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gyn.contraception-management.core.v1PRODUCTION
gyn.contraception-management.core.v1

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

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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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Goal and pregnancy-avoidance imperative framed against the efficacy-tier × US-MEC structure

Patient inputs (16)

Age ≥35 + smoking modifies CHC category to 3/4; adolescence and perimenopause change counseling and method ranking (US-MEC 2024 Nguyen)

Desired duration, reversibility, future fertility timing, and pregnancy-avoidance imperative set the appropriateness prior per method class (ACOG; US-MEC 2024)

Migraine WITH aura makes combined hormonal contraception US-MEC category 4 (do-not-use) at any age (US-MEC 2024 Nguyen; Tepper 2016)

Prior VTE, known thrombophilia, or current anticoagulation drives CHC to category 3/4; favours progestin-only/Cu-IUD (US-MEC 2024 Nguyen)

<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)

Age ≥35 + <15 cig/day = CHC cat 3; age ≥35 + ≥15 cig/day = CHC cat 4 (US-MEC 2024 Nguyen)

Ischemic heart disease, stroke, complicated valvular disease, peripartum cardiomyopathy, multiple ASCVD risk factors → CHC cat 3/4 (US-MEC 2024 Nguyen)

Current breast cancer = all hormonal methods category 4; past breast cancer (no disease ≥5 y) = category 3 (US-MEC 2024 Nguyen)

Enzyme-inducing antiseizure drugs / rifampin / certain ARVs reduce hormonal efficacy (US-MEC drug-interaction tables) (US-MEC 2024 Nguyen)

US-SPR "reasonably certain not pregnant" criteria gate Quick Start and method initiation timing (US-SPR 2024 Curtis)

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)

SLE with positive/unknown antiphospholipid antibodies → CHC and most hormonal methods category 3/4 (US-MEC 2024 Nguyen)

Severe decompensated cirrhosis, hepatocellular adenoma/HCC → CHC and POP/implant category 3/4 (US-MEC 2024 Nguyen)

Malabsorptive bariatric procedures reduce oral contraceptive absorption (POP/COC efficacy) — favour non-oral routes (US-MEC 2024 Nguyen)

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)

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)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningvte_thrombophilia_or_anticoagulated_on_chc
    Current/prior VTE, known thrombogenic mutation, or current anticoagulation with combined hormonal contraception — US-MEC category 4 (US-MEC 2024 Nguyen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremigraine_with_aura_on_or_considering_chc
    Migraine WITH aura at any age while using or requesting combined hormonal contraception — US-MEC category 4 (US-MEC 2024 Nguyen; Tepper 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereage35_smoker_15plus_on_chc
    Age ≥35 years AND smoking ≥15 cigarettes/day with combined hormonal contraception — US-MEC category 4 (US-MEC 2024 Nguyen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecent_postpartum_chc_vte_window
    <21 days postpartum (or 21–42 days with additional VTE risk factors / breastfeeding) considering combined hormonal contraception — US-MEC category 3/4 (US-MEC 2024 Nguyen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_uncontrolled_hypertension_on_chc
    SBP ≥160 or DBP ≥100 mmHg with combined hormonal contraception — US-MEC category 4 (controlled HTN = category 3) (US-MEC 2024 Nguyen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecurrent_breast_cancer_any_hormonal_method
    Current breast cancer and any hormonal contraceptive method — US-MEC category 4 for all hormonal methods (US-MEC 2024 Nguyen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateemergency_contraception_higher_bmi
    Emergency contraception needed with BMI ≥26 kg/m2 or weight ≥70 kg — oral levonorgestrel efficacy reduced (US-SPR 2024 Curtis; Stowers 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateenzyme_inducer_or_malabsorptive_surgery_reduces_oral_hormonal_efficacy
    Enzyme-inducing drug (rifampin/rifabutin, carbamazepine, phenytoin, phenobarbital, topiramate >200 mg, certain ARVs) OR malabsorptive bariatric surgery while on/considering an oral hormonal method — efficacy is route-conditional (US-MEC 2024 Nguyen)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Contraceptive method selection — efficacy tier × US-MEC comorbidity gating (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)
axis: contraceptive_method_selection_by_efficacy_tier_and_us_mecstep 1 - Tier 1 — LARC (most effective reversible): implant, LNG-IUS, Cu-IUD
Selected step "Tier 1 — LARC (most effective reversible): implant, LNG-IUS, Cu-IUD" — Patient wants highly effective, low-maintenance, reversible contraception OR a strong pregnancy-avoidance imperative (teratogen, pulmonary HTN, recent VTE) — efficacy independent of adherence
  • etonogestrel subdermal implant
    first line
    long_acting_reversible_contraception_progestin
    subdermal • in situ up to 3 yr (evidence supports up to 5 yr)
    triggers: wants_LARC, estrogen_contraindicated, postpartum_immediate_eligible, adolescent_wants_top_tier, breastfeeding, enzyme_inducer_on_board_prefer_nonoral
    Typical-use failure ~0.1%/yr — top-tier; US-MEC cat 1 for the great majority incl. migraine-with-aura, VTE history, breastfeeding, age ≥35 smoker (progestin-only). Adherence-independent: CHOICE adjusted HR for unintended pregnancy with pill/patch/ring vs LARC = 21.8 (95% CI 13.7–34.9), undiminished in adolescents. Immediate postpartum insertion improves initiation vs delayed (RR 1.48, 95% CI 1.11–1.98) with little/no impact on breastfeeding at 6 mo (RR 0.97, 95% CI 0.92–1.01); progestin-only implant US-MEC cat 1 from immediately postpartum incl. breastfeeding. Enzyme-inducer-independent efficacy (non-oral) (Trussell 2011; Winner 2012 NEJM; Sothornwit 2022 Cochrane; US-MEC 2024 Nguyen)
  • levonorgestrel intrauterine system (LNG-IUS 52 mg / 19.5 mg / 13.5 mg)
    first line
    long_acting_reversible_contraception_intrauterine
    intrauterine • in situ 3–8 yr by formulation
    triggers: wants_LARC, heavy_menstrual_bleeding_overlap, estrogen_contraindicated, dysmenorrhea_overlap, breastfeeding, enzyme_inducer_on_board_prefer_nonoral
    Typical-use failure ~0.1–0.4%/yr; also therapeutic for heavy menstrual bleeding (AUB overlap) and primary dysmenorrhea. US-MEC cat 1–2 across most comorbidities; valid for EC (Turok 2021 NEJM). Immediate postpartum insertion improves initiation (RR 1.27, 95% CI 1.07–1.51) but conditional expulsion penalty RR 4.55 (95% CI 2.52–8.19) vs delayed — counsel + string check, net benefit retained (Sothornwit 2022 Cochrane). Non-contraceptive benefit routes to gyn.abnormal-uterine-bleeding.core.v1 / gyn.dysmenorrhea.core.v1
  • copper T380A intrauterine device
    first line
    long_acting_reversible_contraception_nonhormonal
    intrauterine • in situ up to 10–12 yr
    triggers: wants_nonhormonal_LARC, all_hormonal_contraindicated, most_effective_EC_needed, current_breast_cancer, enzyme_inducer_on_board_prefer_nonoral
    Typical-use failure ~0.8%/yr; fully non-hormonal — US-MEC cat 1 even when all hormones are cat 3/4 (e.g. current breast cancer) and unaffected by enzyme inducers; the single most effective EC up to 120 h. Immediate-IUD 12-mo unintended pregnancy RR 0.26 (95% CI 0.17–0.41) vs delayed insertion (Trussell 2011; Turok 2021 NEJM; Sothornwit 2022 Cochrane; US-MEC 2024 Nguyen)

outpatient playbook — drug actions (6)

  1. 1. US-MEC category determination
    map comorbidity profile to cat 1–4 per method class • n/a • at visit
    trigger: Any method under consideration
    cat 1–2 proceed, cat 3 caution/alternative, cat 4 do-not-use (US-MEC 2024 Nguyen)
  2. 2. Tier-1 LARC (etonogestrel implant / LNG-IUS / Cu-IUD)
    device per protocol • subdermal/intrauterine • 3–12 yr by device
    trigger: Wants top-tier reversible OR strong pregnancy-avoidance imperative
    Typical-use failure <1%/yr; adherence-independent (Winner 2012; Trussell 2011)
  3. 3. DMPA injectable
    IM 150 mg / SC 104 mg • IM/SC • q12–13 weeks (SC self-admin per US-SPR)
    trigger: Wants private periodic injectable, estrogen contraindicated
    Typical ~4%/yr; reversible BMD loss; ~10-mo fertility delay (Berenson 2008; US-SPR 2024 Curtis)
  4. 4. Combined hormonal contraceptive (pill/patch/ring)
    lowest effective EE (prefer 20 mcg) • PO/transdermal/vaginal • per method
    trigger: No estrogen contraindication; wants user-controlled / non-contraceptive benefit
    Typical ~7%/yr; Quick Start + 7-day back-up (Trussell 2011; US-SPR 2024 Curtis)
  5. 5. Progestin-only pill
    norethindrone 0.35 mg or drospirenone 4 mg • PO • daily
    trigger: Estrogen contraindicated, wants oral
    Estrogen-sparing; norethindrone narrow 3-h window, drospirenone 24-h grace (US-MEC 2024 Nguyen)
  6. 6. Emergency contraception
    Cu-IUD/LNG-IUS, or ulipristal 30 mg, or LNG 1.5 mg • intrauterine/PO • single, ≤120 h
    trigger: Under-protected intercourse
    IUD > ulipristal > LNG; LNG reduced if BMI ≥26 (Turok 2021; Glasier 2010; Stowers 2019)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Request to start/switch contraception (US-MEC 2024 Nguyen); Established method review / annual visit / tolerability (US-SPR 2024 Curtis); Unprotected/under-protected intercourse — emergency contraception (US-SPR 2024 Curtis).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Contraception management (US-MEC / US-SPR — method selection & comorbidity)** (gyn.contraception-management.core.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Contraceptive method selection — efficacy tier × US-MEC comorbidity gating (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)** — step "Tier 1 — LARC (most effective reversible): implant, LNG-IUS, Cu-IUD".
1. etonogestrel subdermal implant subdermal in situ up to 3 yr (evidence supports up to 5 yr) (long_acting_reversible_contraception_progestin, first line) — Typical-use failure ~0.1%/yr — top-tier; US-MEC cat 1 for the great majority incl. migraine-with-aura, VTE history, breastfeeding, age ≥35 smoker (progestin-only). Adherence-independent: CHOICE adjusted HR for unintended pregnancy with pill/patch/ring vs LARC = 21.8 (95% CI 13.7–34.9), undiminished in adolescents. Immediate postpartum insertion improves initiation vs delayed (RR 1.48, 95% CI 1.11–1.98) with little/no impact on breastfeeding at 6 mo (RR 0.97, 95% CI 0.92–1.01); progestin-only implant US-MEC cat 1 from immediately postpartum incl. breastfeeding. Enzyme-inducer-independent efficacy (non-oral) (Trussell 2011; Winner 2012 NEJM; Sothornwit 2022 Cochrane; US-MEC 2024 Nguyen)
2. levonorgestrel intrauterine system (LNG-IUS 52 mg / 19.5 mg / 13.5 mg) intrauterine in situ 3–8 yr by formulation (long_acting_reversible_contraception_intrauterine, first line) — Typical-use failure ~0.1–0.4%/yr; also therapeutic for heavy menstrual bleeding (AUB overlap) and primary dysmenorrhea. US-MEC cat 1–2 across most comorbidities; valid for EC (Turok 2021 NEJM). Immediate postpartum insertion improves initiation (RR 1.27, 95% CI 1.07–1.51) but conditional expulsion penalty RR 4.55 (95% CI 2.52–8.19) vs delayed — counsel + string check, net benefit retained (Sothornwit 2022 Cochrane). Non-contraceptive benefit routes to gyn.abnormal-uterine-bleeding.core.v1 / gyn.dysmenorrhea.core.v1
3. copper T380A intrauterine device intrauterine in situ up to 10–12 yr (long_acting_reversible_contraception_nonhormonal, first line) — Typical-use failure ~0.8%/yr; fully non-hormonal — US-MEC cat 1 even when all hormones are cat 3/4 (e.g. current breast cancer) and unaffected by enzyme inducers; the single most effective EC up to 120 h. Immediate-IUD 12-mo unintended pregnancy RR 0.26 (95% CI 0.17–0.41) vs delayed insertion (Trussell 2011; Turok 2021 NEJM; Sothornwit 2022 Cochrane; US-MEC 2024 Nguyen)

Setting playbook (outpatient) — Provide person-centred, US-MEC-eligible, US-SPR-operationalised contraception same day, removing unnecessary barriers and addressing emergency contraception and postpartum/post-abortion timing (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)
4. US-MEC category determination map comorbidity profile to cat 1–4 per method class n/a at visit — Any method under consideration (cat 1–2 proceed, cat 3 caution/alternative, cat 4 do-not-use (US-MEC 2024 Nguyen))
5. Tier-1 LARC (etonogestrel implant / LNG-IUS / Cu-IUD) device per protocol subdermal/intrauterine 3–12 yr by device — Wants top-tier reversible OR strong pregnancy-avoidance imperative (Typical-use failure <1%/yr; adherence-independent (Winner 2012; Trussell 2011))
6. DMPA injectable IM 150 mg / SC 104 mg IM/SC q12–13 weeks (SC self-admin per US-SPR) — Wants private periodic injectable, estrogen contraindicated (Typical ~4%/yr; reversible BMD loss; ~10-mo fertility delay (Berenson 2008; US-SPR 2024 Curtis))
7. Combined hormonal contraceptive (pill/patch/ring) lowest effective EE (prefer 20 mcg) PO/transdermal/vaginal per method — No estrogen contraindication; wants user-controlled / non-contraceptive benefit (Typical ~7%/yr; Quick Start + 7-day back-up (Trussell 2011; US-SPR 2024 Curtis))
8. Progestin-only pill norethindrone 0.35 mg or drospirenone 4 mg PO daily — Estrogen contraindicated, wants oral (Estrogen-sparing; norethindrone narrow 3-h window, drospirenone 24-h grace (US-MEC 2024 Nguyen))
9. Emergency contraception Cu-IUD/LNG-IUS, or ulipristal 30 mg, or LNG 1.5 mg intrauterine/PO single, ≤120 h — Under-protected intercourse (IUD > ulipristal > LNG; LNG reduced if BMI ≥26 (Turok 2021; Glasier 2010; Stowers 2019))

Non-pharmacologic actions:
- Person-centred shared decision-making within eligible options; non-coercive (US-MEC 2024 Nguyen)
- No routine pelvic exam / cervical screen / STI test / lipids / glucose / thrombophilia screen required to start in an asymptomatic person (US-SPR 2024 Curtis)
- Quick Start same day when reasonably certain not pregnant; method-specific back-up plan (US-SPR 2024 Curtis)
- Advance supply of emergency contraception, especially for barrier/FAB users (US-SPR 2024 Curtis)
- Bridge/overlap when switching methods to avoid an unprotected gap (US-SPR 2024 Curtis)
- Route non-contraceptive-benefit / complex comorbidity questions to PCOS, AUB, menopause, or MFM/cardiology engines

AVOID / contraindication checks:
- CHC category 4 migraine with aura any age (US MEC 2024 Nguyen; Tepper 2016: CHC ~2 4x ischemic stroke in migraineurs)
- CHC category 4 age>=35 and >=15 cig per day; category 3 age>=35 and <15 cig per day (US MEC 2024 Nguyen)
- CHC category 4 postpartum <21d non breastfeeding; category 4 postpartum <42d with VTE risk factors; category 3 21 42d no risk factors; breastfeeding <21d category 4 (conditional: interval x breastfeeding x VTE risk) (US MEC 2024 Nguyen)
- CHC category 4 current or history VTE or known thrombogenic mutation or on anticoagulation (US MEC 2024 Nguyen; Lidegaard 2012; Stegeman 2013 BMJ: COC vs nonuse VT RR 3.5, 95% CI 2.9 4.3)
- CHC category 4 SBP>=160 or DBP>=100; category 3 adequately controlled or elevated BP 140 159/90 99 (US MEC 2024 Nguyen)
- All hormonal category 4 current breast cancer; category 3 past breast cancer no disease 5yr; Cu IUD remains category 1 (US MEC 2024 Nguyen)
- CHC and most hormonal category 3 4 SLE with positive or unknown antiphospholipid antibodies (US MEC 2024 Nguyen)
- CHC category 4 severe decompensated cirrhosis; category 3 or 4 hepatocellular adenoma or carcinoma; POP/implant category 3 (US MEC 2024 Nguyen)
- CHC category 4 ischemic heart disease or current stroke history; category 3 or 4 complicated valvular disease; category 4 peripartum cardiomyopathy normal or mildly impaired EF >6mo is cat 3 (US MEC 2024 Nguyen)
- CHC category 3 or 4 multiple major ASCVD risk factors clustered (older age+smoking+diabetes+hypertension) (US MEC 2024 Nguyen)
- CHC category 3 or 4 diabetes with nephropathy retinopathy neuropathy or >20yr duration; category 2 uncomplicated (US MEC 2024 Nguyen)
- CHC category 4 known thrombogenic mutation includes factor V Leiden prothrombin protein C S antithrombin (US MEC 2024 Nguyen)
- CHC category 3 or 4 major surgery with prolonged immobilization (US MEC 2024 Nguyen)
- CHC progestin type VTE gradient gestodene desogestrel CPA drospirenone ~50 80% higher than levonorgestrel prefer LNG and lowest EE (Stegeman 2013 BMJ; de Bastos 2014 Cochrane)
- Efficacy:enzyme inducers rifampin rifabutin certain ARVs (efavirenz) and some antiseizure (carbamazepine,phenytoin,phenobarbital,topiramate>200mg,lamotrigine CHC interaction) reduce hormonal efficacy prefer DMPA LARC or Cu IUD (US MEC 2024 Nguyen)
- Efficacy:malabsorptive bariatric surgery (RYGB,BPD) reduces oral COC/POP absorption prefer non oral route or LARC; restrictive (sleeve,band) no restriction (US MEC 2024 Nguyen)
- Timing:delay starting or restarting progestin contraception 5 days after ulipristal (antagonism) (US SPR 2024 Curtis; Glasier 2010)
- Efficacy:oral LNG EC reduced efficacy BMI>=26 or weight>=70kg offer Cu IUD/LNG IUS or ulipristal first (Stowers 2019; US SPR 2024 Curtis)
- Immediate postpartum IUD expulsion RR 4.55 (95% CI 2.52 8.19) vs delayed still net benefit counsel and string check (Sothornwit 2022 Cochrane)

Monitoring

Regimen monitoring:
- BP at CHC followup no routine labs (US-SPR 2024 Curtis)
- DMPA long term use and bone density discussion not a mandatory stop (Berenson 2008; US-MEC 2024 Nguyen)
- implant and IUD bleeding pattern counselling per US-SPR (US-SPR 2024 Curtis)
- re-screen US-MEC when new condition appears (new migraine aura / new VTE / BP rise / new breast cancer) (US-MEC 2024 Nguyen)
- LARC continuation and timely removal replacement at duration (Winner 2012 CHOICE)
- return to fertility counselling immediate for LARC CHC median ~10mo after last DMPA (US-MEC 2024 Nguyen)

Setting (outpatient) monitoring:
- Recheck BP at CHC follow-up; no routine labs otherwise (US-SPR 2024 Curtis)
- DMPA long-term-use / bone-density discussion (not a mandatory stop) (Berenson 2008)
- Implant/IUD bleeding-pattern counselling per US-SPR (US-SPR 2024 Curtis)
- Re-screen US-MEC on any new condition (new migraine aura, VTE, BP rise, breast cancer) (US-MEC 2024 Nguyen)
- Support LARC continuation; timely removal/replacement at duration (Winner 2012 CHOICE)

Follow-up plan: 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)
- Close-out criterion: Continuation/removal/transition plan and return-to-fertility counselling complete

Monitoring phase: 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)

Disposition

Current setting: outpatient — Provide person-centred, US-MEC-eligible, US-SPR-operationalised contraception same day, removing unnecessary barriers and addressing emergency contraception and postpartum/post-abortion timing (US-MEC 2024 Nguyen; US-SPR 2024 Curtis)

Disposition criteria:
- Same-day method provided or LARC/sterilization referral booked; outpatient continuation (US-SPR 2024 Curtis)
- Route to endo.pcos.core.v1 / gyn.abnormal-uterine-bleeding.core.v1 / gyn.menopause-management.core.v1 for overlapping indications

Escalation triggers (move to higher acuity):
- New migraine-with-aura, VTE, uncontrolled HTN, or breast cancer on CHC → STOP CHC, switch to progestin-only/Cu-IUD, re-screen US-MEC (US-MEC 2024 Nguyen)
- Suspected pregnancy with IUD in situ → evaluate location (rule out ectopic) and IUD management (US-SPR 2024 Curtis)
- Signs of VTE/arterial event on hormonal contraception → emergency evaluation, discontinue estrogen (Lidegaard 2012)
- Peripartum cardiomyopathy / pulmonary HTN / Fontan considering estrogen → MFM/cardiology + avoid estrogen (US-MEC 2024 Nguyen)

Patient Action Plan

**Contraception use, missed-dose, and warning-sign plan**
Personalised values: chosen_method, us_mec_category_for_method, start_rule_and_backup_window, ec_advance_supply, comorbidity_flags.

**Method working, no warning signs** (green):
Triggers:
- Using the method correctly and consistently
- No new headaches with aura, no leg/chest symptoms
- Blood pressure at goal if on the combined method
Actions:
- Keep using your method as instructed; LARC continuation gives the best protection (Winner 2012 CHOICE)
- Keep your emergency-contraception supply on hand if you use condoms or fertility-awareness (US-SPR 2024 Curtis)
- Keep routine follow-up; recheck blood pressure if on the pill/patch/ring (US-SPR 2024 Curtis)
- Tell your clinician before any new medication (some reduce contraceptive effectiveness) (US-MEC 2024 Nguyen)

**Missed dose, late, or new symptom** (yellow):
Triggers:
- Late or missed pill/patch/ring or DMPA injection
- New irregular bleeding or side effects
- New medication started (e.g. seizure medicine, rifampin)
Actions:
- Follow your method-specific missed-dose rule and use back-up (condoms) for the advised days (US-SPR 2024 Curtis)
- Use emergency contraception if you had unprotected sex and missed doses — Cu-IUD/LNG-IUS most effective; ulipristal better than LNG; LNG less effective if higher body weight (Turok 2021; Glasier 2010; Stowers 2019)
- Bleeding changes are common and usually not dangerous — contact your clinician if bothersome (US-SPR 2024 Curtis)
- Ask whether a new medication lowers effectiveness (US-MEC 2024 Nguyen)
Contact provider when:
- Repeated missed doses or unsure about back-up
- Bleeding that is heavy or persistent
- New medication that may interact

**Stop estrogen / seek urgent care** (red):
Triggers:
- New headache WITH visual aura while on the pill/patch/ring (US-MEC 2024 Nguyen; Tepper 2016)
- Calf swelling/pain, sudden shortness of breath or chest pain (possible clot) (Lidegaard 2012)
- Sudden severe headache, weakness, or speech/vision change (possible stroke)
- Severe abdominal pain with an IUD or possible pregnancy (rule out ectopic)
Actions:
- Stop the combined (estrogen) method now and seek urgent medical care
- Go to the emergency department for clot, stroke, or severe abdominal-pain symptoms
- Tell the clinicians which contraceptive you use
Contact provider when:
- Always seek emergency care for clot/stroke symptoms or severe abdominal pain with an IUD or possible pregnancy (US-MEC 2024 Nguyen)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Current/prior VTE, known thrombogenic mutation, or current anticoagulation with combined hormonal contraception — US-MEC category 4 (US-MEC 2024 Nguyen)
- [SEVERE] Migraine WITH aura at any age while using or requesting combined hormonal contraception — US-MEC category 4 (US-MEC 2024 Nguyen; Tepper 2016)
- [SEVERE] Age ≥35 years AND smoking ≥15 cigarettes/day with combined hormonal contraception — US-MEC category 4 (US-MEC 2024 Nguyen)

Citations

- CDC U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (Nguyen AT et al, MMWR Recomm Rep 2024;73[RR-4]:1-126) + CDC U.S. Selected Practice Recommendations for Contraceptive Use, 2024 (Curtis KM et al, MMWR Recomm Rep 2024;73[RR-3]:1-77); ACOG LARC/contraception; WHO MEC (aligned) [PMID:39106314](https://pubmed.ncbi.nlm.nih.gov/39106314/)
- Cited evidence (PMID 39106301) [PMID:39106301](https://pubmed.ncbi.nlm.nih.gov/39106301/)
- Cited evidence (PMID 21477680) [PMID:21477680](https://pubmed.ncbi.nlm.nih.gov/21477680/)
- Cited evidence (PMID 22621627) [PMID:22621627](https://pubmed.ncbi.nlm.nih.gov/22621627/)
- Cited evidence (PMID 20116841) [PMID:20116841](https://pubmed.ncbi.nlm.nih.gov/20116841/)

Last reconciled with current guidelines: 2026-05-17.
References
  • CDC U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (Nguyen AT et al, MMWR Recomm Rep 2024;73[RR-4]:1-126) + CDC U.S. Selected Practice Recommendations for Contraceptive Use, 2024 (Curtis KM et al, MMWR Recomm Rep 2024;73[RR-3]:1-77); ACOG LARC/contraception; WHO MEC (aligned) — PMID:39106314
  • Cited evidence (PMID 39106301) — PMID:39106301
  • Cited evidence (PMID 21477680) — PMID:21477680
  • Cited evidence (PMID 22621627) — PMID:22621627
  • Cited evidence (PMID 20116841) — PMID:20116841