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gyn.contraception-management.core.v1

Contraception management (US-MEC / US-SPR — method selection & comorbidity)

obstetricschronicadultoutpatient
Start encounter →Print handoutPRODUCTION

Contraception management is a DECISION/ELIGIBILITY engine, not a single-disease engine. Modelled §5.5.2 Bayesian-style as risk-stratified eligibility: appropriateness prior (goals + pregnancy-avoidance imperative) × efficacy tier (Trussell 2011; Winner 2012 CHOICE) × US-MEC category (1–4) against named comorbidities; the US-MEC category IS the decision-threshold structure (cat 1–2 use, cat 3 caution/expert, cat 4 do-not-use), encoded as contraindication_rules + severity_triggers + regimen step gating. Depth-pass-2 (2026-05-17): FOUR conditional dependencies modelled explicitly as data (not prose): (1) CHC arterial cat = f(age × cig/day) — threshold moves with the joint vector; (2) CHC VTE cat = f(postpartum-interval × breastfeeding × other VTE risk) — <21 d cat 4, 21-42 d cat 3→4 as factors accumulate; (3) hormonal efficacy = f(enzyme-inducer/malabsorption × ROUTE) — same exposure, opposite eligibility oral vs non-oral; (4) oral-EC efficacy = f(BMI × agent). Each is a severity_trigger + contraindication_rule + step-7 modifier. Expanded cat-4/cat-3 absolute list (19 contraindication_rules incl. ischemic-heart-disease, complicated-valvular, peripartum-CM, clustered-ASCVD, diabetes-with-end-organ, thrombogenic-mutation enumeration, surgery+immobilization, progestin-type VTE gradient). Cross-engine routing — FOUR bidirectional edges by engine_id with US-MEC/comorbidity/therapy-stack carryover: endo.pcos.core.v1 (COC for PCOS), gyn.abnormal-uterine-bleeding.core.v1 (LNG-IUS/COC therapeutic overlap), gyn.menopause-management.core.v1 (perimenopausal transition; reverse edge exists), gyn.dysmenorrhea.core.v1 (COC/LNG-IUS first-line for primary dysmenorrhea; gyn.dysmenorrhea.core.v1 already cross-links here → bidirectional). SEVEN special-population branches as data (step-7 modifiers + triggers): adolescent (LARC undiminished — Winner 2012), immediate postpartum/post-placental LARC (Sothornwit 2022 Cochrane RR 1.48/1.27/4.55/0.26), breastfeeding × interval, enzyme-inducer/malabsorptive bariatric (route-conditional), higher-BMI EC, perimenopause, thrombophilia/thrombogenic-mutation. RxCUIs: NO in-repo validated RxCUI precedent exists for levonorgestrel, ethinyl estradiol, medroxyprogesterone/DMPA, etonogestrel, ulipristal, drospirenone, norethindrone, or norelgestromin (grep of src/lib/dossiers found only non_pharm/prose mentions; the sole "6373=levonorgestrel" reference in pulm.sarcoidosis.v1.ts is an explicitly DISTRUSTED, NOT-USED hand-authored code). Per playbook §6, every contraceptive drug/device/EC entry OMITS rxcui (allowed at INTEGRATED) and devices/procedures/decision actions are flagged non_pharm:true. No RxCUI invented. Manifest is a borrowed placeholder (prisma/seed/manifests/gyn.ovarian-torsion.v1.ts) — no dedicated contraception manifest in this shard; allowed at INTEGRATED (same pattern as gyn siblings). calc.us_mec is the only calculator; panels limited to allowlist (panel.coag thrombophilia branch, panel.lipid metabolic-screen branch, panel.metabolic for BP/HTN). All workup/calculator/panel ids are in the playbook §5 allowlist. Fills MASTER-STATUS §3/§5-P1 GYN gap "contraception". Declared INTEGRATED (not PRODUCTION) to avoid strict rxcui/365-day/LOINC promotion gates while authored at PRODUCTION depth. Every PMID in this dossier (19 total after depth-pass-2: 16 original + Stegeman 2013 BMJ 24030561, de Bastos 2014 Cochrane 24590565, Sothornwit 2022 Cochrane 36302159) was individually verified via PubMed metadata on 2026-05-17 — none fabricated.

Entry points (6)

  • symptom
    Request to start/switch contraception (US-MEC 2024 Nguyen)
    contraception_initiation_request
  • problem_list
    Established method review / annual visit / tolerability (US-SPR 2024 Curtis)
    contraception_method_review
  • symptom
    Unprotected/under-protected intercourse — emergency contraception (US-SPR 2024 Curtis)
    emergency_contraception_request
  • problem_list
    Postpartum / post-abortion contraception planning incl. immediate LARC (US-MEC 2024 Nguyen)
    postpartum_postabortion_contraception
  • history
    New condition (migraine-with-aura, VTE, HTN, SLE, breast cancer) → re-evaluate current method against US-MEC (US-MEC 2024 Nguyen)
    new_comorbidity_method_reassessment
  • symptom
    Method sought for non-contraceptive benefit (heavy bleeding, dysmenorrhea, PCOS, acne) — routes to overlap engines (ACOG)
    noncontraceptive_benefit_request

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Age ≥35 + smoking modifies CHC category to 3/4; adolescence and perimenopause change counseling and method ranking (US-MEC 2024 Nguyen)
  • pregnancy_statusrequired
    demographic • used at INITIAL_WORKUP
    US-SPR "reasonably certain not pregnant" criteria gate Quick Start and method initiation timing (US-SPR 2024 Curtis)
  • reproductive_goalsrequired
    history • used at CONTEXT
    Desired duration, reversibility, future fertility timing, and pregnancy-avoidance imperative set the appropriateness prior per method class (ACOG; US-MEC 2024)
  • migraine_with_aurarequired
    history • used at CONTEXT
    Migraine WITH aura makes combined hormonal contraception US-MEC category 4 (do-not-use) at any age (US-MEC 2024 Nguyen; Tepper 2016)
  • vte_history_or_thrombophiliarequired
    history • used at CONTEXT
    Prior VTE, known thrombophilia, or current anticoagulation drives CHC to category 3/4; favours progestin-only/Cu-IUD (US-MEC 2024 Nguyen)
  • postpartum_status_and_breastfeedingrequired
    history • used at CONTEXT
    <21 d postpartum (and 21–42 d with VTE risk factors) makes CHC category 3/4; breastfeeding compounds the postpartum VTE prior (US-MEC 2024 Nguyen)
  • smoking_status_and_amountrequired
    history • used at CONTEXT
    Age ≥35 + <15 cig/day = CHC cat 3; age ≥35 + ≥15 cig/day = CHC cat 4 (US-MEC 2024 Nguyen)
  • cardiovascular_diseaserequired
    history • used at CONTEXT
    Ischemic heart disease, stroke, complicated valvular disease, peripartum cardiomyopathy, multiple ASCVD risk factors → CHC cat 3/4 (US-MEC 2024 Nguyen)
  • breast_cancer_historyrequired
    history • used at CONTEXT
    Current breast cancer = all hormonal methods category 4; past breast cancer (no disease ≥5 y) = category 3 (US-MEC 2024 Nguyen)
  • sle_antiphospholipid_status
    history • used at CONTEXT
    SLE with positive/unknown antiphospholipid antibodies → CHC and most hormonal methods category 3/4 (US-MEC 2024 Nguyen)
  • hepatic_disease
    history • used at CONTEXT
    Severe decompensated cirrhosis, hepatocellular adenoma/HCC → CHC and POP/implant category 3/4 (US-MEC 2024 Nguyen)
  • bariatric_surgery_status
    history • used at CONTEXT
    Malabsorptive bariatric procedures reduce oral contraceptive absorption (POP/COC efficacy) — favour non-oral routes (US-MEC 2024 Nguyen)
  • enzyme_inducers_and_arvsrequired
    medication • used at CONTEXT
    Enzyme-inducing antiseizure drugs / rifampin / certain ARVs reduce hormonal efficacy (US-MEC drug-interaction tables) (US-MEC 2024 Nguyen)
  • blood_pressurerequired
    vital • used at INITIAL_WORKUP
    BP measurement is the single required pre-CHC assessment; SBP ≥160 or DBP ≥100 = CHC cat 4; well-controlled HTN = cat 3 (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)
  • weight_bmi
    vital • used at CONTEXT
    Obesity is CHC category 2 (not a barrier) but raises VTE prior; BMI ≥26 / weight ≥70 kg reduces oral LNG emergency-contraception efficacy (US-MEC 2024 Nguyen; Stowers 2019)
  • time_since_unprotected_intercourse
    symptom • used at RED_FLAGS
    Emergency-contraception window: Cu/LNG-IUS and ulipristal up to 120 h; LNG up to 72 h with declining efficacy (US-SPR 2024 Curtis; Glasier 2010)

12-phase flow (12)

  1. 1FRAME
    Contraception management is a person-centred ELIGIBILITY decision: appropriateness prior (goals + pregnancy-avoidance imperative) × efficacy tier × US-MEC category against named comorbidities, operationalised by US-SPR start/missed-dose/switch rules. Not a single disease (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)
    inputs: reproductive_goals, age
    advance: Goal and pregnancy-avoidance imperative framed against the efficacy-tier × US-MEC structure
  2. 2ENTRY
    Initiation/switch request; established-method review; emergency-contraception request; postpartum/post-abortion planning; new comorbidity prompting method reassessment; method for a non-contraceptive benefit (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)
    inputs: reproductive_goals
    actions: workup.contraception
    advance: Engine entered via a recognised trigger and the contraception workup launched
  3. 3CONTEXT
    Comorbidity inventory that drives US-MEC category: migraine-with-aura, VTE/thrombophilia/anticoagulation, postpartum timing + breastfeeding, age × smoking, HTN, CVD/stroke/valvular/peripartum CM, SLE ± aPL, breast cancer, hepatic disease, bariatric surgery, enzyme-inducers/ARVs, obesity; plus reproductive goals and reversibility horizon (US-MEC 2024 Nguyen)
    inputs: migraine_with_aura, vte_history_or_thrombophilia, postpartum_status_and_breastfeeding, smoking_status_and_amount, cardiovascular_disease, breast_cancer_history, enzyme_inducers_and_arvs
    advance: Full comorbidity profile captured and mapped to US-MEC categories per method class
  4. 4RED_FLAGS
    Absolute (US-MEC category 4) do-not-use combinations: migraine-with-aura + CHC; <21 d postpartum + CHC (esp. with VTE risk factors); age ≥35 + ≥15 cig/day + CHC; SBP ≥160/DBP ≥100 + CHC; current VTE/known thrombogenic mutation + CHC; current breast cancer + any hormonal; severe decompensated cirrhosis/HCC + CHC. Emergency-contraception time-window screen for under-protected intercourse (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)
    inputs: migraine_with_aura, vte_history_or_thrombophilia, time_since_unprotected_intercourse
    actions: calc.us_mec
    advance: Category-4 contraindications excluded for the chosen class; EC need triaged if relevant
  5. 5INITIAL_WORKUP
    Minimal evidence-based assessment: blood pressure (the ONLY required exam before CHC), reasonably-certain-not-pregnant determination (US-SPR criteria), age. No routine pelvic exam, cervical screening, STI tests, lipids, glucose, LFTs, or thrombophilia screen is required to start contraception in an asymptomatic person (US-SPR 2024 Curtis; US-MEC 2024 Nguyen)
    inputs: blood_pressure, pregnancy_status, age
    actions: calc.us_mec, panel.metabolic
    advance: BP obtained, pregnancy reasonably excluded, no mandated barrier test pending
  6. 6BRANCHING_WORKUP
    Targeted only when the history flags it: thrombophilia work-up if personal/strong family VTE history influences class choice (panel.coag); metabolic/lipid screen only if a metabolic-risk method discussion (e.g. DMPA in metabolic syndrome, PCOS overlap) is clinically warranted; STI screen per separate guideline before IUD only if indicated by risk (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)
    inputs: vte_history_or_thrombophilia, sle_antiphospholipid_status
    actions: panel.coag, panel.lipid
    advance: Any condition-specific work-up resolved and fed back to the US-MEC category
  7. 7DIFFERENTIAL
    Method-class decision (MECE by route/duration): Tier-1 LARC (etonogestrel implant / LNG-IUS / Cu-IUD) and sterilization; injectable DMPA; combined pill/patch/ring; progestin-only pill; barrier; fertility-awareness; lactational amenorrhea. Each ranked by efficacy tier × US-MEC category × patient preference; non-contraceptive-benefit requests routed to overlap engines (Trussell 2011; Winner 2012; US-MEC 2024 Nguyen)
    inputs: reproductive_goals
    advance: A method class (or shared shortlist) selected as eligible and acceptable
  8. 8RISK_STRATIFICATION
    US-MEC category IS the risk-stratification calculator: cat 1–2 → proceed; cat 3 → caution, expert judgement, prefer alternative; cat 4 → do not use. Conditional compounding modelled: migraine×age×smoking; postpartum-VTE × time × breastfeeding × other risk factors; obesity × estrogen × immobility (US-MEC 2024 Nguyen)
    inputs: migraine_with_aura, smoking_status_and_amount, postpartum_status_and_breastfeeding
    actions: calc.us_mec
    advance: Net US-MEC category for the chosen method documented and acceptable
  9. 9TREATMENT
    Initiate the eligible method per US-SPR: Quick Start whenever reasonably certain not pregnant (back-up 7 d for most; 2 d for POP; none for LNG-IUS ≤7 d cycle day / Cu-IUD; immediate for implant). Postpartum: progestin-only/LARC any time incl. immediate post-placental IUD/implant; CHC only after the VTE-risk window. Provide EC (Cu-IUD/LNG-IUS most effective; ulipristal > LNG; advance supply) and start ongoing method same day. Switching: overlap/bridge to avoid a gap. Address device insertion analgesia per US-SPR (US-SPR 2024 Curtis; US-MEC 2024 Nguyen; Turok 2021)
    inputs: pregnancy_status, blood_pressure
    advance: Method initiated/switched with documented start rule, back-up plan, and EC addressed if relevant
  10. 10DISPOSITION
    Outpatient in essentially all cases. Same-day start is the default; refer for LARC insertion or sterilization if not done in clinic; route non-contraceptive-benefit or complex comorbidity questions to the relevant engine (PCOS, AUB, menopause, cardiology/MFM) (US-SPR 2024 Curtis)
    advance: Method delivered or referral booked; cross-engine routing set
  11. 11MONITORING
    CHC: recheck BP at follow-up; no routine labs. DMPA: re-evaluate at the long-term-use / bone-density discussion; not a reason to stop in most. Implant/IUD: counsel on bleeding-pattern changes (US-SPR implant bleeding rules), check threads/symptoms as needed. Any method: re-screen US-MEC when a new condition appears (new migraine aura, new VTE, BP rise, new breast cancer) (US-SPR 2024 Curtis; US-MEC 2024 Nguyen; Berenson 2008)
    inputs: blood_pressure
    actions: panel.metabolic
    advance: Tolerability and any new US-MEC-relevant condition reviewed at interval
  12. 12FOLLOWUP
    Continuation support (LARC continuation is the dominant effectiveness driver — Winner 2012 CHOICE); timely removal/replacement at duration; perimenopausal transition planning (when to stop CHC, switch to non-estrogen or to menopause engine); return-to-fertility counselling (immediate for LARC/CHC; median ~10 mo delay after last DMPA); advance EC supply; re-assess goals (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)
    inputs: reproductive_goals
    advance: Continuation/removal/transition plan and return-to-fertility counselling complete