What is the proper use of oral contraceptive (OC) pills for contraception?

From the Guidelines

Oral contraceptive pills (OCPs) should be taken once daily at approximately the same time each day to effectively prevent pregnancy, with a recommended approach to missed pills outlined in the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1. When taking OCPs, it is essential to follow the prescribed regimen to maximize effectiveness. Most OCPs come in 28-day packs with 21 active hormone pills and 7 placebo pills, though some brands have 24 active pills and 4 placebos.

Key Considerations for OCP Use

• Begin taking the first pill on the first day of your menstrual period or on the first Sunday after your period starts.
• Take one pill daily, following the order in the pack.
• For maximum effectiveness (over 99% when used perfectly), take the pill at the same time each day; setting a daily alarm can help establish this routine.
• If you miss a pill, take it as soon as you remember, even if it means taking two pills in one day, as outlined in the recommendations 1.
• If you miss two or more pills, use a backup contraception method like condoms for seven days while continuing to take your pills.

Mechanism of Action and Side Effects

OCPs work by preventing ovulation, thickening cervical mucus to block sperm, and thinning the uterine lining to prevent implantation.

• Common side effects may include nausea, breast tenderness, spotting between periods, and headaches, which typically improve after 2-3 months of use.
• OCPs do not protect against sexually transmitted infections, so consider using condoms for additional protection, as noted in the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 2.

Important Considerations

• Consult a healthcare provider before starting OCPs, especially if you have certain medical conditions like high blood pressure, history of blood clots, or are over 35 and smoke.
• The U.S. Selected Practice Recommendations for Contraceptive Use, 2013, provide guidance on the use of combined hormonal contraceptives, including OCPs, patches, and vaginal rings 1, 2.

From the FDA Drug Label

Six different “day label strips” are provided with each cycle pack dispenser in order to accommodate a Day 1 start regimen. The use of Kariva for contraception may be initiated 4 weeks postpartum in women who elect not to breastfeed. When the tablets are administered during the postpartum period, the increased risk of thromboembolic disease associated with the postpartum period must be considered If the patient starts on Kariva postpartum, and has not yet had a period, she should be instructed to use another method of contraception until a white tablet has been taken daily for 7 days. SUNDAY START When initiating a Sunday start regimen, another method of contraception should be used until after the first 7 consecutive days of administration Using a Sunday start, tablets are taken daily without interruption as follows: The first white tablet should be taken on the first Sunday after menstruation begins (if menstruation begins on Sunday, the first white tablet is taken on that day). One white tablet is taken daily for 21 days, followed by 1 light-green (inert) tablet daily for 2 days and 1 light-blue (active) tablet daily for 5 days DAY 1 START Counting the first day of menstruation as “Day 1”, tablets are taken without interruption as follows: One white tablet daily for 21 days, one light-green (inert) tablet daily for 2 days followed by 1 light-blue (ethinyl estradiol) tablet daily for 5 days.

The proper use of oral contraceptive (OC) pills for contraception is as follows:

• Sunday Start: Take the first white tablet on the first Sunday after menstruation begins, and then take one white tablet daily for 21 days, followed by one light-green tablet daily for 2 days, and one light-blue tablet daily for 5 days.
• Day 1 Start: Take the first white tablet on the first day of menstruation, and then take one white tablet daily for 21 days, followed by one light-green tablet daily for 2 days, and one light-blue tablet daily for 5 days.
• If a patient misses one or more pills, she should follow the instructions provided in the label to ensure effective contraception, including using a back-up method of birth control if necessary 3.
• The use of OC pills for contraception may be initiated 4 weeks postpartum in women who elect not to breastfeed, with consideration of the increased risk of thromboembolic disease associated with the postpartum period.

From the Research

Proper Use of Oral Contraceptive (OC) Pills

To use oral contraceptive (OC) pills properly for contraception, several factors must be considered:

• The pills must be used correctly and consistently to be highly effective in protecting against pregnancy 4.
• There are two types of OCs: combination oral contraceptives (COCs) and progestin-only pills (POPs), both of which have failure rates of approximately 7.2% to 9% with typical use 5.
• Patients with conditions associated with a risk of cardiovascular events should not use COCs due to the increased risk of venous thromboembolism 5.
• Blood pressure level should be assessed before initiation of oral contraceptives 5.

Initiation and Regimens

• OCs can be initiated any time the physician can be reasonably certain that the patient is not pregnant 5.
• Extended cycle regimens may be preferred by some patients, and high-quality contraceptive counseling includes working collaboratively with patients to find the most effective and acceptable method for them 5.
• The combined oral contraceptive pill is an effective contraceptive method which can also offer other benefits, and pills containing levonorgestrel or norethisterone in combination with ethinyloestradiol 35 microgram or less are considered first-line 6.

Mechanism of Action and Safety

• The objective of OCs is to suppress ovulation by manipulating events throughout the ovulatory cycle to prevent pregnancy 7.
• The progestin and estrogen components of OCs suppress the mid-cycle surge of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) 7.
• Although OCs are still associated with increased risk in certain patients and are contraindicated in others, they remain effective but require diligent usage 7.
• Estrogen-containing methods, such as combined oral contraceptive pills, increase the risk of venous thrombosis, whereas progestin-only and nonhormonal methods are associated with rare serious risks 8.

Contraceptive Selection and Effectiveness

• Optimal contraceptive selection requires patient and clinician discussion of the patient's tolerance for risk of pregnancy, menstrual bleeding changes, other risks, and personal values and preferences 8.
• Oral contraceptive pills are the most commonly used reversible contraceptives, intrauterine devices and subdermal implants have the highest effectiveness, and progestin-only and nonhormonal methods have the lowest risks 8.
• Contraceptive effectiveness is determined by a combination of drug or device efficacy, individual fecundability, coital frequency, and user adherence and continuation 8.