What advice should be given to a female patient who misses 2 days of oral contraceptive pills (OCPs)?

Management of Missed Combined Oral Contraceptive Pills (2 Days)

If a patient misses 2 consecutive days (≥48 hours) of combined oral contraceptive pills, she should take the most recent missed pill immediately (discarding other missed pills), continue taking remaining pills daily at the usual time (which may require taking two pills on the first day), use backup contraception for 7 consecutive days, and consider emergency contraception if appropriate. 1

Immediate Actions

Pill-Taking Instructions

• Take the most recent missed pill as soon as possible and discard any other missed pills 1
• Continue taking the remaining pills at the usual time each day, even if this means taking two pills on the same day 1
• This simplified approach reduces confusion compared to complex multi-step instructions that patients often misunderstand 2, 3

Backup Contraception Requirements

• Use backup contraception (condoms) or avoid sexual intercourse for 7 consecutive days after resuming pills 1, 4
• The 7-day requirement is based on evidence that ovulation rarely occurs after seven consecutive days of combined oral contraceptive use 2
• Do not rely on the pill for contraception until 7 consecutive days of correct hormone use are established 4, 2

Emergency Contraception Considerations

When Emergency Contraception Is Indicated

• Emergency contraception should be considered if unprotected intercourse occurred during or after the missed pill period 1
• Emergency contraception is especially needed if pills were missed during the first week of the pill pack or in the last week of the previous cycle, as this extends the hormone-free interval beyond 7 days 1, 2
• The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than seven days 2

Special Timing Consideration

• If pills were missed in the last week of the cycle (days 15-21 of a 28-day pack), the patient should omit the next hormone-free interval (skip the placebo pills) and start the next pack immediately 1
• This prevents extending the hormone-free interval and reduces ovulation risk 2

Critical Pitfalls to Avoid

Common Errors

• Do not instruct patients to take all missed pills - only the most recent missed pill should be taken, with others discarded 1
• Patients frequently misunderstand complex missed pill instructions, with comprehension decreasing as the number of missed pills increases 3
• Many women who understand the instructions may still choose not to follow them, highlighting the need for clear, simple guidance 3

Ulipristal Acetate (UPA) Emergency Contraception Interaction

• If the patient takes ulipristal acetate 30 mg for emergency contraception, she should restart her combined oral contraceptive pills immediately on the same day, not wait 5 days as some older guidance suggests 5
• Delaying restart for 5 days after UPA significantly increases ovulation risk (17.4% ovulated with delayed restart vs. 0% with immediate restart) 5

Patient Counseling Points

Prevention Strategies

• Provide both written and oral instructions on missed pill management as part of contraceptive counseling 2
• Graphic-based instructions with less text improve comprehension compared to text-only instructions 3
• Set daily reminders or alarms to maintain consistent dosing 4
• Keep extra medication in multiple locations to ensure access 4

When to Contact Provider

• Contact healthcare provider if unusual symptoms develop (vaginal bleeding, cramping) 4
• If the patient frequently misses pills, consider discussing alternative contraceptive methods that are less user-dependent (IUD, implant, injectable) 1, 6
• Continuous or extended-cycle regimens may reduce risks associated with missed pills by eliminating or reducing hormone-free intervals 6