brand logo

Am Fam Physician. 2021;103(5):291-300

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

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.

RecommendationSponsoring organization
Do not require a pelvic examination or other physical examination to prescribe oral contraceptive medications.American Academy of Family Physicians

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 next menses to ensure that the patient is not pregnant. This practice began before studies showed that hormonal contraceptives do not cause birth defects, pregnancy loss, or fetal growth problems.4 Concern that hormones may mask the symptoms of early pregnancy, thus delaying diagnosis, can be addressed through appropriate use of urine pregnancy tests, emergency contraception, and a barrier method during the first week of hormonal contraceptive use.4 The Centers for Disease Control and Prevention (CDC) has published medical eligibility criteria and selected practice recommendations for contraceptive use to address these issues in detail; a smart-phone app and other tools are available to help clinicians manage hormonal contraception safely and efficiently.4,5

The quick start method allows most patients to begin using contraceptive pills, patches, injections, implants, vaginal rings, or an intrauterine device (IUD) at any point during the menstrual cycle6,7 (Figure 1,Figure 2, and Figure 38 ). This strategy reduces delays and cost. Patients who begin using a new method more than five to seven days after the first day of their last menses should use a backup method during the first week.7 Patients who have had unprotected sex within five days of their office visit can take hormonal emergency contraception that day (levonorgestrel [Plan B], a progestin; or ulipristal [Ella], a progesterone agonist/antagonist).7,9 Ulipristal is more effective than levonorgestrel in patients who are overweight or who had unprotected sex within the past three to five days. Because progestins may decrease the effectiveness of ulipristal, patients should wait five days after taking ulipristal before starting hormonal contraception.9 Patients can begin hormonal contraception immediately after taking levonorgestrel.

The copper IUD can be used for emergency contraception and for long-term contraception; it is nearly 100% effective when inserted up to five days after unprotected sex.9 A randomized trial showed that the levonorgestrel IUD was noninferior to the copper IUD for emergency contraception.25 [updated] Patients with a low risk of pregnancy who choose a hormonal contraceptive that is difficult to discontinue (e.g., injections, implants, progestin-releasing IUD) may choose to wait until a scheduled office visit to begin the chosen method. Because an IUD can complicate pregnancy, clinicians must carefully counsel patients who choose to have an IUD inserted the same day despite a low risk of undiagnosed pregnancy, making sure they understand the risk and the need to remove the IUD if pregnancy occurs.

Patients may have spotting and other menstrual cycle changes for the first few months after starting hormonal contraception. Those who start oral contraceptives between menses have no more menstrual pattern disruption than those who wait until their next menses.10 Counseling about side effects, including anticipatory guidance about spotting, may improve adherence to hormonal contraception.11

Postpartum

Estrogen-containing hormonal contraceptives are often withheld after childbirth because of concerns about postpartum hypercoagulability. The CDC concluded that the risks of estrogen-containing contraceptives may outweigh the benefits during the first three to six weeks postpartum.4 After six weeks, the risk of thrombosis returns to normal, and postpartum patients who are not breastfeeding can take estrogen-containing oral contraceptives without additional restrictions.4 Because low-dose progestins are not associated with thrombosis, progestin-only contraceptives may be initiated immediately postpartum.4 A copper or progestin-releasing IUD can be inserted immediately after childbirth, preferably within 10 minutes of placental delivery.12 Detailed guidance on the timing of postpartum IUD insertion is available in Table 113 and in the CDC's medical eligibility criteria and selected practice recommendations for contraceptive use.4,5

Already a member/subscriber?  Log In

Subscribe

From $145
  • Immediate, unlimited access to all AFP content
  • More than 130 CME credits/year
  • AAFP app access
  • Print delivery available
Subscribe

Issue Access

$59.95
  • Immediate, unlimited access to this issue's content
  • CME credits
  • AAFP app access
  • Print delivery available

Article Only

$25.95
  • Immediate, unlimited access to just this article
  • CME credits
  • AAFP app access
  • Print delivery available
Purchase Access:  Learn More

Continue Reading

More in AFP

More in Pubmed

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.  See permissions for copyright questions and/or permission requests.