Assessment Before Starting Contraception

Assessment before contraceptive initiation is the short, focused evaluation that confirms what the patient wants, excludes pregnancy with reasonable certainty, screens for conditions that make the chosen method unsafe, and identifies the few examinations that a particular method really needs. For most methods the history alone is enough; blood pressure is needed before oestrogen-containing methods; a pelvic examination is needed only before an IUD or sterilisation.

Minimum necessary assessment. Every test or examination that does not change the choice or safety of a method delays care and loses patients. Assessment is method specific and is never a condition for access to a method that does not need it.

Components. Reproductive intentions, medical eligibility, pregnancy exclusion, STI and HIV risk, interacting medicines, method specific examination and the patient's own preferences about bleeding, hormones and privacy.

Focused history.

• Menstrual: first day of the last menstrual period, cycle length and regularity, bleeding pattern, dysmenorrhoea and any unexplained bleeding.

• Obstetric: parity, date of last delivery, breastfeeding status, recent abortion or miscarriage, previous ectopic pregnancy and gestational hypertension or diabetes.

• Contraceptive: methods used, reasons for stopping, current method and whether it is used consistently and correctly.

• Sexual: partners, condom use, symptoms of STI, HIV exposure, coercion or violence.

• Medical: hypertension, VTE, stroke, ischaemic heart disease, valvular disease, migraine with aura, diabetes and its complications, liver disease or tumour, gallbladder disease, breast cancer, systemic lupus erythematosus, sickle cell disease, epilepsy, HIV, tuberculosis, kidney disease, cervical or endometrial cancer and uterine anomalies.

• Surgical: planned major surgery with immobilisation and previous bariatric surgery.

• Drugs: enzyme-inducing medicines (rifampicin, rifabutin, carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, topiramate, efavirenz, ritonavir-boosted regimens, griseofulvin, St John's wort), lamotrigine and teratogenic medicines.

• Habits: age together with number of cigarettes smoked daily.

Blood pressure. Measure before any combined hormonal method. Systolic 140 to 159 mmHg or diastolic 90 to 99 mmHg is category 3 for combined methods; 160/100 mmHg or more is category 4. Repeat a raised reading after 5 minutes of rest before acting on it.

Examinations and tests by method.

Tests not needed to start any method in a healthy patient. Breast examination, cervical cytology or HPV testing, lipid profile, liver function, glucose, haemoglobin (except before sterilisation), thrombophilia screening, hormone levels and routine pelvic examination. Offer cervical screening, HIV testing and STI screening at the same visit as separate services, never as a condition for the method.

Weight and BMI. Not required to start a method. Record them to counsel on the reduced effectiveness of the patch at weight over 90 kg and of levonorgestrel emergency pills at a BMI of 30 kg/m2 or more.

Sequence. Provide privacy and confirm confidentiality; ask about intentions and preferences; take the focused history; establish reasonable certainty that the patient is not pregnant; measure blood pressure where the method needs it; examine only if the method needs it; check the eligibility category for the chosen method; confirm the choice; provide the method at the same visit; document.

Reasonable certainty of non-pregnancy. No symptoms of pregnancy and at least one of: no sex since the last normal period; correct and consistent use of a reliable method; within 5 days of the start of a normal period; fully breastfeeding, amenorrhoeic and under 6 months postpartum; within 21 days after childbirth; within 5 days after abortion or miscarriage; negative pregnancy test and no unprotected sex in the last 3 weeks.

Task sharing. Trained nurses, clinical officers and community health providers can screen with a checklist and provide pills, injectables and condoms. Implants, IUDs and permanent methods need providers trained and equipped for the procedure.

Documentation. Record blood pressure where taken, history flags, the category for the chosen method, the basis for excluding pregnancy, the product and strength given and the next due date.

Common errors.

• Requiring pelvic or breast examination, cervical cytology or laboratory tests before pills, injectables or implants.

• Delaying a method until the next period when pregnancy can be reasonably excluded.

• Starting a combined method without a blood pressure reading.

• Missing an enzyme inducer, lamotrigine, migraine with aura or recent childbirth.

• Withholding a method because an HIV test has not been done.

Special groups. Adolescents need the same assessment as adults and no parity or age restriction. Postpartum patients are assessed on breastfeeding status and time since delivery. People living with HIV do not need a CD4 count or viral load before a method. Patients over 40 need blood pressure, smoking history and cardiovascular risk review before a combined method, and a levonorgestrel IUD is often a good alternative. People with disability need an accessible examination room, adapted communication and support to decide.

Referral and escalation. Refer for blood pressure of 160/100 mmHg or more (offer a progestogen-only or nonhormonal method meanwhile), unexplained vaginal bleeding before IUD insertion, suspected ectopic pregnancy, suspected pelvic infection, suspected malignancy and uterine anomalies.