Contraception Guidance

Contraceptive Methods and Contraindications

• The Centers for Disease Control and Prevention recommends that contraception is not generally contraindicated for most patients, as there are multiple contraceptive methods adapted to nearly all clinical situations 1, 2
• The American College of Obstetricians and Gynecologists suggests that the determination of contraindications depends entirely on the individual medical profile of the patient and the contraceptive method considered 1, 2
• Combined hormonal contraceptives are contraindicated in patients with a high risk of thromboembolism, such as those with a history of deep vein thrombosis or pulmonary embolism (category 4 = absolute contraindication) 1
• The World Health Organization recommends that progestin-only methods, such as the progestin-only pill, implant, or DMPA injection, are generally category 1 or 2, even in the presence of thromboembolic risk factors 1, 2
• The Centers for Disease Control and Prevention suggests that copper intrauterine devices are a non-hormonal, highly effective method with no systemic effects 1

Pre-Initiation Exams

• The American College of Obstetricians and Gynecologists recommends that blood pressure measurement is obligatory before initiating combined hormonal contraception 2
• The Centers for Disease Control and Prevention suggests that no other systematic examination is required before initiating combined hormonal contraception if the patient's medical history is negative 2
• The World Health Organization recommends that a bimanual exam and cervical inspection are required before intrauterine device placement 2
• The Centers for Disease Control and Prevention suggests that screening for sexually transmitted infections should be performed if risk factors are present, but this should not delay intrauterine device placement 2

Important Considerations

• The American College of Obstetricians and Gynecologists recommends that contraception should not be refused, even with contraindications to certain methods, as alternatives always exist 1
• The Centers for Disease Control and Prevention suggests that intrauterine device placement should not be delayed to await sexually transmitted infection screening results if the patient does not have visible purulent cervicitis 2
• The World Health Organization recommends that the risk of unintended pregnancy may be higher than the risks of contraception in many situations 1

Contraception Options for Healthy Adult Females

Most Effective Methods: Long-Acting Reversible Contraceptives (LARCs)

• The Centers for Disease Control and Prevention recommends long-acting reversible contraceptives (LARCs), specifically the levonorgestrel intrauterine device (LNG-IUD) or subdermal implant, as the most effective reversible options with failure rates less than 1% per year, and should be considered first-line choices for healthy adult females 3
• The subdermal implant can be inserted at any time during the menstrual cycle if reasonably certain the patient is not pregnant, and requires backup contraception for 7 days if inserted more than 5 days after menses started 3
• The American College of Obstetricians and Gynecologists recommends that all patients with obesity (BMI ≥30 kg/m²) can use implants without restriction, according to the Centers for Disease Control and Prevention 4, 3

Highly Effective Short-Acting Methods

• The Centers for Disease Control and Prevention recommends that blood pressure measurement is mandatory before initiation of combined hormonal contraceptives (CHCs) 3
• The World Health Organization recommends that no examination is required before initiation of progestin-only pills (POPs), and backup contraception is needed for 2 days if started more than 5 days after menses for norethindrone or norgestrel POP, and 7 days for drospirenone POP 3

Critical Clinical Pearls

• The Centers for Disease Control and Prevention recommends that blood pressure measurement is required only for CHCs, and pelvic exam is required only for IUDs, while no exam is needed for implant, DMPA, and POPs 3
• The American College of Obstetricians and Gynecologists recommends that BMI measurement is not required for medical eligibility but may be helpful for baseline monitoring, according to the Centers for Disease Control and Prevention 3, 5
• The Centers for Disease Control and Prevention recommends that IUD placement should not be delayed to await STI screening results unless purulent cervicitis is visible 3
• The World Health Organization recommends that all contraceptive methods can be used without restriction in patients with obesity (BMI ≥30), according to the Centers for Disease Control and Prevention 3

Evidence‑Based Contraceptive Recommendations for Women with Prior Ectopic Pregnancy

Effectiveness of Contraceptive Methods

• The CDC reports that long‑acting reversible contraceptives (LARCs) have a typical‑use failure rate of 0.05 %–0.6 % per year, which is markedly lower than combined oral contraceptives (≈9 %), condoms (≈18 %), and depot medroxyprogesterone acetate (≈6 %) in women with a history of ectopic pregnancy. 6
• According to the CDC, LARCs do not require daily or weekly user action, thereby eliminating the risk of method failure from missed pills or inconsistent use. 7

CDC Eligibility and Safety

• The CDC Medical Eligibility Criteria place no restriction on the use of the levonorgestrel intrauterine device (LNG‑IUD) for women with a prior ectopic pregnancy. 8
• The CDC states that condoms, while useful for STI protection, are inadequate as the sole contraceptive method for this high‑risk population because of their high typical‑use failure rate. 8
• The CDC notes that depot medroxyprogesterone acetate (DMPA) has a typical‑use failure rate of about 6 % and requires clinic visits every three months for reinjection, making it less suitable than LARCs for preventing recurrent ectopic pregnancy. [6][7]

Implementation and Counseling

• The American College of Obstetricians and Gynecologists recommends that clinicians confirm a patient’s desire for contraception and provide counseling on all options within a shared‑decision‑making framework before selecting a method. 9
• The CDC advises that providers should verify that the patient is not pregnant using clinical criteria before inserting a subdermal etonogestrel implant. 6

Optimal Contraceptive Strategy for Transgender Men Who Decline Implants and IUDs

Preferred Hormonal Method

• The CDC recommends depot medroxyprogesterone acetate (DMPA) injection as the most effective contraceptive option for transgender men who decline implants and intrauterine devices, providing reliable pregnancy prevention and menstrual suppression without daily dosing requirements【10】.

Initiation When Pregnancy Status Is Uncertain

• The CDC advises that, if pregnancy status cannot be confirmed, clinicians should still initiate DMPA because the benefits of immediate contraception outweigh potential risks; a follow‑up pregnancy test should be performed 2–4 weeks later【10】.

Required Assessment Before Combined Hormonal Contraceptives (CHCs)

• The CDC requires a blood pressure measurement before starting combined hormonal contraceptives in transgender men, ensuring cardiovascular safety prior to estrogen exposure【10】.

Drug Interactions That Reduce Contraceptive Efficacy

• The Mayo Clinic notes that peri‑operative use of sugammadex can diminish hormonal contraceptive effectiveness for approximately 1 week, and use of aprepitant can reduce efficacy for about 1 month【11】.

Management of Breakthrough Bleeding on DMPA

• The CDC recommends using non‑steroidal anti‑inflammatory drugs for 5–7 days during episodes of heavy or prolonged bleeding associated with DMPA as first‑line therapy【10】.
• The CDC also reassures patients that irregular bleeding is a common early side effect of DMPA and typically improves over time【10】.