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Choosing a Birth Control Method

(Published September 2011)

Initiation of Hormonal Contraceptives

The World Health Organization (WHO), Planned Parenthood, and American Congress of Obstetricians and Gynecologists support unbundling services and not linking the provision of contraception with a pelvic exam, Pap test, or STI screening.60

  • COCs are not linked to cervical cancer or infection—no need for Pap smear or STI screening before COCs are started or for continuing method. 61
  • Pelvic exams are not required for starting or continuing hormonal contraception.62
  • ACOG recommends first Pap test at age 21 regardless of start age for sexual activity; many institutions follow ACOG guidelines.63
  • WHO guidelines state that measuring blood pressure before starting COCs is desirable.64 COCs are not teratogenic and will not produce adverse fetal effects if the patient is pregnant.

Providers should consider starting the contraceptive method on any day during the menstrual cycle, rather than restricting initiation to the subsequent Sunday or day 1 of the cycle. Initiation on any day of the cycle is referred to as the Quick Start method.

  • Quick Start provides patients with protection from unplanned pregnancy faster and more reliably.
  • Conventional initiation of hormonal contraception within 5 days of the beginning of the next menstrual cycle may mean a delay of several weeks between the time a woman receives her prescription and starts contraceptive use. With the old approach, women have additional exposure to pregnancy risk, and up to 25 percent of women never begin COCs after they receive the prescription.64
  • Quick Start significantly improves the continuation rate for COCs, reduces the likelihood of a potential unplanned pregnancy, and results in better adherence at 3 months among adolescents.65
  • Women who use Quick Start do not experience significant differences in the number of bleeding-spotting days or any other bleeding parameter compared with those who start on a conventional schedule.66

To use Quick Start:

  • If the last menstrual period (LMP) was within the last 5 days, the method can be started immediately.
  • If LMP was more than 5 days ago and a pregnancy test is negative, assess the last episode of unprotected sex to determine if EC is required before the woman starts the method.
  • If the woman had unprotected sex within the last 2 weeks, start the contraceptive method and advise the patient to return for a pregnancy test in 3 weeks.
  • Instruct women who are using the pill, patch, ring, injection, LNG IUS, or implant whose LMP was more than 5 days ago to use back-up contraception for the first 7 days.
  • If IUC is the choice, the provider should consider the possibility of an early undetected pregnancy. IUC poses a risk to the pregnancy (and thus is designated MEC category 4), whereas the other Quick Start contraceptive methods do not

Table 1: Management of Incorrect Use, by Method41,67,68

Combined Oral Contraceptive Pills

  • For pills with 30−35 mcg ethinyl estradiol:
    • If one or two active pills are missed: the woman should take an active pill as soon as possible and continue taking pills daily, one each day; additional contraception is not needed
    • If three or more active pills are missed: the woman should take an active pill as soon as possible and continue taking pills daily, one each day; she should use additional contraception until she has taken active pills for 7 days in a row; if the missed pills are in the third week of the pack, the woman should finish the current pack without taking the inactive pills and start a new pack the next day.
    • If inactive pills are missed: the woman should discard the missed pills and continue taking pills daily, one each day.
  • For pills with 20 µg or less ethinyl estradiol:
    • If one active pill is missed:  the woman should take an active pill as soon as possible and continue taking pills daily, one each day; additional contraception is not needed.
    • If two or more active pills are missed: the woman should take an active pill as soon as possible and continue taking pills daily, one each day; the woman should use additional contraception until she has taken active pills for 7 days in a row; if the missed pills are in the third week of the pack, she should finish the current pack without taking the inactive pills and start a new pack the next day.
    • If inactive pills are missed: the woman should discard the missed pills and continue taking pills daily, one each day.

Progestin-Only Pills

  • The woman should take the missed pill as soon as possible and continue taking pills daily, one each day
  • Use of back-up method for 2 days is recommended if the pill is taken more than 3 hours past the regular time

Transdermal Patch

  • Use of back-up method for 1 week is recommended if the patch has been off more than 7 days during the patch-free week or falls off and is not reaffixed within 24 hours.
  • Use of back-up method for 1 week is also recommended if the patch is applied late in the first week or more than 2 days late in the second or third week (the patch contains 9 days' worth of medication).

Vaginal Ring

  • Use of back-up method for one week is recommended if the ring has been in more than 4 weeks, out more than 7 days during the patch-free week, or falls out and is not reinserted within 3 hours.
  • If the ring is left in for more than 3 weeks but less than 4 weeks, the woman should remove the ring and insert a new ring after 7 days; back-up contraception is not needed.