribing or dispensing a one-year supply of contraceptives lowers costs and improves adherence. Counseling via telemedicine or a patient portal eliminates unnecessary office visits.

Although the rate of unintended pregnancy in the United States has decreased to less than 50% in recent years, it remains much higher than in other industrialized countries, with widening disparities by race, income, and education level.1 Younger people, in particular, may face multiple barriers to timely access to primary care and hormonal contraception.2,3 To address this problem, family physicians should make hormonal contraception easily and safely available.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Hormonal contraception can be started at any point during the menstrual cycle.6,7

C

Consensus opinion from clinical guidelines

Papanicolaou testing should not be required before prescribing hormonal contraception.4,18

C

Consensus opinion from clinical guidelines

A one-year supply of contraceptives should be dispensed or prescribed to reduce patient costs, improve adherence, and increase convenience.21

C

Decision model based on 24,309 veterans


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Hormonal contraception can be started at any point during the menstrual cycle.6,7

C

Consensus opinion from clinical guidelines

Papanicolaou testing should not be required before prescribing hormonal contraception.4,18

C

Consensus opinion from clinical guidelines

A one-year supply of contraceptives should be dispensed or prescribed to reduce patient costs, improve adherence, and increase convenience.21

C

Decision model based on 24,309 veterans


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

 Enlarge     Print

BEST PRACTICES IN GYNECOLOGY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not require a pelvic examination or other physical examination to prescribe oral contraceptive medications.

American Academy of Family Physicians


Source: For more information on the Choosing Wisely Campaign, see https://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN GYNECOLOGY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not require a pelvic examination or other physical examination to prescribe oral contraceptive medications.

American Academy of Family Physicians


Source: For more information on the Choosing Wisely Campaign, see https://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm.

Office Visits Between Menses

When a patient requests contraception during an office visit that occurs between menses, some clinicians delay starting hormonal contraceptives until

The Author

RUTH LESNEWSKI, MD, is an attending physician at the Mount Sinai Downtown Residency in Urban Family Medicine and an assistant clinical professor in the Department of Family Medicine and Community Health at Mount Sinai Beth Israel, New York, N.Y.

Address correspondence to Ruth Lesnewski, MD, The Institute for Family Health, 230 W. 17th St., New York, NY 10011 (email: rlesnewski@institute.org). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374(9):843–852....

2. Grindlay K, Grossman D. Prescription birth control access among U.S. women at risk of unintended pregnancy. J Womens Health (Larchmt). 2016;25(3):249–254.

3. Brittain AW, Loyola Briceno AC, Pazol K, et al. Youth-friendly family planning services for young people: a systematic review update. Am J Prev Med. 2018;55(5):725–735.

4. Tepper NK, Curtis KM, Cox S, et al. Update to U.S. medical eligibility criteria for contraceptive use, 2016: updated recommendations for the use of contraception among women at high risk for HIV infection. MMWR Morb Mortal Wkly Rep. 2020;69(14):405–410.

5. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep. 2016;65(4):1–66.

6. Westhoff C, Kerns J, Morroni C, et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66(3):141–145.

7. Hatcher RA, Zieman M, Allen AZ, et al. 2019–2020 Managing Contraception. 15th ed. Bridging the Gap Communications; 2019.

8. Reproductive Health Access Project. Quick start algorithm for hormonal contraception. Accessed July 5, 2020. https://www.reproductiveaccess.org/wp-content/uploads/2014/12/QuickstartAlgorithm.pdf

9. Trussell J, Raymond EG, Cleland K. Emergency contraception: a last chance to prevent unintended pregnancy. January 2019. Accessed July 5, 2020. https://ec.princeton.edu/questions/ec-review.pdf

10. Brahmi D, Curtis KM. When can a woman start combined hormonal contraceptives (CHCs)? A systematic review. Contraception. 2013;87(5):524–538.

11. Schivone GB, Glish LL. Contraceptive counseling for continuation and satisfaction. Curr Opin Obstet Gynecol. 2017;29(6):443–448.

12. Lopez LM, Bernholc A, Hubacher D, et al. Immediate postpartum insertion of intrauterine device for contraception. Cochrane Database Syst Rev. 2015;(6):CD003036.

13. Reproductive Health Access Project. Medical eligibility for initiating contraception. September 1, 2016. Accessed July 5, 2020. https://www.reproductiveaccess.org/resource/medical-eligibility-initiating-contraception

14. Van der Wijden C, Manion C. Lactational amenorrhoea method for family planning. Cochrane Database Syst Rev. 2015;(10):CD001329.

15. Lopez LM, Grey TW, Stuebe AM, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev. 2015;(3):CD003988.

16. Tang OS, Xu J, Cheng L, et al. The effect of contraceptive pills on the measured blood loss in medical termination of pregnancy by mifepristone and misoprostol: a randomized placebo controlled trial. Hum Reprod. 2002;17(1):99–102.

17. Okusanya BO, Oduwole O, Effa EE. Immediate postabortal insertion of intrauterine devices. Cochrane Database Syst Rev. 2014;(7):CD001777.

18. Sawaya GF, Harper C, Balistreri E, et al. Cervical neoplasia risk in women provided hormonal contraception without a Pap smear. Contraception. 2001;63(2):57–60.

19. Qin J, Saraiya M, Martinez G, et al. Prevalence of potentially unnecessary bimanual pelvic examinations and Papanicolaou tests among adolescent girls and young women aged 15–20 years in the United States. JAMA Intern Med. 2020;180(2):274–280.

20. HealthPocket. The state of medical debt in the United States. November 21, 2019. Accessed May 17, 2020. https://www.healthpocket.com/health-insurance-insights/medical-debt-in-us-2019#.Xdf0ouhKhPY

21. Judge-Golden CP, Smith KJ, Mor MK, et al. Financial implications of 12-month dispensing of oral contraceptive pills in the Veterans Affairs health care system [published correction appears in JAMA Intern Med. 2019;179(9):1303]. JAMA Intern Med. 2019;179(9):1201–1208.

22. Walker AW, Stern L, Cipres D, et al. Do adolescent women's contraceptive preferences predict method use and satisfaction? A survey of Northern California family planning clients. J Adolesc Health. 2019;64(5):640–647.

23. Society for Adolescent Health and Medicine; American Academy of Pediatrics. Confidentiality protections for adolescents and young adults in the health care billing and insurance claims process. J Adolesc Health. 2016;58(3):374–377.

24. Lesnewski R, Prine L. Initiating hormonal contraception. Am Fam Physician. 2006;74(1):105–112. Accessed July 5, 2020. https://www.aafp.org/afp/2006/0701/p105.html

25. Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs. copper intrauterine devices for emergency contraception. N Engl J Med. 2021;384(4):335–344.

 

 

Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

More in Pubmed

MOST RECENT ISSUE


Oct 2021

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article