Contraception Selection & Counseling (CDC US-MEC)

Algorithm Steps

1. ▶

   Start

   Contraception Counseling

   Patient-centered contraceptive decision-making

   1. ●

      Action

      Assess Patient Preferences

      Key questions to ask

      • Desire for future pregnancy (timing)
      • Importance of efficacy vs convenience
      • Preferences: hormonal vs non-hormonal
      • Frequency of dosing tolerable
      • STI protection needs
      • Confidentiality concerns
      1. ●

         Action

         Medical History Screen

         US-MEC Category assessment

         • Current medications (enzyme inducers)
         • Cardiovascular: HTN, migraine with aura, VTE history
         • Metabolic: DM with vascular disease
         • Hepatic: active liver disease
         • Breast cancer history
         • Postpartum status and breastfeeding
         1. ◆

            Decision

            Contraceptive Effectiveness Tiers

            Recommend most effective methods first

            • Tier 1 (Most effective <1%): IUDs, implant, sterilization
            • Tier 2 (Effective 4-7%): Injectable, pills, patch, ring
            • Tier 3 (Less effective 13-27%): Condoms, diaphragm, withdrawal
            1. ●

               Action

               LARC Methods (Tier 1)

               Long-acting reversible contraception

               • Copper IUD (Paragard): 10 years, non-hormonal, heavier periods
               • LNG-IUD (Mirena 8yr, Liletta 8yr, Kyleena 5yr): lighter/absent periods
               • Implant (Nexplanon): 3 years, irregular bleeding common
               • Same-day insertion encouraged
               • No pelvic exam required before LARC (ACOG)
               1. ●

                  Action

                  Special Considerations

                  US-MEC guidance

                  • Migraine with aura: Avoid estrogen (US-MEC 4)
                  • HTN ≥160/100: Avoid CHC
                  • Breastfeeding <6 weeks: Avoid CHC
                  • VTE history: Avoid CHC, progestin OK
                  • Nulliparous: IUDs safe and recommended
                  1. ●

                     Action

                     Quick Start Method

                     Start contraception today

                     • Can start any method any day if reasonably certain not pregnant
                     • Backup method (condoms) x 7 days for most methods
                     • No need to wait for menses
                     • Improves adherence and reduces unintended pregnancy
                     1. ●

                        Action

                        Follow-Up

                        Reassess at visits

                        • CHC: BP check at 3 months, then annually
                        • IUD: String check at 1 month optional
                        • Depo: Every 11-13 weeks for injection
                        • Address side effects, method satisfaction
                        • Offer method change if not satisfied
            2. ●

               Action

               Short-Acting Hormonal (Tier 2)

               Require regular use

               • Combined pills: Take daily, many formulations
               • Patch: Weekly, avoid if >90kg
               • Ring (NuvaRing): Monthly, can remove for intercourse
               • Injectable (Depo-Provera): Every 3 months, weight gain, bone loss
               • Progestin-only pill: Daily at same time (stricter timing)
            3. ●

               Action

               Barrier & Other (Tier 3)

               Require use with each act

               • Male condom: Also protects against STIs
               • Female condom: Can insert in advance
               • Diaphragm/cap: Requires fitting, use with spermicide
               • Fertility awareness: Requires training, partner cooperation
               • Withdrawal: Better than nothing, 20% failure
               1. ●

                  Action

                  Emergency Contraception

                  Discuss at every visit

                  • Copper IUD: Most effective, insert within 5 days
                  • Ulipristal (ella): Rx, effective 120h, delay by BMI
                  • Levonorgestrel (Plan B): OTC, effective 72h, less effective if >75kg
                  • Advance prescription encouraged