Female Reproductive & Breast

Contraception: counseling and method selection

Clinical Overview and When to Suspect Contraceptive Need

— Yes → preconception counseling (folate 400–800 mcg, optimize chronic disease, vaccines, screen teratogens)

— No → contraception counseling

— Unsure/OK either way → shared decision-making, discuss reversible methods

— Adolescents at well visits (confidentiality protected in most states)

— Postpartum visits (initiate within 3 weeks if not breastfeeding; immediate postpartum LARC is evidence-based)

— Post-abortion (immediate initiation, including same-day LARC)

— Perimenopausal women still ovulating sporadically

— Patients on teratogens (isotretinoin, methotrexate, mycophenolate, warfarin, ACEi in reproductive-age women, valproate, topiramate)

— Chronic disease visits (diabetes, lupus, HTN) where pregnancy timing matters

— Tier 1 (<1% failure): implant, IUDs, sterilization

— Tier 2 (6–9%): pills, patch, ring, DMPA injection

— Tier 3 (12–28%): condoms, diaphragm, fertility awareness, withdrawal

Board pearl: USPSTF and Bright Futures both recommend offering contraception counseling at routine visits; on Step 3, missing the opportunity to ask about pregnancy intention in a reproductive-age patient on a teratogen is a classic wrong-answer trap — the "next best step" is contraception counseling before refilling the teratogen.

Scope of the visit: Contraceptive counseling is a core ambulatory family medicine competency. Any visit with a person of reproductive capacity (menarche through ~55 in cisgender women, plus transgender/nonbinary patients with a uterus) is an opportunity to address pregnancy intention.

One Key Question® framework: "Do you want to become pregnant in the next year?" Use answers to triage:

When to suspect unmet need:

Tiered effectiveness counseling (CDC/WHO model):

Reproductive justice framing: Present most-to-least effective but avoid coercion — patient values (bleeding pattern, hormones, autonomy, partner involvement, religious beliefs) drive the choice.

Presentation Patterns and Key History

— "I want to start birth control" — straightforward selection visit

— Refill request, side effect complaint (breakthrough bleeding, weight, mood, libido)

— Emergency contraception request (counts hours since unprotected sex)

— Postpartum/post-abortion contraception

— Pre-procedure: starting isotretinoin (iPLEDGE requires 2 methods), methotrexate, etc.

— Perimenopausal bleeding control + contraception

— Desire for future fertility? Spacing? Done childbearing?

— Timeline matters: someone wanting pregnancy in 3 months should avoid DMPA (delayed return to fertility up to 10 months)

— Migraine with aura (any age)

— Age ≥35 + smoking ≥15 cigarettes/day

— HTN ≥140/90, especially uncontrolled

— VTE, known thrombophilia, current/recent (<6 wk) postpartum

— Ischemic heart disease, stroke, complicated valvular disease

— Breast cancer (current)

— Cirrhosis (severe), hepatocellular adenoma/carcinoma

— SLE with antiphospholipid antibodies

— DM with vascular complications or >20 years duration

Step 3 management: Use the CDC US Medical Eligibility Criteria (US MEC) categories 1–4 to match conditions to methods; categories 3 (risks usually outweigh benefits) and 4 (unacceptable risk) are the testable boundaries.

Why she's in the office (common Step 3 stems):

Pregnancy intention and reproductive life plan:

Cycle history: LMP, regularity, dysmenorrhea, menorrhagia, PMS/PMDD — heavy bleeding favors LNG-IUD or combined methods; very irregular cycles raise PCOS workup.

Sexual history (5 P's): Partners, Practices, Protection, Past STIs, Pregnancy history — STI risk dictates condom counseling regardless of method.

Medical history red flags for estrogen:

Medications: Enzyme inducers (rifampin, carbamazepine, phenytoin, topiramate >200 mg, St. John's wort, some ARVs) reduce COC/POP/implant efficacy — IUD or DMPA preferred.

Social: Substance use, IPV screening (USPSTF B), insurance/cost, access.

Physical Exam Findings and Pre-Initiation Assessment

— Blood pressure is the only universally required measurement before starting combined hormonal contraception (CHC).

— Nothing else is required to start most methods in a healthy patient — no pelvic exam, no Pap, no labs, no STI test, no pregnancy test if reasonably certain not pregnant.

— No intercourse since LMP

— Correct/consistent contraceptive use

— <7 days after normal menses

— <4 weeks postpartum

— Fully breastfeeding, amenorrheic, <6 months postpartum

— <7 days after abortion/miscarriage

— IUD insertion: bimanual exam to assess uterine size/position, speculum to visualize cervix; STI screening if risk factors (don't delay insertion — test and treat concurrently if asymptomatic)

— Diaphragm/cervical cap: fitting exam

— Implant (Nexplanon): palpate non-dominant upper inner arm insertion site

— Sterilization: confirm decisional capacity, no exam-finding contraindication

Board pearl: A 22-year-old healthy woman requesting OCPs needs BP measurement and a urine pregnancy test only if pregnancy cannot be reasonably excluded — ordering a Pap, pelvic exam, or "baseline labs" before prescribing is the wrong answer on Step 3. Removing unnecessary barriers is the right answer.

What is actually required before starting contraception:

"Reasonably certain not pregnant" (CDC criteria, any one):

Method-specific exam needs:

BMI: Obesity is not a contraindication to any method (US MEC 1–2 for most), though efficacy of the patch may be reduced at >90 kg.

Cardiovascular exam in patients endorsing migraine, chest pain, or with HTN history.

Breast/pelvic exam: Not gatekeeping — required cervical cancer screening per USPSTF (start age 21) is independent of contraception.

Diagnostic Workup — Pre-Prescription Labs and Screening

— Urine hCG: if pregnancy cannot be reasonably excluded

— BP: mandatory before CHC

— STI screening (GC/CT NAAT): annual if <25 or risk factors; can be done same day as IUD insertion — do not delay

— Cervical cancer screening: per USPSTF (cytology q3y age 21–29; co-test or hrHPV q5y age 30–65) — independent of contraception

— Lipid panel/glucose: only if standard screening indications met (not for contraception per se)

— Suspected thrombophilia by family history: routine screening not recommended before CHC; selectively test only if strong personal/family VTE history with first-degree relative <50

— Liver disease history: LFTs before estrogen

— Known SLE: check antiphospholipid antibodies — positive APLA = US MEC 4 for CHC

— DM: assess for vascular complications and duration (>20 yr = MEC 3/4 for CHC)

— Pelvic ultrasound not routine before IUD; obtain if abnormal uterine anatomy suspected (fibroids, anomaly), or post-insertion if strings absent (rule out expulsion/perforation/pregnancy)

— Post-IUD lost strings algorithm: UPT → US → if not seen, plain film/CT to locate or confirm expulsion

— Review for enzyme inducers (rifampin, rifabutin, carbamazepine, phenytoin, phenobarbital, primidone, topiramate >200 mg/d, oxcarbazepine, St. John's wort, efavirenz, ritonavir-boosted protease inhibitors)

— Lamotrigine: CHC ↓ lamotrigine levels — seizure risk

Key distinction: Same-day "Quick Start" initiation is preferred over "Sunday start" — start the method today, regardless of cycle day, after excluding pregnancy; use backup contraception × 7 days (except COCs started within 5 days of menses, which need no backup).

Testing rarely required; targeted only:

Special situations requiring labs:

Imaging:

Drug interaction screen:

Smoking and weight: Document; affect MEC scoring.

Diagnostic Workup — Confirmatory and Follow-Up Studies

— IUD post-insertion: patient self-checks strings monthly; clinician confirms strings at follow-up (4–6 weeks optional, not mandatory)

— Implant (Nexplanon): palpate post-insertion; if not palpable → ultrasound (high-frequency linear) → MRI if not found → chest CT (rare migration to pulmonary artery)

— Urine hCG with any missed period, breakthrough bleeding pattern change, or pregnancy symptoms

— If pregnancy occurs with IUD in place: confirm location (rule out ectopic — IUDs reduce absolute ectopic risk but a pregnancy with IUD is more likely to be ectopic); if intrauterine and strings visible, remove IUD to reduce miscarriage/preterm birth risk

— Severe headache, focal neuro deficits, unilateral leg swelling, chest pain, dyspnea, abdominal pain: stop CHC, evaluate for VTE/stroke/MI/hepatic adenoma rupture

— New HTN: recheck; stop CHC if confirmed ≥140/90

— Abnormal uterine bleeding >3 months on method: workup for structural cause (US), infection (GC/CT), pregnancy, cervical pathology

— Cannot reliably check FSH while on hormonal method

— Continue contraception until age 55, OR 12 months amenorrhea off hormones if ≥50, OR 24 months if <50

— Copper IUD inserted at ≥40 may be left until menopause confirmed

CCS pearl: "Lost IUD strings" CCS case → order urine pregnancy test first, then transvaginal ultrasound, then abdominal X-ray if not visualized on US. Skipping the pregnancy test is a scoring penalty.

Confirming method placement and function:

Suspected contraceptive failure:

Workup of new symptoms on CHC:

Perimenopausal contraception cessation:

Bone density: DEXA not routinely needed for DMPA users; reassess need at 2 years.

Method Selection Logic and Shared Decision-Making

— Maximal effectiveness, low maintenance: LARC — implant (3 yr, now labeled up to 5), LNG-IUD (3–8 yr depending on device), Cu-IUD (10–12 yr)

— Avoid hormones: Cu-IUD, condoms, diaphragm, fertility awareness

— Avoid estrogen (smoker ≥35, migraine w/ aura, VTE hx, postpartum <21 d, HTN, SLE w/ APLA): progestin-only pill, DMPA, implant, LNG-IUD, Cu-IUD

— Lighter periods/dysmenorrhea: LNG-IUD, CHC (extended cycle), implant (variable)

— Heavier periods acceptable / avoid hormones: Cu-IUD

— Acne, hirsutism, PMDD: CHC (drospirenone, norgestimate formulations)

— On enzyme inducers: Cu-IUD, LNG-IUD, DMPA preferred

— Postpartum breastfeeding: progestin-only methods immediately; CHC after 4–6 weeks if no other VTE risk

— Permanent; counseling on regret risk (higher if <30, decision near time of stressor)

— Vasectomy is safer, cheaper, more effective, and less invasive than tubal — offer to couples

— Bilateral salpingectomy preferred over tubal ligation (ovarian cancer risk reduction)

— Cu-IUD: most effective, up to 5 days; works regardless of BMI

— Ulipristal acetate (ella) 30 mg: up to 120 hours; more effective than levonorgestrel, especially BMI >25

— Levonorgestrel 1.5 mg (Plan B): up to 72 hr (some effect to 120); less effective if BMI >26

— Yuzpe (combined pills) — last resort

Step 3 management: When the stem offers a LARC-eligible patient who wants "the most effective reversible method," choose implant or IUD — not pills.

Framework: Match patient priorities + medical eligibility (US MEC) + effectiveness tier.

Priority-driven selection:

Sterilization considerations:

Emergency contraception (EC) selection:

Pharmacotherapy — Hormonal Methods in Depth

— COCs: ethinyl estradiol (10–35 mcg) + progestin; monophasic preferred for simplicity; extended/continuous cycling acceptable

— Patch (Xulane, Twirla): weekly × 3, then patch-free week; ↑ estrogen exposure; less effective if >90 kg (Xulane)

— Vaginal ring (NuvaRing, Annovera): 3 wk in, 1 wk out; Annovera reusable 1 year

— Benefits: ↓ ovarian/endometrial cancer risk, ↓ dysmenorrhea, cycle control, acne

— Risks: VTE (3–4× baseline, still lower than pregnancy), MI/stroke (rare, age/smoking dependent), small ↑ breast/cervical cancer risk that resolves after discontinuation

— Norethindrone "minipill": strict 3-hour window; backup if late

— Drospirenone (Slynd): 24-hr window, more forgiving

— Ideal for breastfeeding, estrogen-contraindicated patients

— Amenorrhea common (50% at 1 yr) — counsel as benefit

— Reversible BMD loss; black-box warning but no DEXA screening needed, no duration limit per ACOG

— Weight gain (~5 lb/yr average); delayed fertility return (median 10 mo)

— Most effective reversible method (<0.05% failure)

— Irregular bleeding most common reason for discontinuation — counsel upfront

Board pearl: Missed COC pills: 1 missed → take ASAP, continue; ≥2 missed → take most recent, continue, use backup × 7 days, consider EC if unprotected sex in prior 5 days.

Combined hormonal contraception (CHC):

Progestin-only pills (POPs):

DMPA (Depo-Provera) 150 mg IM or 104 mg SC q13 weeks:

Etonogestrel implant (Nexplanon):

Hormonal IUDs (LNG): Mirena/Liletta (8 yr), Kyleena (5 yr), Skyla (3 yr); progressively lighter bleeding/amenorrhea

Procedural Methods — IUDs, Implant, and Sterilization

— Counsel on cramping; consider NSAID 30–60 min prior (ibuprofen 600–800 mg); paracervical block or lidocaine gel reduces pain

— Sound uterus; insert per device protocol; trim strings to 3 cm

— Insertion safe any cycle day if not pregnant; immediate postpartum (within 10 min of placental delivery) and post-abortion insertion approved

— Complications: expulsion (3–5%, highest first 3 months), perforation (1/1000, higher postpartum and breastfeeding), infection (transient, first 20 days — PID risk not increased beyond this)

— Don't routinely give prophylactic antibiotics; treat asymptomatic GC/CT detected at insertion with IUD in place

— Subdermal, non-dominant upper inner arm, ~8 cm above medial epicondyle (away from sulcus to avoid neurovascular bundle)

— Local anesthesia; confirm palpable post-insertion

— Removal: small incision at distal end; difficult removal → refer to experienced provider, image-guided

— Laparoscopic bilateral salpingectomy (preferred), tubal ligation, or postpartum partial salpingectomy at C-section/postpartum

— Hysteroscopic Essure withdrawn from US market 2018

— Effective immediately; permanent

— Office procedure under local; no-scalpel technique

— Not effective immediately — backup until post-vasectomy semen analysis at 8–16 weeks shows azoospermia or rare nonmotile sperm

— Failure rate ~1/2000; lower than tubal

CCS pearl: For a CCS case requesting "most effective EC in an obese patient who wants ongoing contraception" — insert copper IUD. It solves both problems in one order.

IUD insertion technique highlights:

Implant insertion:

Female sterilization:

Vasectomy:

EC IUD insertion: Cu-IUD within 5 days of unprotected sex = >99% effective; LNG 52 mg IUD also now supported for EC.

Special Populations — Older Reproductive-Age, Renal, and Hepatic Patients

— Fertility declining but pregnancy still possible; unintended pregnancy in this group has high maternal/fetal risk

— CHC: acceptable in healthy nonsmokers without HTN, migraine w/ aura, or VTE risk; provides cycle control and bone protection; stop at 50–55 and reassess

— LNG-IUD: excellent — controls heavy bleeding of perimenopause, can serve as progestin component of HRT after 50

— Cu-IUD ≥40: leave in place until 1 year after menopause (or age 55)

— DMPA: weigh BMD effects; not absolute contraindication

— Controlled, no end-organ damage: CHC = MEC 3

— ≥160/100 or vascular disease: CHC = MEC 4

— Progestin-only methods generally safe (MEC 1–2)

— Uncomplicated, <20 yr: CHC MEC 2

— Nephropathy/retinopathy/neuropathy or >20 yr: CHC MEC 3/4

— IUDs and progestin methods preferred in complicated DM

— No specific renal dose adjustments for contraceptives

— Avoid drospirenone (hyperkalemia) in advanced CKD or on K-sparing agents

— IUDs excellent choice

— Active viral hepatitis, severe cirrhosis, hepatocellular adenoma/HCC: CHC = MEC 3/4

— Progestin methods generally acceptable; IUDs (Cu or LNG) preferred in severe liver disease

Key distinction: Migraine without aura at age <35 is MEC 2 for CHC (usable); migraine with aura at any age is MEC 4 (avoid) — aura, not migraine itself, is the disqualifier.

Perimenopausal women (≥40):

Smoking ≥35 years: CHC = MEC 3 (<15 cig/d) or 4 (≥15 cig/d) — avoid; offer progestin-only or non-hormonal

Hypertension:

Diabetes:

Renal impairment / on dialysis:

Hepatic impairment:

Bariatric surgery: Malabsorptive procedures (RYGB) reduce oral contraceptive efficacy — use non-oral methods.

Special Populations — Adolescents, Postpartum, and Post-Abortion

— LARCs are first-line per AAP and ACOG — safe, effective, no impact on future fertility

— Confidentiality: in most US states, minors can consent to contraception without parental notification; know your state but on Step 3 default to honoring confidentiality

— Always pair with condom counseling for STI prevention (dual method)

— Bone health on DMPA: theoretical concern but ACOG says benefits outweigh; don't withhold if preferred method

— Immediate postpartum LARC (within 10 min of placenta or before discharge) reduces unintended pregnancy; slight ↑ expulsion risk with IUD vs interval

— CHC timing:

– <21 days postpartum: MEC 4 (VTE risk)

– 21–42 days: MEC 3 if other VTE risk factors (age ≥35, obesity, smoking, preeclampsia, C-section, immobility); MEC 2 otherwise

– >42 days: MEC 1–2

— Breastfeeding: progestin-only methods safe immediately; CHC after 4–6 weeks if breastfeeding well-established

— Lactational amenorrhea method (LAM): effective only if <6 mo, amenorrheic, exclusively breastfeeding

— Any method, including IUD/implant, can be initiated immediately after surgical or medical abortion (uterine evacuation complete for medical abortion)

— Ovulation returns within 2–3 weeks

— Testosterone is not contraceptive — pregnancy can occur; offer contraception if uterus/ovaries present and engaging in sperm-exposing sex

— Avoid estrogen if patient is pursuing masculinization goals; progestin methods, IUDs preferred

Step 3 management: A 16-year-old requesting contraception without parental knowledge — provide it; do not require parental consent. Document confidentiality discussion.

Adolescents:

Postpartum:

Post-abortion:

Transgender/nonbinary patients:

Patients with disabilities: Assess decisional capacity individually; respect autonomy; menstrual suppression often a goal (LNG-IUD, continuous CHC, DMPA).

Complications and Adverse Outcomes

— Baseline VTE ~2/10,000 woman-years; CHC ~6–12/10,000; pregnancy ~20–30/10,000; postpartum ~40–65/10,000

— Drospirenone and 3rd-gen progestins have slightly higher VTE risk than levonorgestrel

— Workup of suspected VTE: stop CHC, D-dimer/imaging per Wells; if confirmed → anticoagulation, transition to non-estrogen method

— Breakthrough bleeding common first 3 months on any hormonal method — reassure

— Persistent bleeding >3 months → evaluate (UPT, GC/CT, exam, US if indicated); may add brief course of NSAIDs, supplemental estrogen, or switch

— Amenorrhea on DMPA/LNG-IUD/implant is normal and not harmful

— Expulsion (3–5%, highest first 3 months and immediate postpartum)

— Perforation (rare, ~1/1000; higher in breastfeeding postpartum)

— Pregnancy with IUD: ~50% ectopic if pregnancy occurs (absolute ectopic risk lower than no contraception); remove IUD if intrauterine and strings visible

— PID: transient risk first 20 days post-insertion only

Board pearl: Sudden severe RUQ pain + hypotension in a long-term CHC user = ruptured hepatic adenoma — imaging, resuscitate, surgical/IR consult.

Venous thromboembolism (CHC):

Arterial events: MI, ischemic stroke — risk concentrated in smokers ≥35, uncontrolled HTN, migraine w/ aura

Hepatic: Cholestasis, hepatic adenoma (rare, dose/duration dependent), gallbladder disease

Hypertension: New-onset or worsening — recheck; if confirmed ≥140/90, switch off estrogen

Bleeding patterns:

IUD-specific:

Implant-specific: Bleeding irregularity (#1 reason for discontinuation), migration (rare)

DMPA-specific: Weight gain, BMD loss (reversible), mood effects, delayed fertility

Cu-IUD: Heavier menses, more cramping

Failure → pregnancy: No teratogenicity demonstrated for hormonal contraceptives or IUDs; reassure if inadvertent exposure.

When to Escalate Care — Consultation and Inpatient Triage

— Suspected VTE, PE, MI, stroke on CHC → stop CHC, ED evaluation, anticoagulation

— Severe abdominal pain post-IUD insertion → rule out perforation (US, possibly CT), uterine infection

— Sepsis or pelvic abscess → IV antibiotics, gyn consult; do not delay IUD removal if source

— Ectopic pregnancy with IUD in place → gyn emergency

— Anaphylaxis to copper (rare) or to local anesthetic during insertion

— Difficult or impalpable implant → imaging-guided removal by experienced provider

— Lost IUD strings with confirmed perforation → laparoscopy

— Complex contraception in high-risk patient (mechanical valve on warfarin, severe cardiac disease, organ transplant, complex thrombophilia) → MFM or family planning specialist

— Pregnancy with IUD in place and strings not visualized

— Neurology for migraine w/ aura needing contraception (non-estrogen options)

— Hematology for known thrombophilia

— Hepatology for chronic liver disease

— Cardiology for ischemic disease, valvular disease, peripartum cardiomyopathy

— Rheumatology for SLE (especially APLA-positive)

— Postpartum: place IUD/implant before discharge if desired

— Post-D&C/abortion: same encounter LARC

— After VTE on CHC: switch to non-estrogen before discharge

— Bariatric surgery admission: counsel on absorption issues, transition method

CCS pearl: On a CCS case, a patient with new VTE on COCs — immediate orders: stop OCP, start anticoagulation per VTE protocol, counsel on alternative contraception (LNG-IUD, implant, POP, Cu-IUD) before discharge. Forgetting to switch the method loses points.

Emergency department / hospitalize:

Urgent outpatient gyn/family planning referral:

Specialist co-management:

Inpatient initiation opportunities (don't miss):

Key Differentials — Same-Category Causes of Contraceptive Failure or Method Issues

— Missed pills / inconsistent use — most common; review adherence

— Drug interaction with enzyme inducer (rifampin, anticonvulsants, St. John's wort, some ARVs) — switch method or add backup

— Malabsorption: vomiting/diarrhea within hours of pill, bariatric surgery, IBD flare

— Smoking independently associated with breakthrough bleeding

— New STI (chlamydia cervicitis) — test

— Pregnancy despite method — UPT

— Method-specific: first 3 months of any method is "normalization period"

— Adherence failure (most common across all methods)

— Drug interaction

— Expulsion of IUD (check strings)

— Implant inserted too late or expired

— DMPA dose late (>15 weeks since last)

— Quick Start without backup

— Cu-IUD: longest, hormone-free, heavier menses

— LNG-IUD: lighter/absent menses, hormonal, treats menorrhagia

— Implant: arm-based, no pelvic procedure, irregular bleeding

— Expected on DMPA, LNG-IUD, implant, continuous CHC

— Pregnancy — always rule out with UPT if symptomatic or concerned

— Other causes (thyroid, prolactin, hypothalamic) unrelated to method

— DMPA: real association (~5 lb/yr)

— CHC, IUDs, implant: evidence does not support causation

— Confounders: aging, lifestyle, pregnancy avoidance

Key distinction: Breakthrough bleeding in first 3 months = expected; persistent beyond 3 months = workup, don't just reassure.

Differential for "breakthrough bleeding on hormonal contraception":

Differential for "unintended pregnancy on contraception":

Differential among LARC options when patient says "I want long-acting":

Differential for "amenorrhea on contraception":

Differential for "weight gain on contraception":

Key Differentials — Other-Category Causes Mimicking Contraceptive Side Effects

— Primary mood/anxiety disorder, PMDD, postpartum depression — screen with PHQ-9

— Some evidence drospirenone formulations help PMDD; others may worsen mood

— Counsel and consider switching formulation or method before attributing solely to OCP

— New-onset migraine with aura → stop CHC immediately (stroke risk)

— Tension headache, medication-overuse headache, intracranial pathology (rare but consider with red flags: sudden, worst-ever, focal deficit, papilledema)

— Idiopathic intracranial hypertension — risk factors include obesity, OCPs; fundoscopy

— Some progestins (levonorgestrel, norethindrone) are more androgenic; switch to drospirenone, norgestimate, or desogestrel

— Consider PCOS workup if hirsutism/irregular cycles preceded contraception

— First few weeks: expected cramping

— Persistent: rule out expulsion, malposition, perforation, PID, ectopic pregnancy, endometritis, adenomyosis, endometriosis — pelvic US

— Prolactinoma — check prolactin, TSH; not caused by contraception itself

— Primary HTN unmasked, secondary causes (renal artery stenosis, primary aldosteronism, pheochromocytoma) — workup if very young, very high, or unresponsive to OCP discontinuation

— Telogen effluvium (postpartum, stress), thyroid disease, iron deficiency, androgenetic alopecia — not typically OCP

Board pearl: Attributing every symptom to contraception is a trap; on Step 3, screen for the alternative diagnosis before changing or discontinuing a working method.

"Mood changes on the pill":

"Headache on the pill":

"Acne worse on contraception":

"Pelvic pain with IUD":

"Galactorrhea on contraception":

"Hypertension after starting OCP":

"Hair loss":

Long-Term Plan, Continuation, and Method Switching

— At 1 year: ~80% LARC users continue vs ~50% of pill/patch/ring users

— Most discontinuation in first 6 months — front-load counseling on expected bleeding changes

— Set expectation: "Bleeding will be unpredictable for ~3–6 months, then most users have lighter or no periods" (LNG-IUD, implant, DMPA)

— Pill → IUD: insert IUD any day; continue pills until insertion or use 7-day overlap

— IUD → pill: start pill 7 days before IUD removal, or overlap

— DMPA → other: start new method on or before next due date

— Any → implant: insert during current method coverage

— CHC, POP, ring, patch, IUD, implant: fertility returns immediately (next cycle)

— DMPA: median 10 months to conception after last dose — counsel timing

— Update BP, smoking status, headache pattern, medications, pregnancy intention

— No mandatory pelvic/Pap "to refill" — barrier to be removed

— Refill rules: provide up to 12-month supply at once (improves continuation; legally supported in many states)

— New US MEC 3 or 4 condition arises

— Patient desires pregnancy

— Adverse event

— Age + menopause confirmation

Step 3 management: Prescribe a full year supply of OCPs at the visit when possible; "1 month with 2 refills then return to clinic" is a wrong-answer pattern that increases discontinuation and unintended pregnancy.

Continuation strategies (the real-world battle):

Method switching without gaps:

Stopping for pregnancy attempt:

Annual reassessment:

Discontinuation criteria:

STI re-screening: Per USPSTF, regardless of contraceptive method.

Follow-Up, Monitoring, and Counseling Cadence

— 3 months after initiation (optional but useful): BP, side effects, adherence, bleeding patterns — phone or in-person

— Annually thereafter: BP, screening updates, reproductive plan, method satisfaction

— IUD: optional 4–6 week string check; otherwise annual

— Implant: no scheduled follow-up between insertion and removal at 3–5 years

— DMPA: every 13 weeks for injection; 2-week grace window

— BP every visit on CHC (especially first year)

— Weight trend on DMPA (counseling, not contraindication)

— Bleeding diary if persistent abnormal bleeding

— No routine labs for healthy users

— STI prevention: dual method (condoms + primary method) for at-risk patients

— Emergency contraception access: advance prescription of ulipristal or LNG, especially for condom users or method gaps

— Folic acid 400 mcg/day for any reproductive-age woman regardless of intention (USPSTF A)

— Smoking cessation, BP control, weight management as health priorities

— Confidential time without parent; HEEADSSS assessment

— Vaccinations: HPV catch-up, meningococcal, Tdap

— Mental health screening

— Discuss menopause timing, transition to HRT vs continuation, bone health

— Pill apps, alarms; backup method available; what to do if missed dose

CCS pearl: Order "contraception counseling" and document method-specific anticipatory guidance at the initiation visit on CCS; advance EC prescription is a high-value preventive order.

Routine follow-up:

Monitoring parameters:

Counseling elements at every visit:

Adolescent/young adult specifics:

Perimenopausal:

Patient self-management:

Ethical, Legal, and Patient Safety Considerations

— Most US states allow minors to consent to contraception independently; Title X clinics provide confidential services regardless of state

— Explanation of benefits (EOB) sent to policyholder (often parent) can breach confidentiality — discuss options: Title X, Medicaid, cash-pay generic, mail-order

— Step 3 expectation: maintain confidentiality unless safety concern (abuse, suicidality)

— Document method effectiveness, alternatives, risks (VTE for CHC, expulsion/perforation for IUD), benefits, side effects, what to expect

— Sterilization: requires extra rigor — Medicaid mandates a 30-day waiting period between consent and procedure (with limited exceptions for premature delivery)

— Capacity assessment for sterilization in patients with cognitive disability — never coerce; involve ethics if needed

— Avoid steering vulnerable populations (low-income, minority, disabled, incarcerated) toward LARCs

— Equal emphasis on easy removal access as on insertion — refusing to remove a LARC on patient request is unethical

— Providers may decline to provide specific methods but must disclose and refer to a willing provider; cannot abandon patient

— Sexual activity in a minor below age of consent may trigger reporting depending on partner age and state statutory rape laws — know jurisdiction

— Suspected IPV: screen (USPSTF B); offer resources; reporting varies (mandatory for injury in many states)

— Postpartum discharge without contraception plan = high-risk gap; document method or plan before discharge

— Patient on isotretinoin requires 2 methods + monthly pregnancy tests (iPLEDGE program)

— Switching from CHC after VTE without bridge method risks pregnancy

Board pearl: A 15-year-old requesting an IUD without parental knowledge in a state allowing minor consent — insert the IUD with confidential billing; do not require parental consent. Refusing or notifying parents is the wrong answer.

Confidentiality (especially minors):

Informed consent:

Coercion and reproductive justice:

Conscientious objection:

Mandatory reporting:

Transition-of-care safety:

High-Yield Associations and Rapid-Fire Clinical Facts

— Migraine with aura (any age)

— Smoker ≥35 and ≥15 cig/day

— BP ≥160/100 or vascular disease

— Current VTE, known thrombogenic mutation, history of stroke/IHD

— Current breast cancer

— Severe cirrhosis, hepatocellular adenoma/HCC

— <21 days postpartum

— Major surgery with prolonged immobilization

— SLE with positive antiphospholipid antibodies

— Complicated valvular disease, peripartum cardiomyopathy

— CHC: ↓ ovarian cancer (50% with 5+ years use, lasting decades), ↓ endometrial cancer, ↓ benign breast disease, dysmenorrhea, acne, hirsutism, ovarian cyst suppression

— LNG-IUD: treats heavy menstrual bleeding, endometrial protection in HRT, treats endometrial hyperplasia

— Cu-IUD: most effective EC

— DMPA: seizure threshold ↑, sickle cell pain ↓, endometriosis pain

— 0–72h: LNG (less effective if BMI >26)

— 0–120h: ulipristal (best oral choice), Cu-IUD (best overall)

Key distinction: "Most effective EC" = Cu-IUD; "most effective oral EC" = ulipristal.

CHC contraindications (MEC 4) — memorize:

Non-contraceptive benefits:

EC by hours:

iPLEDGE (isotretinoin): 2 methods of contraception or abstinence; monthly negative UPT

Lactational amenorrhea: only effective if <6 mo + exclusive BF + amenorrheic

Tubal vs vasectomy: vasectomy more effective, safer, cheaper

Discontinuation rates at 1 year: LARC >80%, DMPA ~55%, pill/patch/ring ~50%, condoms <50%

Fertility return: immediate for all except DMPA (~10 mo median)

Ectopic pregnancy: absolute risk lower with any contraception; relative risk among contraceptive failures higher with IUD (still rare)

Board Question Stem Patterns

Step 3 management: Match the MEC category to the condition and pick the highest-effectiveness method that is MEC 1 or 2.

Stem 1: 28-year-old with migraine with aura wants reliable birth control → answer: LNG-IUD, implant, Cu-IUD, POP, or DMPA. Wrong answer: any CHC.

Stem 2: 36-year-old smoker (1 ppd) requests contraception → avoid CHC; offer progestin-only or LARC.

Stem 3: Postpartum day 2, breastfeeding, wants contraception before discharge → immediate postpartum LNG-IUD or implant; CHC contraindicated.

Stem 4: 19-year-old on isotretinoin needs contraception → two methods, ideally LARC + condoms; monthly UPT per iPLEDGE.

Stem 5: 22-year-old healthy, wants OCPs → check BP, prescribe; do not require pelvic exam, Pap, or labs.

Stem 6: Patient with IUD presents with positive pregnancy test; strings visible, intrauterine pregnancy on US → remove IUD to reduce miscarriage/preterm birth.

Stem 7: Unprotected sex 96 hours ago, BMI 34, wants oral EC → ulipristal (LNG less effective at high BMI; >72h); even better → Cu-IUD.

Stem 8: 15-year-old requesting confidential contraception → provide; do not notify parents.

Stem 9: Patient on rifampin for TB needs contraception → Cu-IUD, LNG-IUD, or DMPA (enzyme-inducer resistant).

Stem 10: New onset unilateral leg swelling on COC → stop COC, evaluate VTE, transition to non-estrogen method before discharge.

Stem 11: Patient with SLE and positive APLA wants contraception → avoid CHC (MEC 4); offer IUDs or progestin-only.

Stem 12: Wants pregnancy in 3 months but on DMPA last week → counsel delayed return to fertility (median 10 months); consider alternative if quick conception desired.

Stem 13: Lost IUD strings → UPT first, then transvaginal US.

Stem 14: Postpartum on POPs, 9 months out, resumed menses → effective if compliant; for missed dose >3 hr → backup × 48 hr.

One-Line Recap

Contraceptive counseling is a shared decision-making process that matches patient pregnancy intention and preferences to the most effective method allowed by their US MEC profile, removes unnecessary barriers to initiation, and front-loads counseling about expected side effects to maximize continuation.

Board pearl: When in doubt on Step 3, the answer is usually "offer the most effective method the patient is eligible for and wants, today, without unnecessary testing."

Effectiveness tiering: LARC (implant, IUDs) > injection/pill/patch/ring > barrier/behavioral; offer most-effective-first without coercion.

Estrogen disqualifiers (MEC 4) to remember cold: migraine with aura, smoker ≥35 + ≥15 cig/d, BP ≥160/100, VTE/stroke/IHD history, current breast cancer, <21 days postpartum, severe cirrhosis, SLE with antiphospholipid antibodies.

Remove barriers: only BP is required before CHC; only UPT (if pregnancy can't be excluded) before any method; Quick Start today with 7-day backup; same-day IUD/implant; one-year refills.

Emergency contraception hierarchy: Cu-IUD (most effective, up to 5 days, BMI-independent) > ulipristal (up to 120 h) > levonorgestrel (best within 72 h, less effective if BMI >26); offer advance prescription.

Special situations: immediate postpartum LARC before discharge; iPLEDGE requires 2 methods + monthly UPT; adolescents can consent confidentially in most states; DMPA = ~10-month fertility delay; vasectomy more effective and safer than tubal ligation; pregnancy with IUD in place → remove if strings visible and intrauterine.