Further Options to
Assess for Pregnancy

A woman can start a hormonal contraceptive method or, in most cases, an IUD any time it is reasonably certain that she is not pregnant. This includes a certain number of days after the start of monthly bleeding, depending on the method. At other times in a woman's monthly cycle, the Pregnancy checklist often can be used to be reasonably certain she is not pregnant.

A woman who answers "no" to all questions in the pregnancy checklist may or may not be pregnant. In most situations, such a woman will need to use a backup method* and wait either until her next monthly bleeding to start her method of choice or until it becomes clear that she is pregnant.

In some cases, however, some providers may want to assess for pregnancy by other means. To do so, providers can follow one of the sets of instructions below, as appropriate for their situation and training. These options are especially useful when there are likely explanations—other than pregnancy—that a woman has not had monthly bleeding for several months. Such reasons include:

• She has given birth more than 6 months ago and is still breastfeeding.
• She continues to have no monthly bleeding after recently stopping a progestin-only injectable.
• She has a chronic health condition that stops monthly bleeding.

Assessing for Pregnancy

If a pregnancy test is available:

• Give her a urine pregnancy test or refer her to a facility with such tests. If the pregnancy test is negative, give her the contraceptive method she wants.

If a pregnancy test is not available but a provider can conduct a bimanual pelvic examination:

• Take a history from the woman, including when she had her last monthly bleeding and whether she has signs or symptoms of pregnancy (see symptoms).
• Conduct a bimanual pelvic examination to determine the size of her uterus so that you can make a comparison later.
• Give her a backup method to use and teach her how to use it consistently and correctly. Ask her to return in about 4 weeks or when she has monthly bleeding, whichever comes first.

When she returns:

• If she returns with monthly bleeding, give her the contraceptive method she wants.
• If she returns still without monthly bleeding after 4 weeks, conduct a second pelvic examination.
  • A woman who previously had regular monthly bleeding and now has no bleeding is most likely pregnant and would have some enlargement of the uterus.
  • If there is no enlargement of the uterus, no other signs or symptoms of pregnancy, and she has used a backup method consistently and correctly, give her the contraceptive method that she wants. She may need to continue her backup method for the first few days of use, as specified for each method.

If neither a pregnancy test nor a bimanual examination is available:

• The provider can give the woman a backup method and ask her to return during her next monthly bleeding or in 12 to 14 weeks, whichever comes first.

When she returns:

• If she returns with monthly bleeding, give her the contraceptive method she wants.
• If she returns still without monthly bleeding after 12 to 14 weeks:
  • If she is pregnant, the uterus can be felt externally, through the lower abdominal wall, coming up from below.
  • If there is no enlargement of the uterus and no other signs or symptoms of pregnancy, and she has used a backup method consistently and correctly, give her the contraceptive method that she wants. She may need to continue her backup method for the first few days of use, as specified for each method.

Tell her to return to the clinic any time if she thinks that she might be pregnant, or if she has signs or symptoms of pregnancy. If you suspect an underlying health problem as the reason for a prolonged absence of monthly bleeding, refer for assessment and care.

Signs and Symptoms of Pregnancy

• Nausea
• Breast tenderness
• Fatigue
• Vomiting

* 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.

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