For all methods Rule out pregnancy Review whether patients are using their chosen hormonal contraception method reliably; if they are missing doses, counsel them about setting phone reminders, using medication reminder apps, and asking for support from a family member or partner Inquire about recent use of exogenous hormones (e.g., gender-affirming hormone therapy, emergency contraception) Ensure that cervical cancer screening is up to date Consider screening for sexually transmitted infection Consider other etiologies; more information is available in a previous American Family Physician article (https://www.aafp.org/pubs/afp/issues/2019/0401/p435.html) Inquire about any medication changes, particularly those that might induce metabolism of estrogen (e.g., carbamazepine, azithromycin, rifampin)

For levonorgestrel intrauterine devices Confirm device placement with a pelvic examination and string check; if necessary, perform ultrasonography to ensure placement within the uterus