WHO Selected Practice Recommendations

Selected practice recommendations for contraceptive use, now in their fourth edition (2025), address how to use contraceptive methods safely and effectively once a method is chosen. They complement the medical eligibility criteria by answering practical questions: when to start, what examinations are needed, how long backup is required, what to do with missed or late use, how to manage bleeding problems, and how often to follow up.

Main domains.

• How to be reasonably certain a patient is not pregnant.

• Initiation timing and backup for each method.

• Examinations and tests needed before starting.

• Missed pills, late injections and patch and ring errors.

• Management of bleeding irregularities and other side effects.

• Follow up and resupply intervals.

• Switching between methods.

Examinations and tests before starting.

Backup requirements when starting outside the no-backup window.

Missed combined pills.

• 1 or 2 missed or new pack started 1 or 2 days late: take a pill now, continue; no backup.

• 3 or more missed in week 1 or 2, or pack started 3 or more days late: take a pill now, backup for 7 days, consider emergency contraception if unprotected sex in the last 5 days.

• 3 or more missed in week 3: finish the active pills, omit the inactive pills, start a new pack next day, backup for 7 days.

Late injections.

• DMPA (IM 150 mg or SC 104 mg): repeat every 13 weeks; may be given up to 4 weeks late without backup.

• Norethisterone enanthate 200 mg IM: repeat every 8 weeks; may be given up to 2 weeks late.

• Beyond these windows, reinject if reasonably certain not pregnant and advise backup for 7 days; consider emergency contraception.

Follow up.

• Combined methods: review at 3 months or at resupply with blood pressure annually.

• Implants and IUDs: no routine follow up is required; encourage return for problems or removal. A visit after the first menses or 3 to 6 weeks after IUD insertion is optional.

• Injectables: return for each repeat injection or self-inject at home with DMPA-SC.

Supply. Provide up to 1 year of pills at once where possible.

Common errors.

• Requiring tests in Class C before starting a method.

• Applying the combined pill backup rule (7 days) to progestin-only pills (2 days) or vice versa.

• Turning away patients late for injections without assessing pregnancy risk.

• Delaying an IUD insertion for cervical cytology.

Bleeding problems. For unscheduled bleeding with implants or injectables, exclude pregnancy, infection and gynaecological pathology. Short courses of nonsteroidal anti-inflammatory drugs (for example ibuprofen 400 to 800 mg orally three times daily for 5 days, or mefenamic acid 500 mg orally three times daily for 5 days) or, for implants, a combined pill for up to 3 months where eligible, may help.

Referral and escalation. Refer patients with persistent bleeding after 3 months of treatment, suspected pathology, or method complications that cannot be managed on site.