Lane 04 — Reproductive.

Insertion tray, Wednesday clinic — Mirena 52mg, sound, tenaculum, paracervical block.

Day 01 — Contraception, all of it

We provide every reversible contraceptive method approved by the U.S. Food and Drug Administration except the diaphragm (we do not stock it; we will write the prescription if a member wants one). The framework we use for selection is the WHO Medical Eligibility Criteria for Contraceptive Use, 5th edition¹, alongside the U.S. CDC's U.S. MEC tables for the few places they diverge. The conversation starts with what a member wants, not with what we want. The most common opening question we ask is "what do you want this method to do for you?" — because "prevent pregnancy" is the floor, not the ceiling, and most members have a second goal (cycle regulation, dysmenorrhea reduction, acne, mood predictability, period suppression).

Same day — IUDs and implants

Wednesdays are insertion days. We stock Mirena (LNG 52 mg), Kyleena (LNG 19.5 mg), Liletta (LNG 52 mg), Paragard (Cu T380A), and Nexplanon (etonogestrel 68 mg). We do not require a separate "consultation" visit before insertion in most cases. The 90-minute first visit gives us the time to do the consent, the insertion, and the follow-up plan in one block. That said, we will not insert a device a member is not certain about; we mean it when we say there is no rush.

We use a paracervical block as standard for IUD insertions, which is not always offered elsewhere; the 2022 ACOG committee opinion on IUD pain management² takes a measured stance, but our experience and the ACOG updated 2024 practice bulletin support its use in nulliparous patients and patients with a history of cervical procedures. We document pain on a 0–10 scale at the first speculum, after the block, after the sound, and after insertion; we keep the data; the median pain score across the past 18 months of insertions in this practice is 3 of 10. Members can read the running data on request; we are not embarrassed by it.

Week 04 — Cycle troubleshooting

Most members who come in describing "an irregular cycle" have a cycle that is regular for them and irregular only against the marketing-pamphlet 28-day baseline. We ask members to log a few cycles before we start ordering hormone panels. We use a paper period-tracking sheet (or a privacy-respecting app — drip is open-source and stores data locally; we don't recommend the venture-backed apps for any member who values their cycle data not being commercially traded).

Where a workup is warranted, we run TSH, prolactin, day-3 FSH/LH/E2 in selected cases, total and free testosterone if PCOS is in the differential, and a focused pelvic ultrasound at the Aspirus St. Luke's imaging desk ($148 cash). We follow the 2023 international PCOS guideline³ for the PCOS workup; we do not diagnose PCOS on a single hormone panel.

Year 01 — Preconception

If a member is planning a pregnancy in the coming year, we offer a preconception visit that we frame, openly, as the most important visit of the cycle. We start folate (400–800 mcg/day) at least three months before conception per USPSTF Grade A. We update Tdap, MMR, varicella, and influenza/COVID-19 immunization status. We ask about alcohol and cannabis with no judgment in our voice, because the data on either is more nuanced than the screening questionnaire and a member who feels judged at a preconception visit is a member who will not bring up the second-trimester wine in the third trimester. We screen for hereditary conditions per ACMG tier-1 expanded carrier screening when indicated.

Week 06 — Miscarriage care

Roughly 10–20% of clinically recognized pregnancies end in early loss⁴. The medical management is straightforward; the human management is what we work on. We offer expectant management, medication management with mifepristone-misoprostol per the ACOG Practice Bulletin 200⁵, or referral for surgical management at Essentia's OB/GYN clinic — and we do not have a preference between the three on the member's behalf. We do have a preference about the conversation: it happens in our office, on our time, and not in a triage call from a hospital ED at 2 a.m.

A note on pregnancy options

We provide complete, accurate information about every legal pregnancy option in Minnesota. We are not an abortion provider; the practice does not perform procedural or medication abortion in this clinic. We refer to Planned Parenthood's Duluth Health Center on Miller Trunk Highway, to the University of Minnesota Medical Center's reproductive health clinic in the Twin Cities, and to Whole Woman's Health for telemedicine medication abortion through 11 weeks gestation. The Minnesota PRO Act codifies abortion access in this state through 2026 and beyond. We provide the referral with no waiting period and no counseling script; the member's decision is the member's decision.

Cross-references: this lane shares its lead clinician with 06 · Perimenopause; the IUD-as-period-suppression conversation overlaps with 07 · Sports & performance for endurance athletes; preconception care and 01 · Cardiometabolic meet at the gestational-diabetes-risk and pre-pregnancy-BMI conversation. "Perimenopause as a data problem" in the transcripts walks through the cycle-data thread.