Question: Dr. Zieman, I am an NP with 8 years of family planning experience in a title X clinic in Oklahoma. Managing Contraception has been very influential in my practice. Due to current politics in my state, I believe initiating contraception via the QuickStart method has become exponentially crucial. In terms of contraceptive care, specifically when considering a LARC method, is the withdrawal method considered a reliable method if used consistently and correctly? Thank you for your feedback and time.
Answer: I’m so glad that Managing Contraception is useful to your practice, and I agree that given today’s political climate, expedient and successful contraceptive use is critical.
A LARC method, also known as an implant or IUD, can be inserted at any time during the cycle if you can be reasonably certain a woman is not pregnant, also known as QuickStart if it is not during a specific window at the start of her cycle.
A health care provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any one of the following criteria:
is ≤7 days after the start of normal menses
has not had sexual intercourse since the start of last normal menses
has been correctly and consistently using a reliable method of contraception
is ≤7 days after spontaneous or induced abortion
is within 4 weeks postpartum
is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds), amenorrheic, and
So, you are asking whether withdrawal is considered a reliable method of contraception, as well as the consequences of not using QuickStart for the intended method. Although, I cannot find that the CDC has defined which methods they refer to as “reliable,” reliability depends both on the inherent effectiveness of the method itself and on how consistently and correctly it is used.
For the purposes of the screening tool above—and deciding whether you are reasonably sure someone is not pregnant—I would argue that withdrawal is not considered one of the “reliable” methods. It has a typical use failure rate of 20-22% over the course of the first year of use, and 4% if used perfectly. This discrepancy makes it unreliable—compared for example to a LARC method where typical and perfect use are almost the same. Or compared to someone on pills who reports no missed pills in the last cycle. Withdrawal is in the “least effective” category of methods as defined by the WHO.
But, since withdrawal can be effective if used perfectly, individual situations warrant individual analysis. So, if your patient has been using this method with her partner for a long time and has never gotten pregnant, you could argue that they have been using this method consistently and correctly and it could be considered reliable. There are other factors to consider that may support use of QuickStart for LARC in your patient. As you so rightly mention, the consequences of not starting a LARC method on the day you see your patient.
→ ADDITIONAL SUPPORT FOR QUICKSTART OF AN IMPLANT: Regarding wanting to QuickStart a LARC method, The CDC makes a distinction for whether you want to start an IUD vs. another method, stating: “For contraceptive methods other than IUDs, the benefits of starting to use a contraceptive method likely exceed any risk, even in situations in which the health care provider is uncertain whether the woman is pregnant. Therefore, the health care provider can consider having patients start using contraceptive methods other than IUDs at any time, with a follow-up pregnancy test in 2–4 weeks. The risks of not starting to use contraception should be weighed against the risks of initiating contraception use in a woman who might be already pregnant.”
https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/notpregnant.html
Since use of hormones, whether in the pill or an implant, does not negatively affect a pregnancy, then it is OK to QuickStart an implant even if unsure about her pregnancy status. Some may balk at this because of a) cost and b) it is a procedure. If you choose to do so, then get a follow-up pregnancy test in 2-4 weeks. Given current abortion restrictions, I’d suggest 2 weeks.
Another approach in a situation where you are not sure what to do is to QuickStart use of a “bridge” method, such as provide one pack of pills until she can return for a pregnancy test and then insert the LARC.
→ ADDITIONAL SUPPORT FOR QUICKSTART OF AN IUD: Another issue to consider when using QuickStart for an IUD is when intercourse occurred during this cycle prior to her visit. For example, suppose her LMP (or menses) started ten days ago, and her last intercourse with withdrawal was two days ago. If she has re
gular monthly cycles, the intercourse is probably before her fertile window. Risk of ovulation is low on days 1-7, and her event occurred on day8 – still relatively low. More importantly, the IUD is an effective emergency contraceptive that can be inserted for this purpose up until 5 days after unprotected intercourse. Also, her intercourse wasn’t “unprotected,” but used withdrawal. Adding all of these circumstances up – in my opinion, she could get the IUD that day. By the way, evidence now supports use of Mirena or Liletta as an emergency contraceptive in addition to the well-established use of ParaGard (all off-label uses).
Need for additional back-up contraception after using QuickStart for an implant or IUD:
Implant: If the implant is inserted >5 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.
Cu-IUD (copper): No additional contraceptive protection is needed.
LNG-IUD (hormonal): if it is inserted >7 days since menstrual bleeding started, the woman needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.
DISCLAIMER: This information is for educational purposes only and not intended to guide individual therapy. Answers should never substitute for consultation with a healthcare provider or counselor who can make decisions based on an individual’s history, desires, and circumstances. Always seek the advice of a clinician for any questions regarding health, medical condition, birth control method or other family planning or social issues. Under no circumstances should an individual use this information in lieu of, or to override, the judgment of a treating clinician. Dr. Zieman, or SageMed LLC, is not responsible, or liable, for errors, omissions, or any damage or loss incurred as a result of use of any birth control method or use or reliance on any material or information provided through this website.
