What is the recommended birth control pill regimen?

Recommended Birth Control Pill Regimen

The recommended birth control pill regimen is a monophasic pill containing 30-35 μg of ethinyl estradiol with a progestin such as levonorgestrel or norgestimate, taken daily with a 7-day hormone-free interval. 1

Types of Birth Control Pills

• Monophasic regimens (same dose of estrogen and progestin in each pill) are recommended for most women starting oral contraceptives, particularly adolescents 1
• Low-dose formulations containing 20-35 μg of ethinyl estradiol are preferred to minimize risks while maintaining efficacy 2
• Pills containing levonorgestrel or norethisterone combined with ethinyl estradiol 35 μg or less are considered first-line options due to their effectiveness, relatively low risk of venous thromboembolism, and coverage under many insurance plans 2

Standard Dosing Schedule

• Standard pill packs include 28 pills total, with 21-24 hormone pills and 4-7 placebo (hormone-free) pills 1
• Pills should be taken at the same time each day to maximize effectiveness 1
• If one pill is missed (<24 hours late), it should be taken as soon as possible, and remaining pills continued at the usual time 1
• If two or more consecutive pills are missed (≥48 hours), the most recent pill should be taken immediately, and backup contraception should be used for 7 days 1

Extended or Continuous Cycle Options

• Extended or continuous cycle regimens (skipping the hormone-free interval) may be beneficial for certain conditions including anemia, severe dysmenorrhea, endometriosis, and abnormal uterine bleeding 1
• These regimens optimize ovarian suppression and may increase contraceptive effectiveness, especially for women who frequently miss pills 1
• The most common side effect of extended-cycle regimens is unscheduled bleeding, which typically decreases over time 3

Effectiveness and Safety

• The Pearl index (pregnancies per 100 woman-years) for low-dose ethinyl estradiol/levonorgestrel is approximately 0.84-0.88 with perfect use 4, 5
• Typical-use failure rates are higher at approximately 9% 1
• Combined oral contraceptives work primarily by suppressing ovulation, with additional effects on cervical mucus and endometrial receptivity 6
• Fertility returns quickly after discontinuation, with ovulation typically resuming within one month 3

Special Considerations

Missed Pills Protocol

If one hormonal pill is late (<24 hours):

• Take the late pill as soon as possible
• Continue taking remaining pills at the usual time
• No additional contraceptive protection needed 1

If one hormonal pill has been missed (24 to <48 hours):

• Take the missed pill as soon as possible
• Continue taking remaining pills at the usual time
• No additional contraceptive protection needed 1

If two or more consecutive hormonal pills have been missed (≥48 hours):

• Take the most recent missed pill immediately (discard other missed pills)
• Continue taking remaining pills at the usual time
• Use backup contraception for 7 consecutive days
• If pills were missed in the last week of hormonal pills, skip the hormone-free interval and start a new pack immediately 1

Vomiting or Severe Diarrhea

• If vomiting occurs within 3-4 hours of taking a pill, or if severe diarrhea occurs, contraceptive effectiveness may be reduced 1
• Additional contraceptive measures should be used until symptoms resolve 1

Risks and Benefits

Benefits

• Decreased menstrual cramping and blood loss
• Improvement in acne
• Protection against endometrial and ovarian cancers with use >3 years 1

Risks

• Increased risk of venous thromboembolism, especially in smokers over age 35 6
• Mortality rates associated with circulatory disease increase substantially in smokers over age 35 and non-smokers over age 40 who use oral contraceptives 6
• Combined oral contraceptives may compound the effects of other risk factors such as hypertension, diabetes, and obesity 6

Emergency Contraception Options

If unprotected intercourse occurs or contraceptive failure is suspected, emergency contraception options include:

• Ulipristal acetate (30 mg) - most effective option after copper IUD, can be taken within 5 days of unprotected intercourse 7, 1
• Levonorgestrel (1.5 mg single dose or 0.75 mg twice 12 hours apart) - should be taken as soon as possible within 5 days 1
• Combined estrogen-progestin regimen - less effective than other options and has more side effects 1
• Copper IUD - most effective emergency contraception, can be inserted within 5 days of unprotected intercourse 1