How to Restart Birth Control in a 16-Year-Old Patient
Start a monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate immediately (same-day initiation), without waiting for the next menstrual period. 1
Initial Pill Selection
- Prescribe a monophasic (fixed-dose) combined oral contraceptive with 30-35 μg ethinyl estradiol combined with levonorgestrel or norgestimate as the first-line choice for adolescents. 1
- This dose provides optimal ovulation suppression, which is particularly important for adolescents who frequently miss pills. 1, 2
- Choose the formulation with the lowest copay on the patient's insurance formulary if multiple appropriate options exist. 1
- Standard 28-day pill packs (21-24 hormone pills followed by 4-7 placebo pills) are recommended initially, with the option to transition to extended cycles later based on patient preference or medical needs. 1
Same-Day Initiation Protocol
- Initiate the pill on the day of the visit regardless of where the patient is in her menstrual cycle. 1
- If there is uncertainty about pregnancy, the benefits of starting the pill exceed any risk; proceed with initiation and schedule a follow-up pregnancy test in 2-4 weeks. 1
- Instruct the patient to use backup contraception (condoms) or avoid intercourse for the first 7 consecutive days after starting the pill. 1, 3
Missed Pill Instructions (Critical for Adolescents)
One Pill Late (<24 hours):
- Take the late pill immediately and continue the regular schedule. 1, 2
- No backup contraception needed. 2
One Pill Missed (24-48 hours):
- Take the most recent missed pill immediately (discard any other missed pills). 1, 2
- Continue taking remaining pills at the usual time, even if this means taking two pills on the same day. 1
- Use backup contraception (condoms) or avoid intercourse for 7 consecutive days. 1, 2
Two or More Pills Missed (≥48 hours):
- Take the most recent missed pill immediately and discard other missed pills. 1, 2
- Continue the remaining pills at the usual time. 1
- Use backup contraception for 7 consecutive days. 1, 2
- If pills were missed in the last week of hormonal pills (days 15-21): Skip the hormone-free interval entirely by starting a new pack immediately the next day. 1
- If pills were missed in the first week AND unprotected intercourse occurred in the previous 5 days: Consider emergency contraception. 1
Key Advantages for Adolescents
- Combined oral contraceptives provide noncontraceptive benefits including decreased menstrual cramping, reduced blood loss, and improvement in acne—all relevant concerns for adolescents. 1
- The method is completely reversible with no negative effect on long-term fertility. 1
- Extended or continuous cycles can be considered later for adolescents with dysmenorrhea, endometriosis, anemia, or those who prefer amenorrhea. 1
- Shorter or no placebo intervals optimize ovarian suppression and increase contraceptive effectiveness, especially important given adolescents' higher rates of missed pills. 1
Common Pitfalls to Avoid
- Do not require a pelvic exam or extensive testing before initiation—these are not necessary for healthy adolescents and create unnecessary barriers to contraception. 1
- Do not wait for the next menstrual period to start the pill; same-day initiation is recommended. 1
- Do not prescribe pills with >35 μg ethinyl estradiol as first-line, as higher doses increase stroke risk without improving efficacy. 4
- Ensure the patient understands that unscheduled bleeding is the most common adverse effect and typically improves with continued use—this reassurance prevents unnecessary discontinuation. 1
Follow-Up Considerations
- No routine follow-up visit is required, but the patient should be advised to contact the provider if she experiences side effects, problems, or wants to change methods. 2
- Blood pressure should be monitored during any routine follow-up visits. 2, 4
- If breakthrough bleeding becomes problematic, NSAIDs for 5-7 days can be offered as treatment. 1, 4