Can a patient start Seasonale (levonorgestrel and ethinyl estradiol) BC if they are two days into their menstrual cycle?

Starting Seasonale on Day 2 of Menstrual Cycle

Yes, a patient can start Seasonale (levonorgestrel/ethinyl estradiol) on day 2 of their menstrual cycle without requiring backup contraception, since this falls within the first 5 days of menstrual bleeding. 1, 2

Timing and Backup Contraception Requirements

• Starting within days 1-5 of menstrual bleeding requires no additional contraceptive protection, as the patient is within the safe initiation window for combined hormonal contraceptives 1, 2, 3

• The CDC's U.S. Selected Practice Recommendations clearly state that combined hormonal contraceptives started within the first 5 days of menstrual bleeding do not require backup contraception 1, 2

• If Seasonale were started after day 5 of the menstrual cycle, the patient would need to abstain from intercourse or use backup contraception (such as condoms) for 7 consecutive days 1, 2, 3

Clinical Rationale

• The 5-day window is based on the physiological timing of ovulation and the immediate contraceptive effects of combined hormonal contraceptives when started early in the cycle 1

• Starting on day 2 provides adequate ovarian suppression before ovulation could occur in that cycle 2

• Research demonstrates that pregnancy rates do not differ based on timing of contraceptive initiation during the menstrual cycle, with high-quality evidence supporting this approach 2

Important Considerations for Seasonale Specifically

• Seasonale is an extended-cycle formulation containing 84 active pills (30 mcg ethinyl estradiol/150 mcg levonorgestrel) followed by 7 placebo days, resulting in only 4 menstrual periods per year 4, 5

• Patients should be counseled that unscheduled breakthrough bleeding is common with extended-cycle regimens, particularly in the first cycle, but this decreases with each successive 91-day cycle 4, 5

• The safety and efficacy profile of Seasonale is comparable to conventional 28-day oral contraceptives 4, 5

Common Pitfalls to Avoid

• Do not delay initiation until the next menstrual period, as this unnecessarily increases the risk of unintended pregnancy 3

• Ensure the patient understands that consistent daily timing is important for optimal effectiveness 2

• If there is any uncertainty about pregnancy status, the benefits of starting combined hormonal contraceptives likely exceed any risks, though a follow-up pregnancy test in 2-4 weeks may be considered 2, 3