Lesson
Person-Centered Selection and U.S. MEC
Contraceptive selection begins with the patient's goals, then uses medical eligibility to identify safe options without coercion.
- Reproductive autonomy
- U.S. MEC
- Effectiveness
- Bleeding preferences
- STI prevention
Ask what the patient wants from the method
Remove options with unacceptable risk
Support the patient's preference among safe methods
Start with the person
Ask about pregnancy goals, desired duration, control, privacy, bleeding, sexual health, prior experiences, daily tasks, procedures, cost, and tolerance for uncertainty. Effectiveness is one attribute, not the only value.
Read U.S. MEC correctly
Category 1 means no restriction, 2 means advantages generally outweigh risk, 3 means risks usually outweigh advantages, and 4 means unacceptable risk. Categories apply to a specific condition and method.
Add STI prevention
IUDs, implants, pills, patches, rings, and injections do not prevent STIs. Offer condoms and appropriate testing, vaccination, doxycycline postexposure prophylaxis or PrEP assessment when clinically relevant.
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Nonhormonal Methods and Real-World Effectiveness
Methods used around intercourse depend on correct timing and repeated use. Compare their practical demands alongside pregnancy prevention, STI protection and patient preference.
- Typical use
- Condoms
- Diaphragm
- Vaginal pH gel
- Fertility awareness
Check timing and repeat-use instructions
Barrier placement and method adherence matter
Consider emergency contraception and STI assessment when appropriate
Interpret effectiveness
Typical-use estimates describe pregnancies during a year of actual use, including use errors; they are not the chance from one act. CDC estimates about seven pregnancies per 100 pill, patch or ring users and four per 100 injection users per year. IUD and implant estimates are below one per 100. These averages support discussion rather than dictate the patient's choice.
Separate condom outcomes
External latex condoms reduce STI risk when used consistently and correctly; natural-membrane condoms are not reliable STI protection. Evidence for internal condoms is more limited, so do not claim they prevent infection better than external condoms. Neither a diaphragm nor spermicide replaces STI prevention.
Choose compatible lubrication
Use a new condom for each act, put it on before sexual contact and hold its base during withdrawal. Water- or silicone-based lubricant is compatible with latex; oil-based products can weaken latex. For other materials, follow the specific product instructions. A compatible lubricant does not replace contraception or STI prevention.
Recognize spermicide limitations
Nonoxynol-9 does not add STI protection. It can irritate genital tissue, and use has been associated with increased HIV and urinary infection risk. Do not recommend it to prevent HIV; choose appropriate contraception and a separate STI prevention plan.
Use a diaphragm correctly
For Caya, check that the diaphragm covers the cervix and use compatible contraceptive gel. Its U.S. instructions specify about 4 mL before insertion; the 2021 instructions explicitly call for additional gel without removal for repeat intercourse or insertion more than two hours before sex. Retain it for at least six hours after the last intercourse and never exceed 24 hours of continuous wear. Check the supplied device and gel instructions together.
Distinguish a cervical cap
A cervical cap covers the cervix and requires correct sizing, placement and compatible spermicide. For FemCap, retain it at least six hours after intercourse and do not exceed 48 hours of continuous wear. Do not use it during menses. Its timing differs from Caya and the sponge; follow the supplied device instructions, including repeat intercourse, rather than transferring another barrier's rules. It does not prevent STIs.
Care for the diaphragm
Wash Caya with soap and water, rinse, dry and inspect for damage. Replace it after two years or sooner if damaged. Use water-based gel rather than silicone-oil lubricant, which can damage the device. Recurrent urinary infections, previous toxic shock syndrome or difficulty with fit warrant clinical review; do not use it within six weeks after birth.
Distinguish sponge instructions
The labeled Today sponge regimen requires wetting and gently squeezing it until sudsy before placement over the cervix. It permits repeated intercourse during 24 hours, then requires at least six hours after the last intercourse before removal, with a maximum of 30 hours total wear. Discard after use. These limits differ from Caya's.
Recognize sponge safety limits
The sponge contains nonoxynol-9 and does not protect against STIs. Its label excludes use during menses, within six weeks after birth, after prior toxic shock syndrome, or with relevant product allergies. Fever, a sunburn-like rash, dizziness or vomiting during use can signal toxic shock syndrome: remove it and seek urgent care. A label listing does not establish current retail availability.
Distinguish vaginal pH gel
Phexxi uses one 5 g applicator immediately before or up to one hour before each act of vaginal intercourse, including repeat intercourse within the same hour. It is not emergency contraception. Avoid use with vaginal rings or a history of recurrent UTI or urinary tract abnormalities. Burning, irritation or urinary symptoms need assessment.
Discuss permanent methods
Tubal surgery and vasectomy require an informed choice about intended permanence and reversible alternatives. Vasectomy is not immediately reliable: continue another contraceptive method or abstain until postvasectomy semen analysis confirms success. CDC recommends testing at 8 to 16 weeks; elapsed time or a count of ejaculations alone is insufficient. Neither procedure protects against STIs.
Distinguish contraceptive software
Natural Cycles received FDA authorization as contraceptive software for adults 18 and older; this does not validate every cycle-tracking app. Follow its current instructions and use protection or abstain on fertile days. A low-risk prediction is not a guarantee, and a method with possible pregnancy failure may be unsuitable when pregnancy poses serious medical risk.
Plan behavior-based methods
Fertility-awareness methods require a defined tracking method and avoiding unprotected intercourse during potentially fertile days. Failure rates vary; a cycle app is not automatically a validated contraceptive. Lactational amenorrhea requires all three conditions: no menses, fully or nearly fully breastfeeding, and less than six months postpartum.
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Lesson
Combined Pills, Patches, and Rings
Combined hormonal methods share estrogen and progestin pharmacology but differ in schedule, exposure, adherence demands, and product instructions.
- Ethinyl estradiol
- Progestin
- Ovulation suppression
- Patch
- Vaginal ring
Reduce FSH-driven follicular development
Prevent ovulation and sperm passage
Match schedule and product instructions to real use
Suppress the reproductive axis
Estrogen and progestin feedback suppress follicular development and the LH surge. Progestin also thickens cervical mucus and changes the endometrium. These methods prevent pregnancy before implantation.
Compare delivery systems
Pills require daily use. Patches and rings extend the user-action interval but have product-specific replacement, hormone-free, detachment, and delayed-use instructions.
Distinguish pill packs
Monophasic pills maintain one active-dose combination; multiphasic pills change doses across the active sequence. Placebo tablets, low-dose estrogen tablets and iron-containing inactive tablets are not equivalent. Read the ingredient sequence before extending a regimen or correcting missed tablets.
Read a short-cycle pack
Lo Loestrin Fe has 24 tablets containing norethindrone acetate 1 mg plus ethinyl estradiol 10 mcg, then two estrogen-only 10 mcg tablets, then two nonhormonal iron tablets. Those last four tablets are not all placebo. The iron tablets are reminders, not an anemia-treatment course.
Compare extended and multiphasic schedules
Seasonique uses 84 combined levonorgestrel/ethinyl estradiol tablets followed by seven estrogen-only tablets: 91 days total, with no placebo week. Natazia uses four active dose phases over 26 days, then two inert tablets. Continuous regimens omit a scheduled hormone-free interval. Neither pack color nor the word extended establishes the ingredients; follow the actual sequence.
Apply patch-specific limits
Xulane and Twirla use one patch weekly for three weeks, then one patch-free week. Both U.S. labels contraindicate BMI at least 30 kg/m2. Xulane may be less effective at 90 kg or more; Twirla has reduced effectiveness at BMI 25 to below 30. These product limits are not the same as the general MEC obesity category.
Apply the correct patch
Use clean, dry, intact skin without lotions or oils. Xulane sites include upper outer arm, abdomen, buttock or back; Twirla uses abdomen, buttock or upper torso, excluding breasts. Do not assume the arm is a Twirla site. Wear one patch, do not cut it, and replace a patch that will not adhere rather than securing it with tape.
Distinguish detachment from late replacement
Xulane and Twirla labeling treats detachment for at least 24 hours, or an unknown duration, as a reason to apply a new patch, start a new cycle/change day and use seven days of backup. Twirla's table separately uses a 48-hour boundary for a late week-two or week-three patch change. Missing the first patch of a new cycle requires its own start-over plan.
Name the patch guidance
CDC's patch algorithm uses 48 hours for delayed application or detachment: below that, apply promptly and keep the change day without backup; at least 48 hours requires seven days of backup. It keeps the usual change day and omits a third-week hormone-free interval; first-week errors with intercourse in the previous five days warrant EC assessment. These instructions differ from labeling. Use one explicit plan, including the source, exact timing and recent intercourse.
Separate common effects from warning signs
Nausea, breast tenderness, spotting and headache can occur with combined pills and often improve. Persistent symptoms or major mood changes need review; do not promise weight loss from a drospirenone product.
Check combined drospirenone separately
Yaz contains estrogen, unlike Slynd. It may carry greater VTE risk than levonorgestrel combined pills. Renal or hepatic impairment and adrenal insufficiency contraindicate Yaz. Long-term potassium-raising medicines require potassium testing during its first cycle.
Escalate urgent symptoms
Sudden breathlessness, chest pain, vision loss, severe unusual headache, focal weakness or speech difficulty need emergency assessment. Severe abdominal pain or tenderness also requires immediate assessment. Persistent leg pain or jaundice needs prompt evaluation. Do not dismiss these as routine adjustment effects.
Manage extended-regimen spotting
Spotting often occurs during the first three to six months of extended or continuous CHC use. Check adherence, interactions and other causes when indicated. If treatment is wanted, CDC permits a three- to four-day hormone-free interval after at least 21 days of use, no more than once monthly. Do not automatically increase estrogen or interrupt hormones whenever spotting occurs.
Use the regimen purposefully
Cyclic and extended regimens can be effective. Scheduled bleeding is withdrawal bleeding and is not medically required for every user. Selection should consider adherence, bleeding preference, and estrogen eligibility.
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Vaginal Rings: Product Instructions
A monthly etonogestrel ring and a reusable segesterone ring need different instructions for replacement, storage and interruptions.
- NuvaRing
- Annovera
- Reuse
- Storage
- Dosing errors
Labeled schedule: 21 days in, seven days out
Each cycle: 21 days in, seven days out
Annovera counts cumulative time out; identify label versus CDC instructions
Separate the schedules
NuvaRing contains etonogestrel/ethinyl estradiol: insert for 21 days, remove for seven, then use a new ring. Annovera contains segesterone acetate/ethinyl estradiol: reuse the same system for 13 cycles, each with 21 days in and seven days out. Neither is left in continuously for a year under its labeled regimen.
Store the correct product
Before dispensing, refrigerate NuvaRing at 2 to 8°C. After dispensing, its room-temperature limit is four months or the labeled expiration, whichever comes first; protect from heat and sunlight. Annovera is stored at room temperature, not refrigerated or frozen. Wash, rinse and dry it at removal and before reinsertion; use its case during the scheduled break. Avoid oil- or silicone-based vaginal lubricants with Annovera.
Apply NuvaRing labeling
If expelled for less than three hours, rinse and reinsert promptly. More than three continuous hours in weeks one or two requires reinsertion and seven days of backup. In week three, discard it and follow the label's new-ring options; immediate new-ring insertion avoids extending the break, with seven days of backup.
Handle prolonged NuvaRing wear
Under its label, continuous wear beyond three but no more than four weeks retains protection: remove it, then insert a new ring after a one-week break. Beyond four weeks, remove it and exclude pregnancy before restarting; use backup until the new ring has been worn continuously for seven days. This is different from leaving the ring out too long.
Apply Annovera labeling
More than two cumulative hours outside the vagina during the 21-day use interval requires backup until it has been back in place for seven consecutive days. Count repeated removals together; do not reset the clock after each reinsertion.
Recognize guideline and label differences
CDC's etonogestrel/ethinyl estradiol ring algorithm uses a 48-hour threshold for delayed placement or replacement, rather than the label's three-hour expulsion threshold. At 48 hours or more, replace promptly, use seven days of backup, omit a third-week break and assess emergency contraception for first-week errors with recent intercourse. These CDC instructions do not apply to Annovera; use its label. Give one explicit, coordinated plan rather than mixing thresholds.
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Combined-Method Eligibility and Vascular Risk
Estrogen eligibility depends on the interaction between vascular, neurologic, postpartum, cancer, and medication risks, not on age alone.
- Blood pressure
- Smoking
- Migraine aura
- VTE
- Postpartum risk
Quantify current cardiovascular risk
Separate ordinary headache from focal neurologic aura
Avoid category 4 and carefully evaluate category 3
Assess before prescribing
Measure blood pressure and review smoking, migraine subtype, thrombosis, thrombophilia, cardiovascular disease, postpartum status, breast cancer, liver disease, diabetes complications, and interacting medications.
Recognize category 4 patterns
Migraine with aura and several high-risk thrombotic patterns make combined methods unacceptable. Smoking 15 or more cigarettes daily at age 35 or older is category 4, while fewer cigarettes at that age is category 3.
Use precise risk categories
For combined methods, properly measured blood pressure of at least 160 systolic or 100 diastolic is category 4; controlled hypertension, systolic 140 to 159 or diastolic 90 to 99 is category 3. One reading alone does not diagnose hypertension. Current breast cancer makes hormonal methods category 4, while copper IUD eligibility is category 1 for that condition. Ovarian cancer alone is not the same contraindication; review treatment, thrombosis and other conditions separately.
Do not equate all progestin methods
Thrombophilia, including antiphospholipid syndrome, places DMPA in category 3, compared with category 2 for implants, POPs and LNG IUDs; copper is category 1. With prior DVT/PE, anticoagulation intensity and recurrence risk change the classification. A low estrogen dose does not remove vascular risk.
Assess postpartum timing
Combined methods are category 4 before 21 days postpartum. Later eligibility depends on breastfeeding, days since delivery and additional VTE risks. Progestin-only pills can start immediately postpartum when eligible; a blanket three- to six-week delay is unnecessary.
Reassess changing health
New focal neurologic symptoms, severe hypertension, thrombosis, major surgery with immobilization, or a new interacting drug can change continued eligibility. Urgent symptoms require clinical evaluation, not routine method counseling alone.
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Progestin-Only Pills and DMPA
Progestin-only methods avoid estrogen but still differ substantially in schedule, bleeding, return to fertility, bone effects, and missed-dose rules.
- Norethindrone POP
- Norgestrel POP
- Drospirenone POP
- DMPA
- Testosterone
Use the correct missed-pill window
Plan reinjection, bone counseling, and return to fertility
Do not assume amenorrhea prevents pregnancy
Separate pill instructions
Norethindrone and norgestrel use daily active pills without a placebo break. Drospirenone (Slynd) uses 24 active 4 mg tablets followed by four inactive tablets. Traditional POPs rely importantly on cervical mucus and do not suppress ovulation consistently; drospirenone primarily suppresses ovulation.
Counsel on DMPA
DMPA uses 150 mg IM or 104 mg SC formulations. CDC recommends reinjection every 13 weeks and offering SC self-administration as an additional option; self-administration is off-label in the U.S. Discuss bleeding, bone-density effects, weight concerns, and a potentially delayed return to ovulation after stopping.
Reconcile bone guidance
Depo-Provera CI labeling discourages use beyond two years unless other options are inadequate and calls for BMD evaluation with long-term use. ACOG's bone-effects opinion supports individualized continuation beyond two years rather than an automatic cutoff. Discuss the warning, fracture risks, alternatives and contraceptive goals; do not promise complete bone recovery.
Review the newer warning
The December 2025 Depo-Provera CI label adds meningioma monitoring and directs discontinuation if diagnosed. Reassess a history of meningioma and new neurologic symptoms rather than treating repeat injections as automatic.
Explain fertility timing
The Depo-Provera CI label reports a median of ten months from the last injection to conception among those who conceived, with incomplete follow-up. This is neither a guaranteed waiting period nor evidence of permanent infertility.
Check drospirenone safety
Slynd is contraindicated with renal impairment, adrenal insufficiency or hepatic impairment. Its antimineralocorticoid action can raise potassium. Check potassium before treatment and during the first cycle when chronic medicines can increase potassium; assess long-term strong CYP3A4 inhibitors as well.
Handle a late injection
Up to 15 weeks after the last DMPA injection, CDC permits reinjection without extra protection. Beyond 15 weeks, assess pregnancy certainty, use seven days of barriers or abstinence after reinjection, and consider emergency contraception other than ulipristal when appropriate.
Do not rely on testosterone
Testosterone may suppress bleeding but might not prevent ovulation or pregnancy. People with pregnancy potential who do not desire pregnancy should be offered contraceptive care without assuming gender identity determines method choice.
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Levonorgestrel and Copper IUDs
IUDs provide highly effective reversible contraception, but copper and levonorgestrel produce different bleeding effects and additional benefits.
- LNG IUD
- Copper IUD
- Bleeding
- Placement
- Pain plan
Highly effective contraception with less bleeding over time
Long acting; EC evidence and duration depend on the device
Use person-centered analgesia and avoid routine misoprostol
Compare the devices
Levonorgestrel IUDs thicken cervical mucus and suppress the endometrium, often reducing bleeding and pain. Copper impairs sperm function without hormones but can increase menstrual bleeding and cramps.
Remove access myths
Adolescents and nulliparous patients can use IUDs when eligible. Routine prophylactic misoprostol is not recommended, although it can be useful after a recent failed placement. Lidocaine approaches may reduce pain.
Separate product and indication durations
For U.S. contraception labeling, Mirena and Liletta last up to eight years, Kyleena five years, Skyla three years, Paragard ten years and Miudella three years. Mirena and Liletta have a separate heavy-menstrual-bleeding indication for five years; an eight-year contraceptive duration does not extend that indication. Verify the device and insertion date rather than relying on a generic IUD duration.
Distinguish the newer copper system
Miudella has a nitinol frame and requires insertion training through its REMS. Check component hypersensitivity, including nitinol, as well as copper-related restrictions. Its label contraindicates emergency contraception; do not transfer Paragard EC evidence or duration to it.
Screen without unnecessary delay
Same-day gonorrhea/chlamydia screening need not delay placement in an otherwise eligible asymptomatic patient. Current purulent cervicitis, gonorrhea or chlamydia prevents initiation until appropriately managed. Pelvic infection can threaten fertility; do not confuse that risk with inevitable infertility from reversible IUD use. Paragard is contraindicated with Wilson disease or copper hypersensitivity.
Counsel after placement
Explain expected bleeding, expulsion and perforation warning signs, and removal access. Pregnancy with an IUD needs prompt assessment, including ectopic pregnancy evaluation. New severe pelvic pain, fever or abnormal discharge needs evaluation; a missing string requires checking device location and pregnancy risk rather than assuming the device is correctly positioned.
Give a start plan
Copper IUD placement requires no backup. Under CDC routine initiation guidance, an LNG IUD placed within seven days of menstrual bleeding onset requires none; later placement requires seven days of backup. If pregnancy cannot reasonably be excluded, use a temporary method rather than placing an IUD.
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Etonogestrel Implant and Bleeding Management
The implant combines very high effectiveness with rapid reversibility, while unpredictable bleeding is the most common reason patients seek management or removal.
- Etonogestrel
- Ovulation suppression
- Irregular bleeding
- Evaluation
- Removal autonomy
Suppress ovulation and thicken cervical mucus
Exclude another cause when the pattern requires it
Remove at any time and offer another method if desired
Set expectations
Spotting, light bleeding or amenorrhea is common; heavy bleeding is uncommon. The Nexplanon label describes the first three months as broadly predictive of later patterns for many users, not a guarantee. Improvement is not assured, and a patient need not wait three months to request care or removal.
Evaluate when indicated
A new heavy or otherwise concerning pattern can prompt pregnancy testing, infection assessment, medication review, or evaluation for another gynecologic cause. Treatment is optional and follows patient goals.
Use current duration and procedural safeguards
The January 2026 U.S. Nexplanon label permits use for up to five years, with removal by the end of year five. Its boxed warning and REMS address improper insertion and removal; insertion and removal require appropriate clinician training.
Offer bleeding treatment when wanted
After assessing other causes and the patient's goals, CDC options include a five- to seven-day NSAID course or seven to ten days of tamoxifen; benefit may persist after treatment. Estrogen or a 20 to 30 mcg ethinyl estradiol combined pill, when medically eligible, or five days of tranexamic acid may help during treatment, but bleeding commonly recurs afterward. These are guideline-supported management options, not an FDA-approved implant-bleeding indication; evidence varies across drugs and implant types.
Check treatment eligibility
Do not automatically give estrogen to someone who selected an implant because estrogen is contraindicated. Review renal, gastrointestinal and thrombotic risks for the proposed drug. Oral tranexamic acid labeling contraindicates concomitant combined hormonal contraception; the listed options are not an instruction to combine them.
Locate before removing
A nonpalpable implant requires localization and an experienced removal clinician; blind exploration can injure nerves or vessels. Pregnancy can occur soon after removal, so arrange the next method promptly if pregnancy prevention is desired.
Honor removal requests
Remove the implant whenever the patient wants it removed. Offer another method if desired, but do not require an arbitrary waiting period or treatment trial.
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Emergency Contraception
Emergency contraception is time-sensitive prevention after intercourse, not termination of an established pregnancy.
- Copper IUD
- Ulipristal
- Levonorgestrel
- Five-day window
- Hormonal restart
Place within the eligible five-day window
Wait five days before hormonal contraception
Restart regular hormones immediately with backup
Compare effectiveness
The copper T380A IUD (Paragard) is the established highly effective copper EC option and can be placed within five days of the first unprotected act, or within five days of estimated ovulation. It can remain for ongoing contraception.
Choose an emergency pill
Use ulipristal 30 mg or levonorgestrel 1.5 mg promptly. Plan B labeling specifies 72 hours; CDC permits emergency pills within 120 hours, with weaker LNG effectiveness late in that interval. Prefer UPA over LNG on days three through five when suitable and available. Obesity can reduce oral EC effectiveness, particularly LNG; discuss an IUD or UPA without turning weight into a rigid denial threshold.
Recognize the LNG-IUD evidence
The Society of Family Planning recommends offering the 52 mg LNG IUD for EC within five days, based on noninferiority evidence versus copper. This use is outside FDA labeling; Mirena/Liletta labeling lists postcoital use as contraindicated, and CDC's 2024 EC guidance lists copper, not LNG IUDs. Explain these differences when using an evidence-based local protocol. Do not extrapolate to lower-dose LNG devices.
Handle vomiting and access
CDC advises another EC-pill dose promptly after vomiting within three hours; consider an antiemetic. Plan B packaging uses a two-hour contact/redosing instruction, so identify the guidance used. Advance supply can shorten delays but does not replace ongoing contraception. After sexual assault, offer timely EC alongside trauma-informed evaluation, STI care and urgent HIV postexposure assessment when indicated.
Reassess another exposure
An EC pill does not protect later intercourse. Repeated LNG use is generally permissible; frequent use still warrants review of medical conditions and a more effective ongoing plan. UPA labeling discourages repeat use in one cycle because evidence is limited; Society of Family Planning guidance says repeat dosing should not be withheld when needed, while explaining uncertain contraceptive effectiveness. Reassess timing, recent progestin exposure and IUD options rather than automatically mixing LNG and UPA.
Know the less-preferred combined regimen
The Yuzpe regimen uses 100 mcg ethinyl estradiol plus 0.5 mg levonorgestrel per dose, with a second dose 12 hours later. It is less effective and causes more nausea/vomiting than dedicated LNG or UPA. Verify the exact tablets needed; ordinary pill packs differ in ingredients and strength.
Restart correctly
After ulipristal, start hormonal contraception no sooner than five days later; use barriers or abstain while waiting and for seven days after starting, or until the next menses, whichever comes first. Provider-administered methods can sometimes start sooner after weighing the interaction against access barriers. After levonorgestrel, regular contraception can start immediately; CDC advises barriers or abstinence for seven days. Test for pregnancy if no withdrawal bleed occurs within three weeks.
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Quick Start, Backup, and Missed Methods
Access improves when methods start promptly and the patient leaves with a clear plan for backup, missed use, vomiting, device problems, and pregnancy testing.
- Pregnancy checklist
- Quick start
- Backup
- Missed pills
- Delayed replacement
Use the CDC checklist and testing when useful
Do not require the next menstrual period routinely
Give a method-specific date and action sequence
Be reasonably certain
With no pregnancy signs or symptoms, CDC accepts any one of these: within seven days of normal menses onset; no intercourse since the last normal menses began; consistent correct reliable contraception; within seven days after abortion; within four weeks postpartum; or amenorrheic, fully/nearly fully breastfeeding and less than six months postpartum. A negative urine test alone cannot exclude a pregnancy from recent intercourse.
Manage remaining uncertainty
For an eligible non-IUD method, the benefits of prompt initiation often outweigh risk even when pregnancy remains uncertain. Consider starting with a repeat pregnancy test in two to four weeks. Defer routine IUD placement until reasonably certain, using a temporary method. Assess recent unprotected intercourse separately for EC; a negative test does not substitute for that assessment.
State the routine start interval
Under CDC guidance for a menstruating patient, starting CHC or an implant more than five days after bleeding began requires seven days of backup. For DMPA or an LNG IUD, that seven-day backup applies if starting more than seven days after bleeding began. Copper IUD placement needs none. These are routine-start rules, not substitutes for EC, postpartum or transition instructions.
Separate POP start intervals
Norethindrone/norgestrel started more than five days after menstrual bleeding began requires two days of backup. Drospirenone requires seven days if started after day one. Starting within each stated early-cycle window requires no backup under CDC guidance. Medical eligibility and product-specific instructions still apply.
Recognize the Natazia exception
Natazia labeling starts on menstrual day one with nine days of nonhormonal backup. Its missed-pill instructions depend on the pack day and a 12-hour threshold. For one pill missed by more than 12 hours on days 18 through 24, discard that pack, start day one of a new pack and use nine days of backup. Check its full instructions for other patterns; do not substitute the standard combined-pill algorithm.
Correct missed combined pills
For a standard combined pill, one active pill less than 48 hours overdue is taken promptly; continue the schedule without extra protection. At 48 hours or more, take only the most recent missed pill, continue active pills and use seven days of backup. If this occurs in the final active week, skip the hormone-free interval. First-week misses with intercourse in the preceding five days prompt emergency-contraception assessment.
Correct missed progestin pills
A norethindrone or norgestrel pill more than three hours overdue requires prompt dosing and backup until two days of correct use. For drospirenone, one active pill less than 48 hours overdue requires prompt dosing without backup; two or more missed active pills require seven days of backup. Assess recent intercourse and emergency options; do not use ulipristal without addressing its interaction with restarting progestin.
Apply CDC combined-pill illness guidance
For vomiting or severe diarrhea lasting less than 48 hours, continue combined pills; CDC does not require redosing or extra protection. At 48 hours or longer, continue pills and use backup until seven consecutive active-pill days after recovery. If illness affects the last active week, omit the hormone-free interval. First-week illness with unprotected intercourse in the preceding five days warrants EC assessment, accounting for ulipristal interactions.
Separate POP illness instructions
Under CDC guidance, vomiting or diarrhea within three hours of a norethindrone, norgestrel or drospirenone pill calls for another pill promptly while continuing daily dosing. For norethindrone/norgestrel, use backup until two days after symptoms resolve. For drospirenone, illness lasting more than 24 hours requires backup for seven days after recovery. Assess recent unprotected intercourse for EC, accounting for ulipristal interactions. These are not the combined-pill rules.
Verify before correcting
Missed pills, late injections, delayed patch or ring replacement, vomiting, and device expulsion each have different rules. Identify the exact product and timing before recommending backup or emergency contraception.
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Interactions and Longitudinal Follow-Up
Contraceptive effectiveness and safety can change when medicines induce enzymes, estrogen changes lamotrigine exposure, or a new health condition alters eligibility.
- CYP induction
- Rifampin
- Antiseizure drugs
- Lamotrigine
- Reassessment
Rifampin and selected inducers can reduce efficacy
Estrogen can lower exposure and hormone-free intervals can raise it
Choose an interaction-resistant plan and coordinate care
Find enzyme inducers
Rifampin/rifabutin, carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, topiramate and St. John's wort can compromise susceptible hormonal methods. IUDs avoid these enzyme-mediated efficacy interactions. CDC classifies DMPA as category 1 with rifampin/rifabutin and the listed enzyme-inducing anticonvulsants, while Depo-Provera CI labeling advises backup or an alternative with enzyme inducers. Identify this guideline-label difference and coordinate a consistent plan; assess other eligibility risks. An implant is not automatically interaction-free. Ordinary broad-spectrum antibiotics do not require routine backup solely because they are antibiotics.
Check absorption interactions
Tirzepatide labeling advises a nonoral contraceptive or an added barrier for four weeks after starting and after every dose increase; this is an oral-hormone absorption concern. With twice-daily exenatide (Byetta), take oral contraceptives at least one hour before the injection. Give ethinyl-estradiol/norethindrone pills at least four hours before colesevelam. Do not substitute one drug's timing rule for another.
Separate safety from efficacy interactions
Current U.S. Mavyret labeling permits products containing 20 mcg or less of ethinyl estradiol; more than 20 mcg is not recommended because of ALT elevation risk. Check the current antiviral and contraceptive labels together. Smoking is primarily a cardiovascular eligibility issue, not a reason to increase hormone doses to overcome assumed contraceptive failure.
Plan around mycophenolate
CellCept can reduce oral contraceptive hormone exposure and has major embryo-fetal toxicity. Follow its pregnancy-testing and acceptable-contraception plan during treatment and for six weeks after stopping. Its table permits an IUD alone, while listed hormonal methods require a barrier. Do not independently stop transplant therapy; coordinate any pregnancy plan with the treating team.
Manage lamotrigine deliberately
Estrogen can increase lamotrigine clearance, lowering concentrations during active hormones and allowing concentrations to rebound during hormone-free intervals. Coordinate initiation, discontinuation, and schedule changes.
Follow the patient
Assess satisfaction, correct use, bleeding, relevant blood pressure, new medications, pregnancy goals, and warning symptoms. The patient can switch or stop a method even when no medical emergency exists.
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Benefits Beyond Pregnancy Prevention
A contraceptive may also treat bleeding, pain or androgen-related symptoms, but benefits and labeled indications differ by product.
- Dysmenorrhea
- PCOS
- Acne
- PMDD
- Heavy bleeding
Confirm the diagnosis and desired benefit
Benefits do not override safety restrictions
Oriahnn requires separate nonhormonal contraception
Recognize current terminology
ASRM endorsed the name polyendocrine metabolic ovarian syndrome (PMOS) in May 2026 for the condition formerly called polycystic ovary syndrome (PCOS). Older books and many labels still use PCOS; the two names refer to the same condition.
Match symptoms to treatment
Combined hormonal methods can reduce menstrual cramps and bleeding and may improve acne or unwanted hair growth. Hormonal suppression can help endometriosis-associated pain, but improvement does not establish the cause of pelvic pain or cure endometriosis. New or persistent symptoms need appropriate evaluation.
Discuss cancer associations accurately
Observational studies associate oral contraceptive use with lower ovarian and endometrial cancer risk, but also with increased breast and cervical cancer risk in some use patterns. These findings do not guarantee protection or prove the same effect for every formulation. Balance benefits against individual eligibility; a possible long-term benefit does not override a current contraindication.
Distinguish Orilissa from contraceptives
Orilissa (elagolix) treats moderate-to-severe endometriosis pain. With normal or mildly impaired liver function, labeled limits are 150 mg daily for 24 months or 200 mg twice daily for six months. Moderate hepatic impairment limits use to 150 mg daily for six months.
Screen and counsel before elagolix
Pregnancy, osteoporosis, severe hepatic impairment, hypersensitivity and certain OATP1B1 inhibitors contraindicate Orilissa. Review interactions and bone risk; bone loss may persist. Suicidal thoughts need immediate help; new mood symptoms or jaundice need prompt evaluation.
Keep contraception separate
Use effective nonhormonal contraception during Orilissa and for 28 days afterward. Reduced bleeding does not exclude pregnancy. Hormonal contraceptives can interact; do not add one without review.
Address PCOS goals
The 2023 international PCOS guideline supports combined pills for irregular cycles or hirsutism in eligible adults. This is symptom management, not a cure or fertility treatment. Continue assessment of metabolic risks and reproductive goals; do not assume regular withdrawal bleeding means spontaneous ovulation has recovered.
Use the exact PMDD indication
Yaz is labeled for PMDD symptoms in patients who also choose oral contraception. Its label does not establish treatment of ordinary PMS, and PMDD efficacy beyond three cycles was not evaluated in the registration evidence. Its acne indication requires moderate acne, age at least 14, menarche and desire for oral contraception. Do not extend those claims to every combined pill or ignore estrogen eligibility.
Distinguish heavy-bleeding products
Natazia is labeled for heavy menstrual bleeding without organic pathology in patients choosing oral contraception. Mirena and Liletta have their own five-year heavy-bleeding indications. Oral tranexamic acid treats bleeding without providing contraception; its concomitant use with combined hormonal contraception is contraindicated by U.S. labeling.
Separate Oriahnn from contraception
Oriahnn combines elagolix with estradiol/norethindrone acetate add-back to treat fibroid-related heavy bleeding in premenopausal patients. It is not a contraceptive. Use effective nonhormonal contraception during treatment and for 28 days afterward. Its label limits treatment to 24 months because of bone loss and requires pregnancy assessment when indicated; reduced bleeding can hide pregnancy recognition.
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Lesson
Integrated Counseling and Method Transitions
High-quality contraception care turns one choice into a supported sequence of initiation, expected effects, problem solving, and voluntary transition.
- Teach-back
- Bleeding
- Warning symptoms
- Transition
- Reproductive planning
Confirm start, backup, missed use, and warning symptoms
Assess bleeding, adherence, new conditions, and new medicines
Preserve autonomy and continuous reproductive care
Use the supplied patient information
Review the product’s patient leaflet with the user and retain it for missed doses, storage and warning symptoms. Confirm the actual pack and written plan when changing brands; verbal class-level advice alone can miss important product differences.
Use teach-back
Ask the patient to explain when to start, how to use the method, when backup ends, what to do after missed use, and which symptoms require urgent care.
Normalize without dismissing
Expected bleeding changes can be reassuring, but pregnancy, infection, anemia, structural disease, or a major pattern change still deserves assessment when clinically indicated.
Plan transitions
Coordinate overlap or backup when switching methods, account for return-to-fertility timing, and provide preconception care when pregnancy becomes the goal.
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Module practice
Check the connections.
Each attempt draws 10 questions from the complete 79 question bank.
Each attempt draws a fresh set and rearranges the answer choices.
References
Current clinical foundation.
Core source material was synthesized with the following contemporary guidance. Verify local policy and current guidance before applying clinical information.
- NCI. Oral contraceptives and cancer risk: observational evidence.
- DailyMed. Orilissa indications, dosing limits, safety and contraception.
- DailyMed. Lo Loestrin Fe: tablet sequence and ingredients.
- DailyMed. Seasonique: extended-cycle tablet sequence.
- DailyMed. Levonorgestrel/ethinyl estradiol: patient warning symptoms.
- FDA. FemCap physician labeling: device-specific precautions.
- FDA. Natural Cycles De Novo review (2018).
- DailyMed. Miudella prescribing information, revised May 2026.
- ASRM. PCOS is Now PMOS: Understanding the Name Change. May 27, 2026.
- ACOG. Combined hormonal birth control benefits.
- ACOG. Dysmenorrhea and hormonal treatment.
- International PCOS guideline, 2023: combined oral contraceptive recommendations.
- DailyMed. Yaz product-specific PMDD and acne indications.
- DailyMed. Natazia indication for heavy menstrual bleeding.
- DailyMed. Oriahnn indication and separate contraception requirements.
- CDC. Implant bleeding evaluation and treatment options.
- DailyMed. Depo-Provera CI, revised December 2025.
- ACOG. Committee Opinion 602: DMPA and bone effects.
- CDC. Progestin-only contraceptive eligibility and drug interactions.
- DailyMed. Oral tranexamic acid: combined hormonal contraception contraindication.
- CDC. Condoms and lubricant compatibility.
- CDC. STI primary prevention: condoms and nonoxynol-9.
- CDC. Permanent contraception and postvasectomy confirmation.
- DailyMed. Today contraceptive sponge instructions and warnings.
- Caya. Manufacturer instructions, 2024 file.
- CDC. Pregnancy certainty checklist and uncertain-pregnancy initiation.
- CDC. When to start specific contraceptive methods.
- CDC. Emergency contraception medical eligibility, including obesity and repeated use.
- FDA. Plan B One-Step information and updated mechanism labeling.
- Society of Family Planning. Emergency contraception, 2023; reaffirmed April 2026.
- CDC. Sexual assault and STI care.
- DailyMed. Mounjaro prescribing information: contraception interactions.
- DailyMed. Byetta prescribing information: contraception interactions.
- DailyMed. Colesevelam prescribing information: contraception interactions.
- DailyMed. Mavyret prescribing information: contraception interactions.
- DailyMed. CellCept prescribing information: contraception interactions.
- DailyMed. Mirena prescribing information.
- DailyMed. Liletta prescribing information.
- DailyMed. Kyleena prescribing information.
- DailyMed. Skyla prescribing information.
- DailyMed. Paragard prescribing information.
- CDC. Intrauterine contraception: initiation, screening and pain management.
- DailyMed. NuvaRing prescribing information and instructions for use.
- DailyMed. Annovera prescribing information and instructions for use.
- CDC. U.S. MEC summary classifications, 2024.
- CDC. Contraceptive methods: typical-use effectiveness and barrier methods (implant duration superseded by 2026 FDA label).
- DailyMed. Phexxi prescribing information.
- Caya U.S. instructions for use.
- CDC. Progestin-only pills: initiation and missed doses.
- CDC. Combined hormonal contraceptives: use and missed doses.
- CDC. Injectable contraception: reinjection and self-administration.
- DailyMed. Slynd prescribing information.
- DailyMed. Xulane prescribing information.
- DailyMed. Twirla prescribing information.
- FDA. Nexplanon prescribing information, January 2026: five-year duration and REMS.
- CDC. U.S. SPR 2024: Emergency Contraception.
- CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024
- CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2024
- CDC. Routine Follow-Up After Contraceptive Initiation