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Contraceptive Pearl: Who Needs a Pregnancy Test When Starting Contraception?

Many clinicians or clinic protocols require a pregnancy test for patients who are starting contraception or receiving contraceptive care. However, a routine pregnancy test is not necessary for everyone starting contraception; it can act as a barrier to telehealth care and a negative test can provide false reassurance in some situations.

The US Selected Practice Recommendations for Contraceptive Use (US SPR) from the Centers for Disease Control and Prevention contains guidance to help assess whether someone is at risk for pregnancy (1). Box 2 in the US SPR has a simple list that allows a clinician to be reasonably certain that their patient is not pregnant if they have no signs or symptoms of pregnancy and meet any one of the criteria below:

  • Is 7 days or less from the start of a normal period
  • Has not had vaginal-penile sex since their last period
  • Has been correctly using a reliable contraceptive method
  • Is 7 days or less from a spontaneous or induced abortion
  • Is within 4 weeks postpartum
  • Is less than 6 months postpartum and chestfeeding for at least 85% or more of feeds (1)

A systematic review evaluated the effectiveness of this list compared to a urine pregnancy test, and found that this list correctly ruled out pregnancy with a negative predictive value of 99-100% (2). Depending on the clinic workflow, these questions can be integrated into patient intake paperwork, can be asked by nursing staff during triage, or can be asked by the clinician during the visit.

If someone does not meet any of these criteria, then a pregnancy test is warranted. While a positive pregnancy test is helpful, a negative pregnancy test is unreliable if the person had unprotected sex within the past two weeks. A pregnancy test can miss an early luteal phase pregnancy and is not helpful with pregnancies that may result from very recent sex. Patients who have had unprotected vaginal-penile sex within the previous 5 days should be offered emergency contraception, which can be a pill or an intrauterine device. For most contraceptive methods, the benefits of starting a method when the patient desires generally outweigh the risks, even when pregnancy cannot be ruled out. If patients choose to start contraception right away, then they should perform a follow-up urine pregnancy test in 2-4 weeks (1).


Resources:

Your Birth Control Choices Fact Sheet

Quick Start Algorithm

Emergency Contraception Pill User Guide

 

Sources:

Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. selected Practice recommendations for Contraceptive USE, 2016. MMWR Recommendations and Reports. 2016;65(4):1-66. doi:10.15585/mmwr.rr6504a1

Tepper NK, Marchbanks PA, Curtis KM. Use of a checklist to rule out pregnancy: a systematic review. Contraception 2013;87:661–5. http://dx.doi.org/10.1016/j.contraception.2012.08.007

 

Pharma-free

The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or contraception. The information in the Contraceptive Pearls is unbiased, based on science alone.