What it is:Preventing pregnancy by stopping sperm from reaching a mature ovum (most hormonal and barrier methods) or by stopping a fertilized ovum from implanting (copper IUD, and technically anything working after ovulation). Not one drug class, it's a menu of mechanisms that all interrupt the same 28-day loop at different points.
The core problem:Perfect-use efficacy and typical-use efficacy are two different numbers, and the gap between them is almost entirely user error, not drug failure. A combined pill is 99%+ effective used perfectly and only ~91% effective as actually used. An implant is 99%+ either way because there's no daily step to forget.
What you do about it:Match the method to the patient, not the patient to the method. Efficacy, adherence capacity, comorbidities, STI risk, and desire for future pregnancy all steer the choice, and the U.S. Medical Eligibility Criteria (US MEC) tells you what's safe given the patient's history.
Anderson framed the whole visit as "efficacy tiers first, preference second."Methods that remove the user from the daily equation (implant, IUDs) beat methods that depend on remembering something (pills, patch, ring), which beat methods that depend on remembering something at the moment of sex (condoms, spermicide, fertility tracking). If a patient can't reliably do a daily task, don't prescribe a daily task and blame them later for the "failure."
You can't reason about contraceptive choice without the cycle underneath it. Every drug class on this page is blocking a specific step below.
| Component | Contraceptive action |
|---|---|
| Estrogen (EE, estetrol, estradiol valerate) | Suppresses FSH, which prevents follicle recruitment and blunts the LH surge. Stabilizes the endometrium so bleeding is predictable instead of erratic. |
| Progestin | Thickens cervical mucus (blocks sperm transport), causes endometrial atrophy (hostile to implantation), and at higher/steadier doses blocks the LH surge to suppress ovulation outright. |
| Copper | Directly toxic to sperm and ova. No hormones, no ovulation suppression. Works almost entirely pre-fertilization by making the uterine environment spermicidal. |
This is why dose matters within progestin-only methods.A norethindrone POP delivers just enough progestin to thicken mucus, and that's a fragile effect (hence the 3-hour missed-pill window). DMPA and the implant deliver enough progestin to reliably suppress ovulation itself, which is why they're far more forgiving of imperfect timing. Same mechanism family, very different margin for error, because the dose determines how many of the three progestin effects you actually get.
Ask about efficacy needs, ability to comply, medical history, STI risk, desire for future pregnancy, ability to pay, and partner involvement, then narrow using the tier below before you even get to individual products.
Implant, hormonal IUD, copper IUD. No daily/weekly/monthly step. Efficacy is essentially the same typical-use and perfect-use.
Pill, patch, ring, DMPA injection. Highly effective if used correctly, but user-dependent.
Condoms, diaphragm, cervical cap, sponge, spermicide. Only external condoms add STI protection.
Tracking cycle, cervical mucus, or basal temperature to avoid intercourse near ovulation.
LARC and permanent contraception have the lowest typical-use failure rates precisely because they remove the user from the equation.When a question asks "why is the implant more effective than the pill in real-world use" the answer is adherence, not pharmacology. Both suppress ovulation; only one requires the patient to remember something every day.
A study offering patients free reversible contraception with efficacy-first counseling (not preference-first) cut teen births to 6.3 per 1,000 versus 34.1 per 1,000 nationally, and cut abortions to 4.4 versus 19.6 per 1,000. LARC use in teens saved an estimated $17 for every $1 spent.The lesson Anderson pulled from this: lead with efficacy tiers when counseling, don't assume patients will decline LARC, and don't let cost or a myth about nulliparity block the most effective options.
The US MEC is the reference for "is this method safe given this patient's history." It sorts every condition into four categories, per method, per whether you're initiating (I) or continuing (C) the method.
| Category | Meaning |
|---|---|
| 1 | No restriction, method can be used |
| 2 | Advantages generally outweigh theoretical or proven risks |
| 3 | Risks usually outweigh the advantages, use only if no better option and with close follow-up |
| 4 | Unacceptable health risk, do not use |
A complete physical exam and Pap smear are notrequired before prescribing a CHC. What you actually need is a history and a blood pressure. Students consistently overestimate the workup bar here, don't repeat that mistake on rotation.
| Condition | Why it's category 4 for CHC |
|---|---|
| Smoking ≥15 cigarettes/day, age ≥35 | Estrogen + smoking synergistically raises MI and stroke risk |
| Migraine with aura, any age | Estrogen raises ischemic stroke risk on top of the aura-associated risk |
| BP ≥160/100 or vascular disease | Estrogen further raises BP and clot risk |
| Current or recent DVT/PE, known thrombophilia | Estrogen increases hepatic clotting factor production |
| Current breast cancer | Hormone-sensitive malignancy |
| <21 days postpartum | Baseline VTE risk is already sharply elevated postpartum |
| Severe (decompensated) cirrhosis, liver tumor | Hepatically metabolized hormones, hepatic mass risk |
Abdominal pain (severe) · Chest pain, cough, shortness of breath · Headache (severe), dizziness, weakness, numbness · Eye problems (vision loss, blurred vision) · Severe leg pain (calf or thigh). These map onto VTE, MI, stroke, and retinal vein thrombosis. Any one of these is an emergency evaluation, not a "let's watch it" conversation.
Because progestin-only methods (POP, DMPA, implant, hormonal IUD) don't carry estrogen's clotting and vascular risk, they stay category 1 or 2 for almost everything on the table above, including smoking, migraine with aura, and history of DVT/PE. This is the single biggest reason to reach for a progestin-only method instead of just declining to prescribe anything.
These matter for two reasons: they're the only OTC options for someone who can't get a prescription today, and condoms are the only method (besides abstinence) that also covers STIs.
| Method | Failure (typical use) | Key facts |
|---|---|---|
| External (male) condom | 13% | Latex is impermeable to viruses; lambskin is not. Use water-based lubricant (Astroglide, K-Y), oil-based lubricants degrade latex. Spermicide-coated condoms add no benefit and may increase HIV vulnerability. |
| Internal (female) condom | 21% | Covers labia and cervix, protects against HIV and other viruses. Higher pregnancy rate than external condoms. Never use external and internal condoms together. |
| Diaphragm + spermicide | 17% | Insert up to 6h before sex, leave in ≥6h after, remove within 24h(TSS risk). Efficacy drops with more frequent intercourse. |
| Cervical cap (FemCap) | 4–29% | Same spermicide requirement. Leave in place no longer than 48h. Cannot use during menses. |
| Spermicide alone (Phexxi) | 21–28% | Nonoxynol-9-free, prescription vaginal pH modulator. Use within 1h before each act of intercourse. Carries cystitis risk. |
| Sponge (Today) | 14–27% | Contains nonoxynol-9, OTC. Leave in ≥6h after sex, no more than 24–30h total. Cannot use during menses. |
Diaphragm: max 24 hours in place. Cervical cap: max 48 hours. Sponge: 6h minimum after sex, max 24–30 hours total.None of these protect against STIs, including HIV. Nonoxynol-9 used more than twice daily can actually increase HIV transmission risk by irritating vaginal tissue.
Fertility awareness-based methodstrack the cycle (calendar, basal body temperature, or cervical mucus changes) to avoid unprotected sex near ovulation. They're free and non-hormonal, but require meticulous, consistent record-keeping across several cycles before they're reliable, and they fall apart with irregular cycles, which is common in adolescents, breastfeeding, perimenopause, and right after a pregnancy loss or delivery. Emergency contraception itself can delay ovulation and throw off the tracking.
Pill, patch, or ring, all delivering estrogen plus progestin, all working primarily before fertilization. With perfect use, efficacy exceeds 99%; with typical use, up to 7% experience unintended pregnancy.
| Estrogen | Notes |
|---|---|
| Ethinyl estradiol (EE) | The default, available 10–50 mcg. Most modern pills use 20–35 mcg ("low-dose"). |
| Estetrol (E4) | Nextstellis only, a "native" estrogen with a different clotting-factor profile than EE. |
| Estradiol valerate | Natazia only, four-phasic dosing with dienogest. |
| Progestin generation | Agents |
|---|---|
| 1st generation | |
| Estranes | Norethindrone, norethindrone acetate, ethynodiol diacetate |
| 2nd generation | |
| Gonanes | Levonorgestrel, norgestrel |
| 3rd generation | |
| Lower androgenicity | Norgestimate, desogestrel (active form etonogestrel) |
| 4th generation | |
| Antiandrogenic / SPRM-adjacent | Drospirenone, dienogest, segesterone acetate; ulipristal acetate is a separate selective progesterone receptor modulator (SPRM) used for EC, not daily contraception |
All CHCs raise sex hormone-binding globulin (SHBG) via the estrogen component, which mops up free testosterone. But older, more androgenic progestins (norgestrel, levonorgestrel) partially fight that effect. Newer, less androgenic progestins (norgestimate, desogestrel, and especially drospirenone) don't fight it, so free testosterone drops further and acne improves more. That's the mechanism behind "which pill for acne" questions, it's not magic, it's just less androgen competing with the estrogen effect.
| Start method | When | Backup needed? |
|---|---|---|
| First-day start | Day 1 of menses | None |
| Sunday start | First Sunday after menses begins | 7 days if >5 days since bleeding started |
| Quick start | Day of the office/pharmacy visit | 7 days (none if within first 5 days of menses) |
Quick start is preferred in practice: about a quarter of patients told to "wait for your period" never actually start, whether from forgetting, an unplanned pregnancy in the interim, or simply not filling the prescription. A second method should be used for 7–30 days after CHC initiation depending on product labeling, and hormonal contraception should not resume sooner than 5 days after ulipristal-based emergency contraception.
Xulane/Zafemydeliver 35 mcg EE + 150 mcg norelgestromin daily. Twirladelivers 30 mcg EE + 120 mcg levonorgestrel daily. Apply to abdomen, buttock, upper torso, or upper arm; one patch weekly for 3 weeks, then a patch-free week. Efficacy drops in patients over roughly 90 kg for Xulane/Zafemy or BMI ≥30/weight >92 kg for Twirla, so this isn't a great option for higher body weight. Should not be used continuously.
| Missed patch | Action |
|---|---|
| Week 1, any delay | Apply now, backup x7 days, new Day 1 and patch-change day |
| Weeks 2–3, <48h late | Remove old, apply new, no backup, same patch-change day |
| Weeks 2–3, ≥48h late | Remove, apply new patch as a new cycle, backup x7 days |
| Week 4 | Remove when remembered, no backup, start next cycle on the usual day |
NuvaRingreleases ~15 mcg EE + 120 mcg etonogestrel daily, lasts 3 weeks in, 1 week out, needs refrigeration before dispensing (stable at room temp for 4 months once out of the fridge). Can be removed up to 3 hours without needing backup. Annoverareleases 13 mcg EE + 150 mcg segesterone acetate, lasts a full year (13 cycles) on a 3-weeks-in/1-week-out schedule, doesn't need refrigeration, and hasn't been studied above BMI 29. No precise placement is needed for either ring, and both can stay in during sex, tampon use, and water-based topical antifungals or spermicides. Douching should be avoided.
Baseline VTE risk in a healthy person of reproductive age is about 1–5 per 10,000 person-years.A combined oral contraceptive raises that to roughly 3–9 per 10,000.Pregnancy itself carries 5–20 per 10,000, and the postpartum period is 40–65 per 10,000, several times higher than the pill ever gets. Patients (and pharmacists in training) tend to catastrophize CHC clot risk while ignoring that pregnancy is the riskier state for clotting. Newer progestins (drospirenone, desogestrel, norgestimate) carry a modestly higher thrombosis risk than older ones like levonorgestrel, through mechanisms that aren't fully worked out, which matters when choosing among otherwise-similar options in a patient with borderline VTE risk factors.
The 2017 Danish cohort data behind the ACOG advisory put the excess breast cancer risk from CHC use at a number needed to harm (NNH) of about 1 in 7,690overall, and 1 in 50,000for those under 35. Compare that to the VTE NNH of about 1 in 729, VTE is the more clinically meaningful risk to counsel on, even though breast cancer is the one patients usually ask about first.
Nausea, breast tenderness, and breakthrough bleeding are common in the first cycle and typically resolve by the third. If breakthrough bleeding persists: first check adherence (missed pills are the most common cause), then ask about smoking. A patient who smokes needs cessation counseling or a method switch, not a dose change, since smoking itself destabilizes the endometrium. If adherence is good and the patient doesn't smoke, refer for evaluation of other causes, or consider increasing the EE dose slightly (to 30–35 mcg) and switching the progestin.
| Class | Agents |
|---|---|
| Antiepileptics | Carbamazepine, oxcarbazepine, phenytoin, topiramate, phenobarbital, primidone, felbamate |
| Antiretrovirals | Fosamprenavir (only when not ritonavir-boosted) |
| Antifungal | Griseofulvin |
| Antibiotics | Rifampin and rifabutin |
| Other | Lumacaftor/ivacaftor (cystic fibrosis), tirzepatide (delayed gastric emptying), St. John's wort |
Most antibiotics do NOT interact with hormonal contraception.Rifampin and rifabutin are the real interaction; routine antibiotics like amoxicillin or azithromycin are not. Reflexively telling every patient on antibiotics to use backup contraception is outdated advice. The reverse interaction also exists and is easy to miss: CHCs can lower lamotrigine levelsand raise seizure risk, that one doesn't happen with progestin-only methods.
Best for patients who are lactating, estrogen-intolerant, or have an estrogen contraindication. Less effective than CHC and prone to irregular, unpredictable bleeding, and they carry more ectopic pregnancies than other hormonal methods. Must be taken at approximately the same time daily.
| Formulation | Missed-pill threshold | If missed |
|---|---|---|
| Norethindrone 0.35 mg / Norgestrel 0.075 mg (OTC as Opill) | >3 hours late | Take the missed pill, resume regular time, backup x48h |
| Drospirenone 4 mg (Slynd, 24 active + 4 placebo) | >24 hours late(1 missed pill) | 1 pill late: resume as prescribed, no backup. ≥2 pills: take last dose + next dose, backup x7 days |
Not all progestin-only pills have the same missed-dose window.Norethindrone and norgestrel POPs have a strict 3-hour window because their progestin dose mainly acts on cervical mucus, an effect that fades fast. Slynd (drospirenone) behaves like a CHC with a 24-hour window because its dose reliably suppresses ovulation. If a question gives you "3 hours" as the missed-pill cutoff for a POP, it's not talking about Slynd.
| Formulation | Dose / route | Site |
|---|---|---|
| Depo-Provera | 150 mg intramuscular | Gluteal or deltoid |
| Depo-SubQ Provera 104 | 104 mg subcutaneous, prefilled syringe only | Abdomen or anterior thigh |
DMPA carries a boxed warning for reduced bone mineral density, not for increased fracture risk, that distinction is tested. Loss is greater with longer duration and when started before age 20, but it's largely reversibleeven after more than 4 years of use. Guidance is not to continue beyond 2 yearsunless other methods are inadequate for that patient, and to ensure adequate calcium intake and weight-bearing exercise while on it. Do not routinely order a DXA scan just because someone is on DMPA.
Most common adverse effect by far is menstrual irregularity, worst in the first 6–12 months and improving after. Weight gain is typically modest (2–6 lb average). Weigh gain, mood change, and bone density concerns against DMPA's real advantages: no estrogen, minimal drug interactions, and a typical-use failure rate (4%) that's much better than the pill's.
A 4-cm radiopaque rod placed subdermally in the upper arm, releasing 60 mcg/day of etonogestrel initially, tapering to about 30 mcg/day by the end of use. Approved for 5 yearsas of a recent label update (previously 3). Efficacy exceeds 99% but may fall in patients over 130% of ideal body weight. Fertility returns within 30 days of removal; effects are quickly reversible. Watch for interactions with potent CYP450 inducers (rifampin, phenytoin, carbamazepine).
| Product | Type | Duration | Bleeding effect |
|---|---|---|---|
| ParaGard | Copper, non-hormonal | 10 years | Heavier menses, more cramping, especially first 3–6 months |
| Mirena, Liletta | Levonorgestrel | 8 years | Lighter periods, up to 90% reduction in flow, many become amenorrheic |
| Kyleena | Levonorgestrel, lower dose | 5 years | Lighter periods, more spotting than Mirena/Liletta |
| Skyla | Levonorgestrel, lowest dose | 3 years | Lighter periods |
All IUDs act mainly before implantation. Levonorgestrel IUDs add endometrial suppression and thickened mucus on top of the local foreign-body/inflammatory effect; copper works through direct spermicidal and ovicidal toxicity, no hormones at all. Both exceed 99% efficacy and reverse quickly on removal, with no long-term fertility impact and low PID risk despite the insertion procedure.
Nulliparity and adolescence are not reasons to avoid an IUD or implant.Given their high efficacy and low complication rates, LARCs are appropriate first-line options in both populations. The old "IUDs are only for women who've had children" teaching is wrong and costs patients access to the most effective reversible methods.
Period late, abnormal bleeding · Abdominal pain or pain with intercourse · Infection exposure/STI, abnormal discharge · Not feeling well, fever, chills · String missing, shorter, or longer than expected. Any of these warrants an exam to check for expulsion, perforation, pregnancy (including ectopic), or infection.
Dozens of brand names exist for a handful of formulations. Know the representative dose combinations and the method-level doses below, not every brand name.
| Method / Example brand | Composition | Regimen |
|---|---|---|
| Monophasic COC (representative low-dose) | ||
| e.g. Aviane, Lutera (Levonorgestrel/EE) | EE 20 mcg + levonorgestrel 0.1 mg | 21 active + 7 placebo |
| e.g. Yasmin, Ocella (Drospirenone/EE) | EE 30 mcg + drospirenone 3 mg | 21 active + 7 placebo, monitor K⁺ |
| Nextstellis | Estetrol 14.2 mg + drospirenone 3 mg | 24 active + 4 placebo |
| Lo Loestrin Fe | EE 10 mcg + norethindrone acetate 1 mg | 26 active (ultra-low estrogen) + 2 placebo; adherence critical |
| Multiphasic COC (representative) | ||
| Ortho Tri-Cyclen and generics | EE 35 mcg + norgestimate 0.18/0.215/0.25 mg stepped | 21 active (triphasic) + 7 placebo |
| Natazia | Estradiol valerate + dienogest, four-phasic | 26 active + 2 placebo |
| Extended cycle | ||
| Seasonique and similar | EE 30 mcg + levonorgestrel 0.15 mg | 84 active + 7 low-dose EE (4 cycles/year) |
| Progestin-only pill | ||
| Norethindrone (Camila, Micronor, generics) | Norethindrone 0.35 mg | 28 active, no placebo, 3h window |
| Slynd | Drospirenone 4 mg | 24 active + 4 placebo, 24h window |
| Transdermal / vaginal | ||
| Xulane / Zafemy patch | EE 35 mcg + norelgestromin 150 mcg/day | 1 patch weekly x3, then patch-free week |
| Twirla patch | EE 30 mcg + levonorgestrel 120 mcg/day | Same schedule; BMI <30 for full efficacy |
| NuvaRing | EE 15 mcg + etonogestrel 120 mcg/day | 3 weeks in, 1 week out |
| Annovera | EE 13 mcg + segesterone acetate 150 mcg/day | 3 weeks in, 1 week out, reusable x1 year |
| Injectable / implant | ||
| Depo-Provera | Medroxyprogesterone 150 mg IM | Every 12 weeks |
| Depo-SubQ Provera 104 | Medroxyprogesterone 104 mg SubQ | Every 12 weeks |
| Nexplanon | Etonogestrel 68 mg rod | Every 5 years |
| Emergency contraception | ||
| Levonorgestrel (Plan B and generics, OTC) | 1.5 mg single dose | Within 72h (up to 120h), less effective >75 kg |
| Ulipristal acetate (Ella, Rx) | 30 mg single dose | Within 120h, more weight-tolerant than LNG |
| Population | Guidance |
|---|---|
| Age >35, nonsmoker | CHC with <50 mcg EE is reasonable if healthy. No demonstrated increased CV risk with low-dose CHC in healthy, nonobese patients. |
| Age >35, smoker ≥15 cig/day | CHC contraindicated. Use progestin-only. |
| Smoker <35 | If using CHC, favor <50 mcg EE to reduce MI risk. |
| Hypertension | CHC acceptable if <35 and well-controlled/monitored. Avoid CHC at 140–159/90–99. Contraindicated at ≥160/100. CHC itself can raise BP 6–8 mmHg regardless of dose. |
| Diabetes | CHC safe if <35, nonsmoking, no vascular disease. Avoid CHC with >20 years duration or vascular complications. |
| Obesity | COC efficacy drops with obesity, especially low-dose formulations. IUD, implant, and DMPA remain highly effective. VTE risk is also elevated with obesity, favor progestin-only after 35. |
| Migraine without aura | CHC reasonable if <35, nonsmoking, and monitored; can go either direction on frequency. |
| Migraine with aura | CHC contraindicated at any age due to stroke risk. Switch to progestin-only if aura develops on CHC. |
| Breast cancer, current or past | CHC contraindicated. BRCA1/2 carriers without active cancer: use is controversial, individualize. |
| SLE with antiphospholipid antibodies | Avoid CHC and progestin-only products; copper IUD is often the best option. |
| Postpartum, breastfeeding | Avoid estrogen <21 days (VTE risk); avoid through 42 days if breastfeeding with other VTE risk factors. Progestin-only methods are fine sooner. |
| Postpartum, non-breastfeeding | CHC still category 4 (contraindicated) <21 days, category 2–3 21–42 days depending on VTE risk factors. |
| Seizure disorder on enzyme-inducing AEDs | CHC and POP efficacy reduced (phenytoin, carbamazepine, barbiturates, topiramate, oxcarbazepine). Favor IUD, implant, or DMPA instead. |
Oregon law lets a pharmacist prescribe and administer injectable hormonal contraception and prescribe/dispense self-administered hormonal contraceptives, for patients ≥18 (or under 18 with evidence of a prior prescription for the method).
Required of the pharmacist:complete Board of Pharmacy-approved training, provide a self-screening questionnaire, refer to a women's health provider when appropriate, and give the patient a record of the prescription. Records and training documentation must be retained (training 6 years, visit records 7 years minimum), and the visit must follow the PPCP with a face-to-face physical assessment (BP).
Prohibited:requiring an appointment, prescribing to someone without evidence of a clinical visit within the past 3 years, and prescribing to yourself or family members. Insurance covers the medication; the visit itself is typically billed as a separate service fee.
The workflow mirrors the PPCP: Collect(insurance, questionnaire, meds, BP) → Assess(pregnancy status, contraindications against US MEC) → Plan(patient preference, options, refer if indicated) → Implement(counsel, provide record, notify PCP) → Follow-Up(3 months for new starts, sooner for side effects, refer as needed).
In the original Direct Access pilot study behind this law, of 214 patients screened by community pharmacists: 8.8% were referred out for contraindications, and among those started, 97.7% were satisfied and 97.1% said they'd refer a friend. The self-screening questionnaire performed well enough that patients could reliably assess their own risk factors compared to a provider doing it, which is the evidence base the whole statewide protocol rests on.
Used after unprotected or inadequately protected intercourse: no method used, condom failure, or a missed pill/late injection/expelled ring or patch. It is not a routine ongoing contraceptive method, it's a backstop.
| Option | Dose / access | Window | Key limiting factor |
|---|---|---|---|
| Copper IUD | Placed by provider | Most effective option; can be placed and left as ongoing contraception | None, effective regardless of weight |
| Ulipristal acetate (Ella) | 30 mg single dose, prescription only | Up to 120h (5 days) | Efficacy declines >88 kg / BMI 35. Won't work if a progestin-containing method is used within 5 days before or after. |
| Levonorgestrel (Plan B, generics) | 1.5 mg single dose, OTC | Labeled 72h, effective to ~120h with declining efficacy | Efficacy approaches placebo at >70–75 kg or BMI ≥26 |
| Yuzpe method | Higher-dose combined pills | Historical, rarely used now | More nausea/vomiting than dedicated EC products |
Body weight is the single strongest predictor of EC failure.Obese patients have roughly 3x the pregnancy risk on levonorgestrel EC compared to normal weight. Ulipristal holds up better at higher weights but also declines past 88 kg/BMI 35. The copper IUD is the only EC option unaffected by weight, so it's the first offer for a higher-weight patient at real risk, if they're willing.
If a copper IUD is declined: use UPA + delayed startof a progestin-containing method (wait 5 days) for a patient at higher pregnancy risk, higher weight, or likely to return for follow-up. Use LNG + immediate startof ongoing contraception for lower-risk patients unlikely to return or wait. Starting a progestin method right after UPA blunts UPA's efficacy, this is a real interaction, not a theoretical one.
EC does not cause birth defects. EC does not cause an abortion(it works before or around ovulation/fertilization, not after implantation). EC can be purchased in advance of need.A Florida pharmacist survey found 56%, 46%, and 78% of pharmacists respectively believed the opposite of each of these, all false. Correct these proactively, patients pick up on hesitation.
In Oregon,pharmacists can prescribe both LNG and UPA emergency contraception, and OHP covers LNG EC without a prescription requirement. Counsel on antiemetic pretreatment (about 1 hour before the dose) if nausea is a concern, expected menstrual changes including a delayed next period, and to test for pregnancy and follow up if menses hasn't returned within 3 weeks. EC offers no STI protection, use the visit to screen for STI risk and discuss ongoing contraception.
For early pregnancy termination (≤70 days gestation), the FDA-approved regimen is mifepristone 200 mg orally on day 1, then misoprostol 800 mcg buccally 24–48 hours later.Combined, this regimen is about 98% effective through 49 days.
Mifepristone carries a boxed warning for infection and excessive bleeding.Heavy bleeding can signal an incomplete termination or another complication and needs prompt medical attention, this is not a "wait and see" adverse effect.
| Method | When | Watching for |
|---|---|---|
| Blood pressure (all CHC users) | Baseline, then annually | Rising BP that would push the patient into a higher MEC category |
| Glucose (diabetes/glucose intolerance) | When CHC is started or stopped | Glycemic shifts from estrogen/progestin effects |
| Potassium (drospirenone products) | Regularly if on ACEi, ARB, K-sparing diuretic, or aldosterone antagonist | Hyperkalemia (drospirenone has mild antimineralocorticoid activity) |
| Nexplanon | Annually | Menstrual disturbance, weight change, site inflammation/infection, acne, breast tenderness, headache, hair loss |
| DMPA | Every 3 months (at reinjection) | Weight gain, menstrual disturbance, mood changes; BMD concern with >2 years of use |
| IUD (any type) | 1–3 month intervals after placement | Proper positioning, string check, menstrual pattern changes, upper genital tract infection |
| All hormonal contraception | Annual visit | Cytologic screening if due, pelvic/breast exam if indicated, breakthrough bleeding, amenorrhea, weight gain, acne. None of these need to happen before the first prescription. |
| All patients | Ongoing | STI/HIV risk screening and condom counseling, since most methods here don't cover STIs |