Contraception Initiation Guidelines

Primary Recommendations

The Centers for Disease Control and Prevention recommends starting with a low-dose combined oral contraceptive pill containing ≤35 mcg ethinyl estradiol plus levonorgestrel or norethindrone as the first-line option, offering immediate availability and ease of initiation 1
The American College of Obstetricians and Gynecologists suggests beginning COCs at any time if reasonably certain the patient is not pregnant, within 7 days of menses onset, no intercourse since last menses, or currently using reliable contraception correctly 1, 2

The Centers for Disease Control and Prevention recommends a blood pressure measurement only, with no pelvic exam, lab work, or Pap smear needed, before initiating COCs 1, 2
Screening for contraindications to estrogen, such as history of VTE, stroke, cardiovascular disease, migraine with aura, or current smoking if age >35, is necessary before initiating COCs 1

The Centers for Disease Control and Prevention suggests no backup contraception is needed if COCs are started within 5 days of menses 1, 3
The American College of Obstetricians and Gynecologists recommends 7 days of barrier methods or abstinence if COCs are started >5 days after menses 1, 3

The Centers for Disease Control and Prevention recommends progestin-only pills (POPs) as the next most accessible option for women with estrogen contraindications, requiring only 2 days of backup contraception if started >5 days after menses 1, 5
The American Academy of Family Physicians suggests no pre-initiation examination is required for POPs 2

The Centers for Disease Control and Prevention recommends prescribing multiple cycles upfront (ideally 12 months) to improve continuation rates 2
The American Academy of Family Physicians suggests using the "quick start" method, beginning same-day rather than waiting for next menses 2, 5
The Centers for Disease Control and Prevention advises counseling on expected bleeding changes, as irregular bleeding is common initially and not harmful 3
The Centers for Disease Control and Prevention recommends providing emergency contraception information for missed pills 7

The American College of Obstetricians and Gynecologists states that for women with thrombophilia (e.g., protein S deficiency), combined hormonal contraceptives are absolutely contraindicated, and levonorgestrel IUD or copper IUD should be used instead 6