Selected practice recommendations for contraceptive use, 4th edition

What this guideline says

GMJ summary

This fourth edition of the WHO Selected Practice Recommendations (SPR) provides comprehensive, evidence-based recommendations on the safe initiation, continuation, and management of contraceptive methods including copper and levonorgestrel IUDs, progestogen-only and combined hormonal contraceptives, emergency contraception, fertility-awareness methods, and male sterilization. The guideline complements the Medical Eligibility Criteria (MEC) by addressing not who can use methods safely, but how to use them effectively once medical appropriateness is established.

New in this edition are conditional recommendations on medication to ease interval IUD placement: paracervical blocks with lidocaine, topical anaesthetics, and NSAIDs may be offered routinely where available, but IUDs should not be withheld when these agents are unavailable; misoprostol is not recommended for routine use. The guideline emphasizes that in healthy women, very few examinations are mandatory before contraceptive initiation—only pelvic examination and STI risk assessment are essential for IUDs; no tests are mandatory for hormonal methods, though blood pressure measurement is desirable when feasible.

A central message is the removal of unnecessary medical barriers: women should not be denied hormonal contraception simply because blood pressure cannot be measured, and up to one year’s supply of pills may be provided at once. All recommendations prioritize informed consent, contraceptive choice, and client values, with detailed guidance on managing common problems such as menstrual irregularities, missed pills, and dosing errors to support method continuation.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. For interval IUD placement, paracervical lidocaine blocks, topical lidocaine (gel/spray/cream), and NSAIDs (ibuprofen, ketorolac, naproxen) may be offered routinely but are not mandatory; misoprostol is not recommended for routine use (conditional recommendations, low-to-moderate quality evidence).
2. Cu-IUDs can be placed within 5 days of unprotected intercourse for emergency contraception, or up to 5 days after ovulation if timing can be estimated.
3. For progestogen-only injectables among breastfeeding women <6 weeks postpartum, MEC classification has changed from Category 3 to Category 2 (can generally use).
4. Combined hormonal contraceptives (COCs, patch, ring) can be initiated within 5 days of menses with no additional protection needed; if started after day 5, abstinence or back-up contraception is needed for 7 days.
5. DMPA reinjection can be given up to 4 weeks late without additional protection; NET-EN up to 2 weeks late. If later, pregnancy must be excluded and back-up contraception used for 7 days.
6. For COC pills containing 30–35 µg ethinyl estradiol: missing 1–2 pills requires no back-up; missing ≥3 pills requires 7 days of back-up contraception and omission of hormone-free interval if pills were missed in week 3.
7. Only pelvic/genital examination and STI risk assessment are Class A (mandatory) before IUD placement; all other tests including cervical cancer screening, routine labs, and haemoglobin are Class B or C.
8. No examinations or tests are Class A (mandatory) before initiating any hormonal contraceptive; blood pressure measurement is desirable but women should not be denied hormonal methods if it is unavailable.

Examinations and tests before initiation of Cu-IUD or LNG-IUD

Table extracted from the guideline

Source: World Health Organization, Selected practice recommendations for contraceptive use, 4th edition. Reproduced in summary form.

What changed in this edition

Versus the previous edition

• New conditional recommendations on medication to ease interval IUD placement: paracervical lidocaine blocks, topical lidocaine, and NSAIDs may be offered routinely; misoprostol not recommended for routine use.
• MEC classification for DMPA use among breastfeeding women <6 weeks postpartum changed from Category 3 (usually not recommended) to Category 2 (can generally use).
• New topic reviewed on non-pharmacological interventions to ease IUD placement; insufficient evidence for recommendations.
• All other recommendations from the third edition (2016) were reaffirmed with no changes after CIRE review found no new evidence requiring updates.

From the guideline

Verbatim

“Women should not be denied use of hormonal methods simply because their blood pressure cannot be measured.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

Related on GMJ

Interconnected resources

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