Ask the client the questions below about known medical conditions. Examinations and tests are not necessary. If she answers “no” to all of the questions, then she can start COCs if she wants. If she answers “yes” to a question, follow the instructions. In some cases she can still start COCs. These questions also apply for the combined patch and the combined vaginal ring.

1.  Are you breastfeeding a baby less than 6 months old?

NO   YES

• If fully or nearly fully breastfeeding: Give her COCs and tell her to start taking them 6 months after giving birth or when breast milk is no longer the baby’s main food—whichever comes first (see Fully or nearly fully breastfeeding).
• If partially breastfeeding: She can start COCs as soon as 6 weeks after childbirth (see Partially breastfeeding).

2.  Have you had a baby in the last 3 weeks and you are not breastfeeding?

NO   YES Give her COCs now and tell her to start taking them 3 weeks after childbirth. (If there is an additional risk that she might develop a blood clot in a deep vein (deep vein thrombosis, or VTE), then she should not start COCs at 3 weeks after childbirth, but start at 6 weeks instead. These additional risk factors include previous VTE, thrombophilia, caesarean delivery, blood transfusion at delivery, postpartum hemorrhage, pre-eclampsia, obesity (≥ 30 kg/m²), smoking, and being bedridden for a prolonged time.)

3.  Do you smoke cigarettes?

NO   YES If she is 35 years of age or older and smokes, do not provide COCs. Urge her to stop smoking and help her choose another method, but not patch or ring if she smokes fewer than 15 cigarettes a day, and also not monthly injectables if more than 15 cigarettes a day.

4.  Do you have cirrhosis of the liver, a liver infection, or liver tumor? Have you ever had jaundice when using COCs?

NO   YES If she reports serious liver disease (such as severe cirrhosis or liver tumor), acute or flare of viral hepatitis, or ever had jaundice while using COCs, do not provide COCs. Help her choose a method without hormones. (She can use monthly injectables if she has had jaundice only with past COC use.)

5.  Do you have high blood pressure?

NO   YES If you cannot check blood pressure and she reports a history of high blood pressure, or if she is being treated for high blood pressure, do not provide COCs. Refer her for a blood pressure check if possible or help her choose a method without estrogen.

Check blood pressure if possible:

• If her blood pressure is below 140/90 mm Hg, provide COCs. No need to retest before starting COCs.
• If blood pressure is 160/100 mm Hg or higher, do not provide COCs. Help her choose a method without estrogen, but not a progestin-only injectable.
• If blood pressure is 140–159/90–99 mm Hg, one measurement is not enough to diagnose high blood pressure. Give her a backup method* to use until she can return for another blood pressure measurement, or help her choose another method.
  • If her next blood pressure measurement is below 140/90 mm Hg, she can start COCs.
  • However, if her next blood pressure measurement is 140/90 mm Hg or higher, do not provide COCs. Help her choose a method without estrogen, but not a progestin-only injectable if systolic blood pressure is 160 or higher or diastolic pressure is 100 or higher.

6.  Have you had diabetes for more than 20 years or damage to your arteries, vision, kidneys, or nervous system caused by diabetes?

NO   YES Do not provide COCs. Help her choose a method without estrogen but not progestin-only injectables.

7.  Do you have gallbladder disease now or take medication for gallbladder disease?

NO   YES Do not provide COCs. Help her choose another method but not the combined patch or combined vaginal ring.

8.  Have you ever had a stroke, blood clot in your leg or lungs, heart attack, or other serious heart problems?

NO   YES If she reports heart attack, heart disease due to blocked or narrowed arteries, or stroke, do not provide COCs. Help her choose a method without estrogen but not progestin-only injectables. If she reports a current blood clot in the deep veins of the legs (not superficial clots) or lungs, help her choose a method without hormones.

9.  Do you have or have you ever had breast cancer?

NO   YES Do not provide COCs. Help her choose a method without hormones.

10.  Do you sometimes see a bright area of lost vision in the eye before a very bad headache (migraine aura)? Do you get throbbing, severe head pain, often on one side of the head, that can last from a few hours to several days and can cause nausea or vomiting (migraine headaches)? Such headaches are often made worse by light, noise, or moving about.

NO   YES If she has migraine aura at any age, do not provide COCs. If she has migraine headaches without aura and is age 35 or older, do not provide COCs. Help these women choose a method without estrogen. If she is under 35 and has migraine headaches without aura, she can use COCs (see Identifying Migraine Headaches and Auras).

11.  Are you taking medications for seizures? Are you taking rifampicin or rifabutin for tuberculosis or other illness?

NO   YES If she is taking barbiturates, carbamazepine, lamotrigine, oxcarbazepine, phenytoin, primidone, topiramate, rifampicin, or rifabutin, do not provide COCs. They can make COCs less effective. Help her choose another method but not progestin-only pills, patch, or combined ring. If she is taking lamotrigine, help her choose a method without estrogen.

12.  Are you planning major surgery that will keep you from walking for one week or more?

NO   YES If so, she can start COCs 2 weeks after she can move about again. Until she can start COCs, she should use a backup method.

13.  Do you have several conditions that could increase your chances of heart disease (coronary artery disease) or stroke, such as older age, smoking, high blood pressure, or diabetes?

NO   YES Do not provide COCs. Help her choose a method without estrogen but not progestin-only injectables.

Also, women should not use COCs if they report having thrombogenic mutations or lupus with positive (or unknown) antiphospholipid antibodies. For complete classifications, see Appendix D – Medical Eligibility Criteria for Contraceptive Use.

Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable, when relevant to the client.

* Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptive methods. If possible, give her condoms.