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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
Key points
- Most effective reversible methods: IUDs and etonogestrel implant
- Combined estrogen-progestin methods are contraindicated in migraine with aura, VTE history, smoking age >=35, breast cancer, severe hypertension, and early postpartum high-risk states
- Progestin-only methods are safer when estrogen contraindicated
- Copper IUD is the most effective emergency contraception and works up to 5 days
- Use CDC US MEC categories to match method safety to medical conditions
Overview
Contraception counseling should be patient-centered and noncoercive. Method choice depends on efficacy, contraindications, bleeding preferences, privacy, reversibility, access, STI protection, and reproductive goals.
Epidemiology
LARC methods have the lowest typical-use failure among reversible methods. Pills, patch, ring, and condoms have higher typical-use failure because adherence matters. Access and counseling quality influence use.
Clinical Features
Symptoms
Needs vary with postpartum status, breastfeeding, conditions, bleeding preference, fertility goals
Chest pain, dyspnea, unilateral leg swelling, neuro deficits on estrogen suggests thrombosis
Severe pelvic pain after IUD insertion requires evaluation
Amenorrhea is common with LNG-IUD, implant, DMPA, continuous hormones
Irregular bleeding common with progestin-only methods
Signs
BP measurement required before combined hormonal contraception
Pregnancy should be reasonably excluded before initiation when uncertain
IUD strings may be visible after placement
Cervical motion tenderness/purulent discharge suggests PID
Signs of VTE/stroke on estrogen require immediate evaluation
Investigations
First-line
Pregnancy assessmentHistory criteria and urine test when uncertain
Blood pressureNeeded before combined hormonal contraception
STI screeningBased on age/risk; IUD placement need not wait if no cervicitis/PID symptoms
Second-line
No routine pelvic exam for most methodsPelvic exam required for IUD placement, not pills/patch/ring/injection/implant
Lipid/glucose testingNot routinely required solely for contraception
Ultrasound for missing IUD stringsConfirms intrauterine position after excluding pregnancy
Specialist
Complex contraception consultationHigh-risk cardiac disease, active cancer, transplant, migraine, thrombophilia, interacting meds
Permanent contraception counselingDiscuss permanence, alternatives, consent, regret risk
1
Highly effective reversible methods
- Copper IUD: hormone-free, long-acting, may increase bleeding/cramping, most effective emergency contraception
- Levonorgestrel IUD: reduces heavy bleeding/dysmenorrhea
- Etonogestrel implant: highly effective, irregular bleeding common
2
Hormonal methods
- Combined pill/patch/ring regulate bleeding and suppress ovulation; avoid when estrogen contraindicated
- Progestin-only pill useful when estrogen contraindicated
- DMPA every 3 months; weight gain, irregular bleeding, delayed fertility return, reversible BMD reduction
3
Emergency contraception
- Copper IUD within 5 days is most effective and provides ongoing contraception
- Ulipristal more effective than levonorgestrel later in window or higher BMI
- Levonorgestrel EC widely available and best as soon as possible
4
Contraindications/cautions
- Combined hormonal contraception contraindicated in migraine with aura, VTE/stroke history, severe hypertension, smoking age >=35 with heavy use, current breast cancer, early postpartum high VTE risk
- Copper IUD avoided in active PID, unexplained bleeding suspicious for malignancy, copper allergy/Wilson disease
- Hormonal methods do not protect against STIs; condoms reduce transmission
Complications
- Estrogen-related thrombosis: VTE, stroke, or MI risk in susceptible patients
- IUD expulsion/perforation: Rare but important after insertion
- Ectopic pregnancy: Absolute risk reduced, but pregnancy with IUD is ectopic until proven otherwise
- Irregular bleeding: Common with progestin-only methods
- Reduced bone density: DMPA can reduce BMD, generally reversible
USMLE Step 2 CK Exam Tips
- 1Most effective reversible contraception = IUD or implant
- 2Most effective emergency contraception = copper IUD within 5 days
- 3Migraine with aura = no estrogen
- 4Smoker age >=35 = avoid combined hormonal contraception
- 5Breastfeeding postpartum patient can use progestin-only contraception; avoid estrogen early postpartum
- 6DMPA adverse effects: weight gain, irregular bleeding, delayed fertility, decreased BMD
- 7Pregnancy with IUD in place = evaluate for ectopic
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