Starting Combined Oral Contraceptives Without Prior Menstruation
Yes, combined oral contraceptives (COCs) can be started at any time if it is reasonably certain that the woman is not pregnant, including in women who have not yet menstruated. 1
When to Start COCs Without Prior Menstruation
- Combined hormonal contraceptives can be started at any time if pregnancy can be reasonably ruled out, regardless of whether the woman has experienced menstruation 1
- For women with amenorrhea (not related to postpartum), COCs can be initiated immediately with the understanding that additional contraceptive protection will be needed 1
- When starting COCs without prior menstruation, the woman needs to abstain from sexual intercourse or use additional contraceptive protection (such as condoms) for the next 7 days 1
How to Be Reasonably Certain a Woman is Not Pregnant
A provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any one of the following criteria:
- Has not had sexual intercourse since the start of last normal menses 1
- Has been using a reliable method of contraception correctly and consistently 1
- Is ≤7 days after spontaneous or induced abortion 1
- Is within 4 weeks postpartum 1
- Is fully or nearly fully breastfeeding (exclusively breastfeeding or ≥85% of feeds are breastfeeds), amenorrheic, and <6 months postpartum 1
Starting Instructions for COCs
- When initiating COCs in a woman who has not menstruated, follow the standard "Day 1 start" or "Sunday start" regimen as directed in the package instructions 2
- For a "Day 1 start," counting the first day of menstruation as "Day 1" is not possible without prior menstruation, so the woman would start on the day the provider determines she is not pregnant 1
- For a "Sunday start," the woman would start on the first Sunday after the provider determines she is not pregnant 2
Special Considerations
- In situations where the healthcare provider is uncertain whether the woman might be pregnant, the benefits of starting combined hormonal contraceptives likely exceed any risk 1
- A follow-up pregnancy test in 2-4 weeks may be considered in cases where pregnancy status is uncertain 1
- No physical examination needs to be performed before starting hormonal contraception, except for blood pressure measurement for COCs 1
Effectiveness and Safety
- The effectiveness of COCs does not differ based on the timing of initiation 1
- Starting COCs at any time is safe when pregnancy has been ruled out, and this approach may improve initial continuation rates 1
- For women with amenorrhea due to conditions like PCOS, starting COCs can help regulate hormonal patterns and provide contraceptive protection 3
Common Pitfalls to Avoid
- Unnecessarily delaying COC initiation until the next menstrual period is not recommended and may increase the risk of unintended pregnancy 1
- Requiring unnecessary examinations or tests (such as pelvic examinations, cervical cytology, HIV screening, or laboratory tests for lipid, glucose, liver enzyme, and hemoglobin levels) before starting COCs can create barriers to contraception access 1
- Failing to provide adequate instructions about the need for 7 days of backup contraception when starting COCs without prior menstruation 1
Remember that providing contraception promptly with clear instructions about backup methods is the most effective approach to prevent unintended pregnancy, regardless of menstrual history.