Initiating Hormonal Contraception

Key points

Overview

This American Family Physician review explains how to start hormonal contraception safely and without unnecessary delay. The main takeaway is that an evidence-based, flexible, patient-centered approach, including quick start, remote counseling and longer supplies, promotes health and reproductive autonomy. The rate of unintended pregnancy in the United States has fallen below 50% but remains much higher than in other industrialized countries.

Starting between menses

With the quick start method, pills, patches, injections, implants, vaginal rings or an intrauterine device (IUD) can be started at any point in the cycle. Patients who start more than five to seven days after the first day of their last menses should use a backup method for the first week. After unprotected sex within the past five days, hormonal emergency contraception can be taken the same day; after ulipristal, patients should wait five days before starting hormonal contraception, whereas they can start immediately after levonorgestrel. The copper IUD is nearly 100% effective when inserted up to five days after unprotected sex. Spotting is common in the first months, and counseling about it may improve adherence.

Postpartum, lactation and abortion

After six weeks, postpartum patients who are not breastfeeding can take estrogen-containing pills without additional restrictions. A copper or progestin-releasing IUD can be inserted immediately after childbirth, preferably within 10 minutes of placental delivery. Lactation is up to 98% effective in the first six months if the patient remains amenorrheic and the infant receives at least 90% of calories from breast milk. Progestin-only methods show no effect on breast milk volume or composition and can be used without restriction after six weeks postpartum. Implants can be inserted on the day of an aspiration abortion or on the day mifepristone is taken.

Clinical evaluation and route

The history should cover cardiovascular risk factors, medications, allergies, smoking, hypertension and migraine. Estrogen-containing methods are contraindicated in patients at high risk of thromboembolic disease, for example with blood pressure above 160/100 mm Hg, a history of deep venous thrombosis, or age 35 years or older with smoking of at least 15 cigarettes per day. Recently assessed patients who choose a method other than an IUD or implant can start without an office visit, with counseling by telemedicine or a patient portal. Apart from blood pressure checks in patients using estrogen, no specific follow-up is needed. Because depot progestin injections leave measurable hormone levels for months, they are less suitable for unstable conditions or for patients wishing to conceive within the next year.

Frequently asked questions

Do I have to wait for my period to start the pill?

No. Most patients can start at any point in the cycle, using a backup method for the first week if starting more than five to seven days after the last menses began.

Is a Pap test or pelvic examination required first?

No. Pap testing has minimal effect on the decision, and Choosing Wisely advises against requiring a pelvic or other physical examination to prescribe oral contraceptives.

When can contraception start after giving birth?

Progestin-only methods can start immediately, and an IUD can be inserted right after delivery, preferably within 10 minutes of placental delivery.

Source

Lesnewski R. Initiating Hormonal Contraception. American Family Physician. 2021;103(5):291-300. Published by the American Academy of Family Physicians; the article updates an earlier review by Lesnewski and Prine. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.