What are the guidelines for a patient on birth control (hormonal contraception)?

Guidelines for Patients on Hormonal Birth Control

For patients on combined oral contraceptives (COCs), the critical management principles center on proper initiation, handling missed pills systematically, and managing breakthrough bleeding—with the overarching goal of preventing unintended pregnancy while maintaining quality of life. 1

Initiation and Supply

• Start COCs on the first day of menstrual bleeding (Day 1 start) or the first Sunday after bleeding begins (Sunday start). 2
• If using Sunday start, backup contraception (condoms) is required for the first 7 consecutive days of pill use. 2
• Provide or prescribe up to a 1-year supply (13 packs) at initial and return visits, as this significantly improves continuation rates and reduces unintended pregnancy risk. 1

Managing Missed Combined Oral Contraceptives

The response to missed pills depends entirely on timing and number missed 1:

One Pill Late (<24 hours)

• Take the late pill immediately
• Continue regular schedule (even if taking 2 pills same day)
• No backup contraception needed
• Emergency contraception generally not needed 1

One Pill Missed (24-48 hours)

• Take the most recent missed pill immediately (discard any other missed pills)
• Continue regular schedule
• Use backup contraception or abstain for 7 consecutive days 1
• Consider emergency contraception if pills were missed in first week AND unprotected intercourse occurred in previous 5 days 1

Two or More Pills Missed (≥48 hours)

• Take the most recent missed pill immediately (discard others)
• Continue regular schedule
• Use backup contraception or abstain for 7 consecutive days 1
• If missed pills occurred in Week 3 (days 15-21): Skip the hormone-free interval entirely—finish current pack and start new pack immediately 1
• Emergency contraception should be strongly considered if missed pills were in Week 1 and unprotected intercourse occurred in previous 5 days 1

Managing Vomiting or Diarrhea

The duration of gastrointestinal symptoms determines the action needed 1:

<24 Hours After Taking Pill

• No action required—do not retake pill
• Continue pills at usual time
• No backup contraception needed 1

24-48 Hours of Symptoms

• Continue taking pills daily
• Use backup contraception or abstain until 7 consecutive days of pills taken after symptoms resolve 1
• If symptoms occur in Week 3: Skip hormone-free interval, start new pack immediately 1
• Consider emergency contraception if symptoms in Week 1 with unprotected intercourse in previous 5 days 1

≥48 Hours of Symptoms

• Same management as 24-48 hours above 1

Progestin-Only Pills (POPs)

POPs require stricter timing than COCs—a pill is considered missed if >3 hours late, as these pills rely on consistent daily dosing for efficacy. 1

Missed POP (>3 hours late)

• Take one pill immediately
• Continue daily schedule (even if 2 pills same day)
• Use backup contraception or abstain until pills taken correctly for 2 consecutive days 1
• Consider emergency contraception if unprotected intercourse occurred 1

Initiation

• Can start anytime if reasonably certain patient is not pregnant 1
• If started within first 5 days of menstrual bleeding: no backup needed 1
• If started >5 days after bleeding: backup contraception needed for 2 days 1

Extended/Continuous Regimens

• For extended regimens (84-91 days active pills), if breakthrough bleeding occurs, a 3-4 day hormone-free interval may be taken—but NOT during the first 21 days and not more than once per month 3
• Extended regimens are particularly beneficial for heavy menstrual bleeding, severe dysmenorrhea, and anemia 3

Follow-Up and Monitoring

• No routine follow-up visit is required after initiation 1, 3
• Patients should return anytime for side effects, concerns, or desire to change methods 1, 3
• At routine visits: assess satisfaction, changes in health status, and any contraindications that have developed 1
• Blood pressure monitoring is recommended at follow-up visits for COC users 3

Managing Breakthrough Bleeding

• For heavy or prolonged bleeding with COCs: Consider NSAIDs for 5-7 days 3
• For extended regimen users: A 3-4 day hormone-free interval may help (with restrictions noted above) 3
• Always rule out pregnancy, STDs, or new pathologic conditions (polyps, fibroids) before treating breakthrough bleeding 3

Critical Safety Considerations

• COCs increase venous thromboembolism risk 3-4 fold (up to 4 per 10,000 woman-years) 3
• All hormonal contraceptives do NOT protect against STDs—consistent condom use is essential for STD/HIV prevention 1, 3
• Smoking is NOT a contraindication to COCs in women <35 years old 3

Common Pitfalls to Avoid

• The "7-day rule" is critical: After missing pills or having prolonged GI symptoms, 7 consecutive days of correct pill-taking are required before contraceptive protection is restored 1
• Lower-dose estrogen pills (20 μg vs 30 μg ethinyl estradiol) show more follicular activity when missed, potentially increasing pregnancy risk 1
• Never extend the hormone-free interval beyond 7 days, as this significantly increases ovulation risk 1