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 monthly injectables if she wants. If she answers "yes" to a question, follow the instructions. In some cases she can still start monthly injectables.

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

NO   YES

• If fully or nearly fully breastfeeding: She can start 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 monthly injectables as soon as 6 weeks after giving birth (see Partially breastfeeding).

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

NO   YES She can start monthly injectables as soon as 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 monthly injectables at 3 weeks after childbirth, but can 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 15 or more cigarettes a day?

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

4.    Do you have severe liver disease—active hepatitis, severe cirrhosis, or liver tumor?

NO   YES If she reports active hepatitis, severe cirrhosis, or liver tumor, do not provide monthly injectables. Help her choose a method without hormones. (If she has mild cirrhosis or gallbladder disease, she can use monthly injectables.)

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 monthly injectables. Refer her for a blood pressure check if possible or help her choose another method without estrogen.

Check her blood pressure if possible:

• If blood pressure is below 140/90 mm Hg, provide monthly injectables.
• If systolic blood pressure is 140 mm Hg or higher or diastolic blood pressure is 90 or higher, do not provide monthly injectables. Help her choose a method without estrogen, but not progestin-only injectables if systolic blood pressure is 160 or higher or diastolic pressure is 100 or higher.

(One blood pressure reading in the range of 140–159/90–99 mm Hg is not enough to diagnose high blood pressure. Provide a backup method^* to use until she can return for another blood pressure check, or help her choose another method now if she prefers. If blood pressure at next check is below 140/90, she can use monthly injectables.)^†

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 monthly injectables. Help her choose a method without estrogen but not progestin-only injectables.

7.    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 monthly injectables. 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 leg (not a superficial clot) or in the lungs, help her choose a method without hormones.

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

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

9.    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 monthly injectables. If she has migraine headaches without aura and is age 35 or older, do not provide monthly injectables. Help these women choose a method without estrogen. If she is under 35 and has migraine headaches without aura, she can use monthly injectables (see Identifying Migraine Headaches and Auras).

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

NO   YES If so, she can start monthly injectables 2 weeks after the surgery. Until she can start monthly injectables, she should use a backup method.

11.  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 monthly injectables. Help her choose a method without estrogen, but not progestin-only injectables.

12.  Are you taking lamotrigine?

NO   YES Do not provide monthly injectables. Monthly injectables can make lamotrigine less effective. Help her choose a method without estrogen.

^*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.

^†For guidance on routine blood pressure testing, see Chapter 1, Question 18.

Also, women should not use monthly injectables 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.