Provision of Contraception: Key Recommendations from the CDC

DAVID A. KLEIN; JAMES J. ARNOLD; ERIKA S. REESE

DAVID A. KLEIN, MD, MPH, JAMES J. ARNOLD, DO, AND ERIKA S. REESE, MD

Am Fam Physician. 2015;91(9):625-633

Patient information: See related handout on birth control, written by the auhors of this article.

Author disclosure: No relevant financial affiliation.

The Centers for Disease Control and Prevention has released comprehensive recommendations for provision of family planning services. Contraceptive services may be addressed in five steps, and counseling may be provided in a tiered approach, whereby the most effective options are presented before less effective options. Clinicians should discuss all contraceptive methods that can be used safely by the patient, regardless of whether a method is available on site and even if the patient is an adolescent or a nulliparous woman. Physical assessment is usually limited to blood pressure evaluation before starting hormonal contraceptives or pelvic examination before placing an intrauterine device. Monitoring the patient's weight also may be helpful. If it is reasonably certain that the patient is not pregnant, any contraceptive may be started immediately. When hormonal contraceptives are selected, one year's supply should be prescribed to reduce barriers to use. Condoms should be made readily available. Documentation of visits for contraception should include patient understanding of use, benefits, and risks, plus an individualized follow-up plan. Bleeding irregularities generally are not harmful and may resolve with continued use of the contraceptive method. All patients—including adolescents; those who identify as lesbian, gay, bisexual, or transgender; and patients with disabilities or limited English proficiency—should receive high-quality care in an accommodating, nonjudgmental environment. The Centers for Disease Control and Prevention supports advance provision of emergency contraceptives. Because no test reliably verifies cessation of fertility, it is prudent to consider contraceptive use until menopause, or at least until 50 to 55 years of age.

Family physicians are uniquely suited to deliver comprehensive, unfragmented family planning services to patients of all ages.¹ With access to an increasingly robust evidence base on ways to prevent or achieve pregnancy and treat sexually transmitted infections (STIs), clinicians are challenged to offer and manage the safest and most effective options available for patients with various medical conditions, social circumstances, adherence patterns, and financial barriers to care.

Clinical recommendations	Evidence rating	References
Clinicians should consider a tiered approach to contraceptive counseling, whereby the most effective and appropriate options are presented before less effective options.	C	⁴, ^12–15
Requiring prerequisite preventive services, such as cervical cytology; breast examination; or evaluation for sexually transmitted infections, diabetes mellitus, dyslipidemia, liver disease, or thrombophilia, can introduce unnecessary barriers to contraceptive care.	C	⁴, ¹⁸, ¹⁹
If a patient's pregnancy status is uncertain, clinicians may consider same-day start of a nonintrauterine method to provide immediate coverage, and should order follow-up pregnancy testing two to four weeks later.	C	⁹, ¹⁷, ²¹, ²²
Prescription of hormonal contraceptives should preferentially cover one year's supply to decrease barriers to care.	C	⁴
Family planning services should be offered to adolescents with assurances of confidentiality, in the context of relevant law.	B	⁴, ¹⁵, ³², ^35–37
Intrauterine devices and contraceptive implants are safe and effective for postmenarchal adolescents.	B	⁴, ⁹, ¹⁵, ¹⁷, ^39–43
Estrogen-containing contraceptives should be deferred until at least three or up to six weeks postpartum, partly because of the risk of venous thromboembolism.	C	¹⁰, ⁵²
Contraceptive use for unintended pregnancy prevention should be considered until menopause, or at least until 50 to 55 years of age.	C	¹⁷, ⁵⁴

Approximately one-half of the 6.6 million pregnancies each year in the United States are unintended, and the rates are highest among young, poor, and minority women.² In 2008, women 15 to 44 years of age with incomes at or below the federal poverty level were five times more likely than women at the highest income level to become pregnant unintentionally.² Women who use contraception consistently and correctly account for only 5% of unintended pregnancies.³

To help clinicians provide optimal sexual and reproductive health services, the Centers for Disease Control and Prevention (CDC) has released comprehensive, evidence-based recommendations that have been methodically and scientifically established by technical and expert panels⁴ (eTable A). Recommendations pertaining to contraceptive management are addressed in this review. At every health care visit, clinicians should discuss family planning needs with patients of reproductive age and provide requested services as appropriate.⁴

Clinical question	Resource	Content	Website
Which services should be offered in a family planning visit?	Providing Quality Family Planning Services: Recommendations of the CDC and the U.S. Office of Population Affairs (2014)	Family planning services Achieving pregnancy Basic infertility services Contraceptive services Preconception counseling Pregnancy testing and counseling Sexually transmitted infection screening Related preventive health services Screening for breast or cervical cancer Other preventive health services Screening for lipid disorders, etc. Conducting quality improvement	http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/QFP.htm
What are the best ways to initiate and manage specific contraceptive methods?	U.S. Selected Practice Recommendations (US SPR) for Contraceptive Use, 2013 (adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, 2nd ed.)	How to be reasonably certain a woman is not pregnant Contraceptive options Examinations and tests needed Follow-up planning Managing common adverse effects Method initiation Method switching Postpartum and postabortion use When women can stop using contraceptives	http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USSPR.htm
Which contraceptive methods are safe for women with specific characteristics and medical conditions?	U.S. Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2010 (updated for use during postpartum period, and for those with, or at high risk of, human immunodeficiency virus infection)	Common contraceptive options are evaluated based on common patient characteristics and medical conditions, and are assigned a numerical value based on evidence review: 1 = A condition for which there is no restriction on the use of the contraceptive method 2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks 3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method 4 = A condition that represents an unacceptable health risk if the contraceptive method is used	http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm
What is the appropriate treatment of persons who have or are at risk of sexually transmitted infections?	Sexually Transmitted Diseases Treatment Guidelines, 2010 (updated for drug resistance patterns)	Acceptable treatment options for sexually transmitted infections are presented based on most recent treatment resistance patterns, patient drug allergies, and complicating factors	http://www.cdc.gov/std/treatment/2010/default.htm
What information is available for patients who are considering various contraceptive options?	CDC patient resource on contraception	Risks and benefits of common contraceptive options (patient resource)	http://www.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.htm

Provision of Contraception

The CDC recommends a systematic approach to contraceptive counseling and education to ensure safe, high-quality care. Figure 1 includes a summary of the five steps clinicians should take when providing contraception to patients.⁴

STEP 1: ESTABLISH RAPPORT

Family planning discussions can be inherently sensitive; therefore, establishing and maintaining rapport is critical for success.^4–8 Clinicians should ask open-ended questions; demonstrate expertise, trustworthiness, accessibility, and empathy; ensure privacy and confidentiality; explain how personal information will be used; and encourage patients to ask questions.

STEP 2: OBTAIN CLINICAL AND SOCIAL INFORMATION

Contraceptive recommendations should be personalized, focusing on the patient's safety and reproductive life plan.⁴ The interview should elicit, at minimum, menstrual, gynecologic, and obstetric history; medication allergies; infectious or chronic health conditions; and tobacco use. These may alter the patient's medical eligibility for a particular method^9,10 (eTable B).

Condition		Associated risk	Comment
Category 4: unacceptable health risk if method is used
Breast cancer		Theoretical concern for worse prognosis of disease	Category 3 if in complete remission for 5 years
Deep venous thrombosis or pulmonary embolism		Thromboembolic disease; stroke	Category 3 if no risk factors for recurrence and if condition is resolved or patient is on anticoagulation therapy for ≥ 3 months
Hypertension (systolic ≥ 160 mm Hg or diastolic ≥ 100 mm Hg)		Acute MI and stroke	—
Ischemic heart disease		Acute MI	Current or history of ischemic heart disease
Known thrombogenic mutations		Thromboembolic disease; stroke	Routine screening is not appropriate
Liver disease (severe cirrhosis; hepatoma or hepatocellular adenoma)		May affect estrogen metabolism and place additional burden on decompensated liver	—
Major surgery with prolonged immobilization		Thromboembolic disease; stroke	—
Migraine with aura		Stroke	—
Smoking, age ≥ 35 years		Cardiovascular disease including acute MI	Category 3 if age ≥ 35 years and < 15 cigarettes per day
Solid organ transplantation		Theoretical concerns for worse prognosis, cardiovascular disease, and decreased contraceptive effectiveness with immunosuppressive therapy	Only if complicated
Stroke		Recurrence or worsening of disease	Any history of cerebrovascular accident
Systemic lupus erythematosus (with antiphospholipid antibodies)		Arterial and venous thrombosis	Only if positive (or unknown) antiphospholipid antibodies
Valvular heart disease		Arterial thrombosis	Only if complicated
Vascular disease		Acute MI and stroke	Other than superficial disease
Category 3: method is theoretical or proven risks usually outweigh its advantages
Acute viral hepatitis		May affect estrogen metabolism and place additional burden on decompensated liver	Initiation of method only; category 4 if severe
Bariatric surgery		May decrease contraceptive effectiveness of oral contraceptives (not patch or ring)	Only malabsorptive procedures (e.g., Roux-en-Y gastric bypass); not restrictive procedures (e.g., gastric banding)
Diabetes with complications (or > 20 years duration)		May worsen control of diabetes, which may worsen diabetic complications	Category 4 if severe
Hypertension (systolic = 140 to 159 mm Hg or diastolic = 90 to 99 mm Hg)		Acute MI and stroke	—
Inflammatory bowel disease		Thromboembolic disease; stroke	Active or complicated disease only (treatment or sequelae may predispose patient to thromboembolism)
Medication interactions
	Lamotrigine (Lamictal) monotherapy	Seizure activity may increase	Lamotrigine levels may decrease
	Rifampicin or rifabutin (Mycobutin) therapy	Reduces contraceptive effectiveness	This interaction does not apply to most broad-spectrum antibiotics, antifungals, and antiparasitics
	Specific anticonvulsants (e.g., topiramate [Topamax], phenytoin [Dilantin])	Reduces contraceptive effectiveness	Consider other contraceptive options and ethinyl estradiol dose of at least 30 mcg
	Specific antiretrovirals	Reduces contraceptive effectiveness	Recommend condom use and ethinyl estradiol dose of at least 30 mcg
Migraine without aura and age ≥ 35 years		Stroke	Age < 35 years, if migraine without aura develops during method use

Knowing the patient's contraceptive experience and intentions regarding pregnancy is useful. A sexual health assessment—including practices, partners, STI status, condom use, and recent intercourse—may aid in selecting and safely initiating appropriate contraception.⁴

STEP 3: WORK INTERACTIVELY TO HELP THE PATIENT SELECT THE MOST EFFECTIVE AND APPROPRIATE METHOD

Clinicians should discuss all available contraceptive methods that the patient can use safely, regardless of which are available on site.^4,11 The CDC encourages a tiered approach to counseling, whereby the most effective and medically appropriate options are presented before less effective options^4,12–15 (eFigure A).

Other factors that may be important to the patient should be considered, such as her ability to use the method correctly and consistently, and possible adverse effects.⁴ Information on noncontraceptive benefits of various methods, such as a potential reduction in dysmenorrhea, abnormal uterine bleeding, or acne, may help patients select and adhere to medication regimens.⁴ For patients with or at risk of an STI, dual-method contraception, which combines condoms and another method, should be discussed.^4,16

Medication adherence concerns apply to patients with substance use, mental illness, difficulties with medication regimens, and sociobehavioral factors.⁴ For example, if intimate partner violence is suspected, in addition to providing appropriate safety referrals (e.g., to law enforcement and violence support groups), clinicians may offer long-acting reversible contraception to decrease barriers to contraception adherence.⁴

STEP 4: CONDUCT PHYSICAL ASSESSMENT

Clinicians should determine the patient's pregnancy status before initiating a contraceptive method; conduct a blood pressure evaluation before prescribing hormonal contraception; and perform a bimanual examination and cervical inspection before inserting an intrauterine device (IUD) or fitting a cervical cap.^4,17 A bimanual examination is needed before diaphragm fitting.^4,17 In patients with cervicitis or pelvic inflammatory disease, IUD placement should be deferred until appropriate treatment has occurred.^4,9,17

Requiring other preventive services (e.g., cervical cytology; breast examination; evaluation for STI, diabetes mellitus, dyslipidemia, liver disease, thrombophilia) can introduce barriers to contraceptive care; therefore, such services should be offered as optional adjuncts and not as prerequisites.^4,18,19 Testing for STIs can be performed at the time of IUD placement in asymptomatic patients, and should be performed if routine screening has not occurred according to CDC guidelines.

Monitoring weight may be useful, although weight does not preclude eligibility for any contraceptive method.^4,9,17 A recent Cochrane review suggested that mean weight gain from progestin-only methods was less than 2 kg (4.4 lb) at 12-month follow-up.²⁰

STEP 5: INITIATE METHOD AND ESTABLISH PLAN

If it is reasonably certain that a patient is not pregnant (Table 1^4,17,21–24) and that she meets appropriate medical eligibility criteria, any contraceptive may be started immediately.^4,9,10,17 If pregnancy status is uncertain, clinicians may consider same-day start of a nonintrauterine method to provide immediate coverage, and then order follow-up pregnancy testing two to four weeks later.^9,17,21,22

A negative pregnancy test result is insufficient for definitively ruling out pregnancy because results can be affected by test characteristics, the time since most recent intercourse, and recent pregnancy. It may help confirm that pregnancy is unlikely in patients who meet the criteria in Table 1^4,17,21–24; accordingly, pregnancy testing is not universally required before initiating contraception.^17,23,24

To reduce barriers to care when prescribing combined contraceptives, the prescription for hormonal contraceptives should cover one year's supply, and condoms should be made readily available.^4,17 If requested contraceptive services are unavailable, a temporary method should be established until the patient can be referred for further assessment.⁴ Recommendations for backup contraception during method initiation and switching are provided in Table 2.¹⁷

	Backup method
Contraceptive method	Initiation*	Method switching
Copper-containing IUD	None needed	None needed
Levonorgestrel-containing IUD	7 days; only needed if > 7 days after starting menses	7 days; only needed if > 7 days after starting menses†
Implant	7 days; only needed if > 5 days after starting menses	7 days; only needed if > 5 days after starting menses‡
Injectable	7 days; only needed if > 7 days after starting menses	7 days; only needed if > 7 days after starting menses‡
Combined hormonal contraceptives	7 days; only needed if > 5 days after starting menses	7 days; only needed if > 5 days after starting menses‡
Progestin-only pill	2 days; only needed if > 5 days after starting menses	2 days; only needed if > 5 days after starting menses‡

Clinicians should reserve adequate time to counsel patients, particularly on common adverse effects (e.g., abnormal uterine bleeding, weight gain), to help reduce inconsistent use or early method discontinuation.^{4,17,20,25,26} Educational resources are presented in eTable A. Concern about forgetfulness may be mitigated by reminder systems (e.g., smartphone applications) or use of long-acting reversible contraception.^4,17,26

Documentation should include the patient's understanding of use, benefits, and risks, plus an individualized follow-up plan.^4,26 The teach-back method, in which the patient is asked to repeat important points, may be helpful.⁴

Follow-Up Considerations

Patients should be advised to return at any time to discuss questions or concerns about contraceptive method use, but for most women, routine follow-up visits are not required.¹⁷ When patients present for other routine visits, clinicians should assess for satisfaction and concerns, changes in health status or medication use that might affect eligibility for continued use, and changes in blood pressure (if using a combined hormonal method).^4,17 Patients who use methods inconsistently or incorrectly, or who experience vomiting or severe diarrhea (i.e., affecting absorption), should be counseled on appropriate backup contraception (Table 3¹⁷ ).

Contraceptive method	Duration since last dose or use	Recommendation	Transition to next cycle	Backup method	Emergency method
Combined oral contraceptives	< 48 hours and only one missed pill	Take the missed pill as soon as possible; this is not needed in cases of vomiting or diarrhea	Take the remaining pills at the usual time each day (this may require taking two pills on the first day)	None	Not usually needed*
	≥ 48 hours and two or more missed pills	Take the most recent missed pill as soon as possible In cases of vomiting or severe diarrhea, take the next pill as soon as tolerated Other missed pills should be discarded	Take the remaining pills at the usual time each day (this may require taking two pills on the first day)†	7 consecutive days (without vomiting or severe diarrhea)	If appropriate‡
Progestin-only pill	> 3 hours past recommended dose (i.e., > 27 total hours since previous dose), or vomiting or diarrhea within 3 hours of dose	Take one pill as soon as possible	Take the remaining pills at the usual time each day (this may require taking two pills on the first day)	2 consecutive days (without vomiting or severe diarrhea)	Consider if recent unprotected intercourse
Combined hormonal patch (delayed application or detachment)	< 48 hours	Apply a new patch as soon as possible	Keep the same patch-change day	None	Not usually needed*
	≥ 48 hours	Apply a new patch as soon as possible	Keep the same patch-change day†	7 consecutive days	If appropriate‡
Combined vaginal ring (delayed insertion of a new ring or reinsertion of a current ring)	< 48 hours	Insert ring as soon as possible	Keep the ring in until scheduled removal day	None	Not usually needed*
	≥ 48 hours	Insert ring as soon as possible	Keep the ring in until scheduled removal day†	7 consecutive days	If appropriate‡
Injectables (i.e., depot medroxy-progesteroneacetate [Depo-Provera])	< 2 weeks late (< 15 weeks after previous injection)	Proceed with injection	Not applicable	None	None
	≥ 2 weeks late	Treat as new start	Not applicable	7 consecutive days	Consider use

Irregular bleeding with contraceptives is generally not harmful, and may decrease with continued method use.^17,27 Other reasons for bleeding may be considered, including inconsistent use, medication interactions, infection, pregnancy, and pathologic uterine conditions.^17,27 If patients request treatment for bleeding, five to seven days of nonsteroidal anti-inflammatory drugs may be offered to those using the copper-containing IUD (Paragard), etonogestrel implant (Nexplanon), or depot medroxyprogesterone acetate (Depo-Provera). Alternatively, patients who use an implant or depot medroxyprogesterone acetate may benefit from low-dose combined oral contraceptives or estrogen for 10 to 20 days.¹⁷ Bleeding with the levonorgestrel-containing IUD (Mirena) tends to resolve in three to six months without treatment.¹⁷ Patients who use combined hormonal methods without hormone-free intervals (e.g., continuous use) may skip contraceptive pills for three to four consecutive days to temporarily induce bleeding and endometrial thinning, although not more often than monthly or before the first 21 days of use.¹⁷

If irregular bleeding persists and is unacceptable to the patient, the clinician should assist with choosing another contraceptive method.^17,27 Women who use intrauterine contraception and who are diagnosed with pelvic inflammatory disease should be treated according to the CDC's STI treatment guidelines; however, the clinician may leave the device in place for two to three days and then reassess the patient for disposition.^17,28 If the device is removed, emergency contraception should be offered if residual sperm are potentially present.

Special Populations

Clinicians should ensure that all patients—including special populations, such as those who have disabilities or limited English proficiency, or who identify as lesbian, gay, bisexual, or transgender—receive high-quality care in a nonjudgmental, accommodating environment. Sexual behaviors and pregnancy risk should not be assumed.^4,15,29–31

When evaluating males, clinicians should remember to ascertain the patient's sexual health care needs, including contraceptive, preconception, and STI services.⁴ Condoms should be made available without additional evaluation, and the principles of the five contraceptive care steps should be applied.⁴

Adolescents should be given the opportunity to privately discuss their family planning needs and to subsequently receive care in the context of relevant law.^4,15,32–34 Without assurances of confidentiality, adolescents are significantly less likely to use family planning services; however, parent-patient communication about sexual and reproductive health may be encouraged to foster support, access to services, contraceptive use, and healthy development.^4,15,34–38 Some adolescents may initially prefer to limit patient-parent discussion to the noncontraceptive uses of hormonal methods.

IUDs and implants are safe and effective for postmenarcheal adolescents,^{4,9,17,39–41} and may be considered first-line options regardless of parity.^15,42,43 Of 1,099 patients 14 to 19 years of age in the Contraceptive CHOICE Project, a large prospective contraception study, more than 80% of long-acting reversible contraceptive users continued their method over 12 months vs. only one-half of those using short-acting methods.⁴⁴

Emergency Contraception

Emergency contraceptives have been reviewed in American Family Physician, including oral methods and the copper-containing IUD received within five days of unprotected intercourse to reduce unintended pregnancy risk.⁴⁵ Notably, the CDC highlights that ulipristal (Ella) may be more effective than levonorgestrel formulations after the first 72 hours and for women who are overweight or obese.^17,46,47 The CDC also supports advance provision of emergency contraceptive pills.^17,48

Any contraceptive method may be started after completion of emergency contraceptive pills. The patient should use a barrier method or abstain from intercourse for seven days (14 days after ulipristal use), and should take a pregnancy test if she does not experience withdrawal bleeding within three weeks.¹⁷ Patients who vomit within three hours after using emergency contraceptive pills should take another dose, at which point an antiemetic may be offered.¹⁷ As of 2013, Plan B One-Step is available over the counter to patients of any age.⁴⁹

Postpregnancy Contraceptive Options

Clinicians should emphasize postpregnancy contraception counseling. Almost one-half of abortions are repeat abortions, and nearly one in five births to teenagers is a repeat birth.^50,51 The CDC specifies time frames for postpregnancy contraception (Table 4).^9,10,17 Estrogen-containing methods should be deferred until at least three or up to six weeks postpartum, partly because of the risk of venous thromboembolism.^10,52 Progestin-only methods can be safely started immediately postpartum.¹⁰

Category		Combined hormonal pill, patch, or vaginal ring	Progestin-only pill	Depot medroxy-progesterone acetate (Depo-Provera)	Etonogestrel implant (Nexplanon)	Levonorgestrel IUD (Mirena)*	Copper IUD (Paragard)*
Postpartum, nonbreastfeeding women
< 21 days		4	1	1	1	2	2†
21 to 29 days
	With other risk factors for VTE‡	3	1	1	1	2	2
	Without other risk factors for VTE	2	1	1	1	2	2
30 to 42 days
	With other risk factors for VTE‡	3	1	1	1	1	1
	Without other risk factors for VTE	2	1	1	1	1	1
> 42 days		1	1	1	1	1	1
Postpartum, breastfeeding women
< 21 days		4	2	2	2	2	2†
21 to 29 days
	With other risk factors for VTE‡	3	2	2	2	2	2
	Without other risk factors for VTE	3	2	2	2	2	2
30 to 42 days
	With other risk factors for VTE‡	3	1	1	1	1	1
	Without other risk factors for VTE	2	1	1	1	1	1
> 42 days		2	1	1	1	1	1
Postabortion, spontaneous or induced		1	1	1	1	1§	1§

Contraception in Women Approaching Menopause

In the United States, the median age of menopause is 51 years, but the normal range is from 40 to 60 years.^53,54 Because there is no reliable test to verify permanent cessation of fertility, it is prudent to consider contraceptive use to prevent unintended pregnancy until menopause, or at least until 50 to 55 years of age.^17,54

All contraceptive methods are considered U.S. Medical Eligibility Criteria category 1 or 2 (i.e., no restriction, or advantages generally outweigh theoretical or proven risks, respectively) based on the patient's age alone. However, clinicians must balance risks of pregnancy at advanced maternal age against risks of contraceptives—particularly those containing estrogen, which may precipitate acute cardiovascular and thromboembolic events.^9,17 Patients should be screened for preexisting conditions that affect medical eligibility criteria.^9,17

Sterilization

Several permanent sterilization options are available in the United States, including abdominal, laparoscopic, or hysteroscopic tubal ligation for women and vasectomy for men^17,55–57 (eTable C). Patients should be counseled about the intended irreversibility of these procedures and the availability of long-acting reversible contraception.^9,17

Method	Annual failure rates (after proper follow-up)	Sterility onset	Additional contraception
Abdominal tubal ligation	1 in 100 to 200	Immediately	None
Laparoscopic tubal ligation	1 in 100 to 200	Immediately	None
Hysteroscopic tubal ligation (coil placement)	1 in 100 to 200 (possibly less once confirmed by hysterosalpingography)	Three to four months	Alternative method advised until confirmatory hysterosalpingography performed three months after procedure
Male vasectomy	1 in 100 overall	Two to four months	Alternative method until confirmatory semen analysis showing azoospermia (or rare, nonmotile sperm) eight to 16 weeks after procedure
	1 in 2,000 with confirmed azoospermia

Data Sources: A PubMed search was completed using the MeSH function with the key phrase contraception combined with at least one of the following terms: effectiveness, safety, recommendations, guidelines, adolescent, female, or male. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were Essential Evidence Plus, the Cochrane Database of Systematic Reviews, and the U.S. Preventive Services Task Force website. The references of the relevant CDC resources were reviewed, as were the references from the systematic reviews generated to create the highlighted CDC resources. Search dates: May 1 to July 1, 2014, and November 23, 2014.

The authors thank Ms. Margaret Freiberg for her editorial assistance.

The opinions and assertions contained herein are the personal views of the authors and are not to be construed as official or as reflecting the views of the U.S. armed services or any of their medical departments.

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A clinician can be reasonably certain that a woman is not pregnant if:
	(1) The patient has no signs or symptoms of pregnancy
		and
	(2) The patient meets at least one of the following:
		Is seven days or less after start of her normal menses
		Has not had intercourse since the start of her last normal menses
		Has been correctly and consistently using a reliable method of contraception
		Is seven days or less after a spontaneous or induced abortion
		Is within four weeks postpartum
		Is fully or nearly fully breastfeeding (exclusively breastfeeding or most feeds [≥ 85%] are breastfeeds), amenorrheic, and less than six months postpartum