CLINICAL ACTIONS

Combined hormonal contraceptives contain both estrogen and a progestin. This contraceptive category includes combined oral contraceptives, transdermal patches and vaginal rings. They are effective when taken as directed, reversible and can be used by women of all ages.  It is important to alert women that they will not protect against STDs and other preventative measures will be required to protect against infections.  The following assumes there are no contraindications to estrogen component (e.g., breast cancer, hyperlipidemia, liver disease etc.). Only BP is “essential and mandatory” and when BP cannot be measured by a provider, a measurement obtained in other setting can be reported by the woman to her provider. The following are highlights from the CDC recommendations on initiation:  

Initiation – Criteria and Timing

Obesity

Patient with Amenorrhea (Not Postpartum)

Postpartum (Breastfeeding)

Postpartum (Not Breastfeeding)

Postabortion (Spontaneous or Induced)

Need for Follow-up

Switching from Another Contraceptive Method

Switching from an IUD

VTE WARNING Category 3 or 4

Initiation – Criteria and Timing  

CDC Criteria to determine with ‘reasonable certainty’ that woman is not pregnant (≥1 of the following)  

• ≤7 days after the start of normal menses 
• No sexual intercourse since the start of last normal menses 
• Correctly and consistently using a reliable method of contraception 
• ≤7 days after spontaneous or induced abortion 
• Within 4 weeks postpartum 
• Fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds), amenorrheic, and <6 months postpartum  

Timing  

• Start at any time if ‘reasonably certain’ not pregnant criteria are met  

Back-Up Contraception 

• If combined hormonal contraception begun within the first 5 days since menstrual bleeding started 
  • No additional contraceptive protection is needed 
• If combined hormonal contraception started >5 days since menstrual bleeding started 
  • Abstain from sexual intercourse or  
  • Use additional contraceptive protection for the next 7 days 

Obesity

• Combined hormonal contraceptives are a category MEC 2 and therefore can be prescribe to women regardless of BMI
• Obesity is a risk factor for VTE, but lower than risk from pregnancy

Patient with Amenorrhea (Not Postpartum) 

• Timing 
  • Start at any time if ‘reasonably certain’ not pregnant criteria  
• Back-up contraception 
  • Abstain from sexual intercourse or  
  • Use additional contraceptive protection for the next 7 days 

Postpartum (Breastfeeding) 

• Timing 
  • Start when the woman is medically eligible (MEC guidance) and meets ‘reasonably certain’ not pregnant criteria  
• US MEC postpartum guidance (combined hormonal contraceptives)  
  • Avoid combined hormonal contraceptives during the first 3 weeks (risk of VTE)  
  • Avoid combined hormonal contraceptives during the first 4 weeks (concerns regarding breastfeeding performance)  
  • Caution: Women who are postpartum with additional risk factors for VTE should not use combined hormonal contraceptives 4–6 weeks after delivery (please see ‘Primary Sources’ and ‘Related ObG Topics below for further guidance on medical eligibility)
• Back-up contraception  
  • <6 months postpartum, amenorrheic, and fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds)  
    • no back-up needed 
  • If not in the above category, and patient is ≥21 days postpartum and has not experienced return of her menstrual cycle  
    • Abstain from sexual intercourse or  
    • Use additional contraceptive protection for the next 7 days 
  • Menstrual cycles have returned and >5 days since menstrual bleeding started 
    • Abstain from sexual intercourse or  
    • Use additional contraceptive protection for the next 7 days 

Postpartum (Not Breastfeeding)

• Timing 
  • Start when the woman is medically eligible (MEC guidance) and meets ‘reasonably certain’ not pregnant criteria  
• US MEC postpartum guidance (combined hormonal contraceptives)  
  • Avoid combined hormonal contraceptives during the first 3 weeks (risk of VTE)  
  • Caution: Women who are postpartum with additional risk factors for VTE should not use combined hormonal contraceptives 4–6 weeks after delivery (Please see ‘Primary Sources’ and ‘Related ObG Topics’ for further guidance on medical eligibility)
• Back-up contraception 
  • <21 days postpartum 
    • No additional contraceptive protection needed
  • ≥21 days postpartum and whose menstrual cycles have not returned  
    • Abstain from sexual intercourse or  
    • Use additional contraceptive protection for the next 7 days 
  • Menstrual cycles have returned and it has been >5 days since menstrual bleeding started 
    • Abstain from sexual intercourse or  
    • Use additional contraceptive protection for the next 7 days 

Postabortion (Spontaneous or Induced) 

• Timing: 
  • Start combined hormonal contraception within the first 7 days following first-trimester or second-trimester abortion, including immediately postabortion  
• Back-up contraception
  • If combined hormonal contraception not started at time of surgical abortion  
    • Abstain from sexual intercourse or  
    • Use additional contraceptive protection for the next 7 days

SYNOPSIS:

There may be times there is uncertainty whether a woman is pregnant. According to the CDC, “the benefits of starting combined hormonal contraceptives likely exceed any risk; therefore, starting combined hormonal contraceptives should be considered at any time, with a follow-up pregnancy test in 2–4 weeks.” In a situation where a woman needs to use additional contraceptive protection when making the switch to combined hormonal contraception, consider continuing previous contraceptive methods for 7 days after starting combined hormonal contraception

KEY POINTS

Need for Routine Follow-Up

• The CDC states that if a patient is otherwise healthy,  “No routine follow-up visit is required”
• Women should be advised to return at any time to discuss
  • Side effects | Desire to change contraceptive method | Any other issues or concerns
• At other routine visits, assess
  • Patient satisfaction | Concerns
  • Change in health status and medications that may impact use of combined hormonal contraceptives (e.g., move to MEC category 3 and 4 conditions)
  • Blood pressure
  • Weight changes, including if patients are concerned regarding perceived changes

Switching from Another Contraceptive Method 

• Timing 
  • Start at any time if ‘reasonably certain’ not pregnant criteria are met  
  • Waiting for her next menstrual cycle is unnecessary
• Back-up contraception  
  • If combined hormonal contraception started >5 days since menstrual bleeding started 
    • Abstain from sexual intercourse or  
    • Use additional contraceptive protection for the next 7 days 

Switching from an IUD

• If the woman has had sexual intercourse since the start of her current menstrual cycle and it is >5 days since menstrual bleeding started, consider any of the following  
  • Retain the IUD for at least 7 days after combined hormonal contraception initiated and return for IUD removal or  
  • Abstain from sexual intercourse or use barrier contraception for 7 days before removing the IUD and switching 
• If cannot return for IUD removal and has not abstained from sexual intercourse or used barrier contraception for 7 days 
  • Use emergency contraceptive pills at the time of IUD removal 
  • Combined hormonal contraceptives can be started immediately after use of emergency contraceptive pills (except for ulipristal acetate) 
  • Ulipristal acetate: Combined hormonal contraceptives can be started no sooner than 5 days after use  
• Note: The CDC considers IUDs separately because in theory, if a woman has had sexual intercourse and it is >5 days from the time of her period, residual sperm could still potentially be active with a risk for fertilization

VTE WARNING Category 3 or 4 (risk outweigh benefits or unacceptable risk)

The following factors elevate risk of VTE sufficiently to classify as 3 or 4 and alternate methods should be used

• Smoking ≥35 years of age
• Postpartum <21 days
• Postpartum 21-42 days with additional risk factors
  • ≥35 years of age | Previous VTE | Thrombophilia | Immobility | Transfusion at delivery | Peripartum Cardiomyopathy | BMI ≥30 | PPH | Postcesarean delivery | preeclampsia | smoking
• Major surgery with immobilization
• History of DVT or PE
• Hereditary thrombophilia including antiphospholipid syndrome
• Inflammatory Bowel Disease with
  • Active or extensive disease | Surgery | Immobilization | Steroid use | Vitamin deficiencies | Fluid depletion
• SLE with positive or unknown antiphospholipid antibodies
• Superficial DVT (acute or history)

Learn More – Primary Sources:

CDC: U.S. Selected Practice Recommendations for Contraceptive Use, 2016

CDC MEC: Classifications for Combined Hormonal Contraceptives

ACOG Practice Bulletin 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions

CDC: Effectiveness of Family Planning Methods

Related ObG Topics:

Hormonal Contraception Benefits – Beyond Pregnancy Prevention

Emergency Contraception: What, When and How?

ACOG & SMFM Guidance on the Use of IUDs and Contraceptive Implants

IUDs and Implants: How to Manage Potential LARC Complications

CDC Guidance: Contraception in Women with Medical Conditions

No Restrictions: ACOG Supports Over-the-Counter Access to Hormonal Contraception