How should a pharmacist dispense Microgestin (norethindrone acetate 1.5 mg/ethinyl estradiol 30 µg) to a non‑pregnant woman of reproductive age without contraindications?

How to Dispense Microgestin 1.5/30

Dispense Microgestin 1.5/30 as a 28-day pack (21 active green tablets containing 1.5 mg norethindrone acetate/30 mcg ethinyl estradiol, followed by 7 days of either placebo or ferrous fumarate tablets), with instructions for the patient to start within 5 days of menstrual bleeding or immediately if pregnancy can be reasonably excluded, using backup contraception for 7 days if started after day 5 of the cycle. 1

Dispensing Instructions

Package Configuration

Microgestin 1.5/30 comes in two formulations 1:

• Microgestin 1.5/30: 21 green active tablets only
• Microgestin Fe 1.5/30: 21 green active tablets + 7 brown ferrous fumarate (75 mg) tablets

The tablet dispenser is pre-arranged with days of the week printed above the first row to facilitate a Sunday-Start regimen. Six additional day label strips are included for patients preferring a Day-1 Start regimen 1.

Starting Regimens

Two evidence-based starting options 2, 1:

Option 1: Sunday-Start Regimen

• Patient takes first tablet on the first Sunday after menstrual flow begins
• If menstrual flow begins on Sunday, start that same day
• Backup contraception required: Use condoms or abstain for the first 7 days of the initial cycle 2, 1
• All subsequent cycles will start on Sunday

Option 2: Day-1 Start Regimen

• Patient applies the appropriate self-adhesive day label strip over preprinted days
• First tablet taken on Day 1 of menstrual flow
• Backup contraception required: Use condoms or abstain for 7 days if started >5 days after bleeding began 2
• All subsequent cycles start on the same day of the week

Quick Start Option (Same-Day Initiation)

Combined hormonal contraceptives can be started immediately at any time if reasonably certain the patient is not pregnant 2, 3. A provider can be reasonably certain if the patient meets any of these criteria 3:

• ≤7 days after start of normal menses
• Has not had intercourse since last normal menses
• Has been using reliable contraception correctly
• ≤7 days post-abortion
• Within 4 weeks postpartum
• Fully breastfeeding, amenorrheic, and <6 months postpartum

If Quick Start is used >5 days since menstrual bleeding started, backup contraception is needed for 7 days 2.

Patient Counseling Points

Administration

• Take one tablet daily at the same time, preferably with a meal or at bedtime 1
• After completing 21 active tablets, either stop for 7 days (Microgestin 1.5/30) or take 7 brown iron tablets (Microgestin Fe 1.5/30)
• Menstruation typically begins 2-3 days after the last active tablet, but may occur as late as day 4-5 1

Missed Pill Instructions

Based on CDC guidelines 4:

One pill late (<24 hours): Take as soon as remembered, continue as usual

One pill missed (24-48 hours):

• Take most recent missed pill immediately
• Continue remaining pills at usual time
• No backup needed

Two or more pills missed (>48 hours):

• Take most recent missed pill immediately (discard others)
• Use backup contraception for 7 consecutive days
• If missed pills occurred in Week 3 (days 15-21): Skip the hormone-free interval and start new pack immediately
• If missed pills occurred in Week 1 AND unprotected intercourse in previous 5 days: Consider emergency contraception 4

Safety Information

Counsel that this product does not protect against HIV or other sexually transmitted diseases 1.

Key contraindications to screen for (based on U.S. MEC guidelines):

• Current or history of venous thromboembolism
• Smoking ≥15 cigarettes/day if age ≥35 years
• Uncontrolled hypertension (≥160/100 mmHg) 5
• Migraine with aura
• Current breast cancer
• Severe liver disease
• Known thrombogenic mutations

Prescribing Considerations

This 30 mcg ethinyl estradiol formulation is appropriate for most patients 4. The 2014 Pediatrics guideline notes that many adolescent medicine providers begin with a COC containing 30-35 mcg ethinyl estradiol with progestins like levonorgestrel or norgestimate, making Microgestin 1.5/30 a reasonable first-line choice 4.

No routine examinations required before dispensing 3:

• Pelvic exam: NOT needed
• Breast exam: NOT needed
• Pap smear: NOT needed
• Laboratory tests (glucose, lipids, liver enzymes, hemoglobin, thrombogenic mutations): NOT needed
• Blood pressure measurement: Recommended but not mandatory for healthy women without risk factors

Dispense multiple cycles (ideally 12 months) to improve adherence and reduce barriers to access 3.

Common Pitfalls to Avoid

• Do not delay initiation waiting for next menstrual period if pregnancy can be reasonably excluded 2, 3
• Do not require unnecessary medical examinations that create barriers to access 3
• Do not forget to emphasize the 7-day backup contraception rule when starting >5 days after menses or using Quick Start 2
• Ensure patient understands that spotting/breakthrough bleeding is common initially and not harmful 4