Offering counseling on birth control options should be included as part of comprehensive abortion care. It’s totally okay for people not to want to talk about birth control on the day of their abortion, but for those who do want to start a method, they may have questions about their options and how to get started after having an abortion. Many factors, such as past contraceptive use, weight, desire for pregnancy, experiences with intimate partner violence, and past medical conditions, can impact the choice of birth control method.
When can hormonal birth control be started after an abortion?
Right away! Combined hormonal contraceptives, such as the pill, patch, and ring, as well as progestin-only methods including the progestin only, mini pill (like Opill, which patients can now get over the counter), shot, or implant can be started as soon as the same day as an abortion procedure or a medication abortion during the first or second trimester. When exactly to start them is up to the patient, and counseling should include that if these methods are started more than seven days after having an abortion, a backup method of birth control, such as condoms or internal condoms, is needed. For progestin-only pills, a backup method is needed for two days and for the other hormonal methods, a backup method is needed for seven days.
What about placing an IUD after an abortion?
The timing of IUD placement after abortion depends on the type of abortion. After an abortion procedure, any type of IUD, that means either the copper IUD or any levonorgestrel containing, hormonal IUD, can be inserted immediately after the procedure, although IUDs should not be inserted immediately if the patient experienced a septic abortion. There is evidence that an IUD can safely be placed within 48 hours after a medication abortion is complete (bleeding with clots and heavy bleeding has stopped) when the gestational duration was less than 63 days. IUDs can be placed as soon as a provider can determine the abortion is complete, even before someone has a negative pregnancy test or has their next period. When an IUD is placed within seven days of an abortion, including at the time of procedural abortion, no backup method is needed for any type of IUD. If it’s been more than seven days since having an abortion, patients who get a LNG 52mg IUD, such as Mirena or Liletta, or a copper IUD, also don’t need to use a backup method. However, patients getting other LNG IUDs with less than 52mg of LNG (Kyleena or Skyla), should be counseled to use a backup method for seven days after placement.
Could hormonal birth control impact medication abortion effectiveness?
This depends. A recent systematic review and meta-analysis of the effect of systemic hormonal contraception on medical abortion effectiveness included 16 studies, seven of which were randomized controlled trials (RCTs). Most studies meeting eligibility criteria were of poor or fair quality in high income or upper middle income settings. There did not appear to be a difference in abortion effectiveness between immediate and delayed initiation of systemic hormonal contraceptive methods following first trimester medication abortion. One included study found a significant increased risk of ongoing pregnancy with immediate depot medroxyprogesterone acetate injection compared to delayed initiation.
A recent Cochrane review including three RCTs and 1,162 participants evaluated immediate versus delayed insertion of the contraceptive implant post medical abortion. Provision of the contraceptive implant concurrently with medication abortion had little or no impact on failure rate of medication abortion. Utilization rates of the implant were slightly higher for immediate insertion compared to delayed insertion leading to a potentially improved unintended pregnancy rate six months post abortion.
Bottom line
For patients who are interested in starting birth control after having an abortion, most methods can safely be initiated immediately. The need for a backup method varies depending on the birth control method selected. Advantages to immediate placement or administration of birth control following an abortion include prevention of additional clinic visits (which can be particularly important for people who are traveling to get abortion care), fewer unintended pregnancies in the year after an abortion, and potentially higher utilization rates of birth control.
For additional quick answers for patients, visit Bedsider for patient-focused answers on how to start birth control after an abortion.
