What is the proper way for a female patient of reproductive age with no significant medical history to take an oral contraceptive pill, such as Alesse (levonorgestrel and ethinyl estradiol)?

How to Take Oral Contraceptive Pills

Take one pill by mouth at the same time every day, starting either on the first day of your menstrual period (Day 1 start) or on the first Sunday after your period begins (Sunday start), with backup contraception needed for 7 days if starting more than 5 days after menstruation began. 1

When to Start

Two Starting Options

Day 1 Start (Preferred for Immediate Protection):

• Begin taking the first active pill on the first day of menstrual bleeding 1, 2
• No backup contraception needed if started within the first 5 days of menstruation 1, 3
• This provides immediate contraceptive protection 4

Sunday Start:

• Take the first pill on the first Sunday after menstruation begins (or that same Sunday if bleeding starts on Sunday) 2
• Use backup contraception (condoms) or abstain from sex for the first 7 consecutive days 1, 2
• This method provides predictable weekend scheduling but requires initial backup protection 2

Starting at Any Time

• Combined oral contraceptives can be initiated at any time if you are reasonably certain you are not pregnant 1, 3
• If starting more than 5 days after menstruation began, use backup contraception for 7 days 1
• Evidence shows no increased pregnancy risk when starting on different cycle days, though follicular activity increases with later cycle day initiation 4

Daily Administration

Taking Pills Correctly

• Take one pill every day at the same time, ideally within the same hour each day 2
• Pills must be taken at intervals not exceeding 24 hours for maximum effectiveness 2
• Continue taking pills daily without interruption, even during menstruation 2

Typical Pill Pack Schedule

For standard 28-day packs (like Alesse):

• Take 21 active hormone-containing pills consecutively 2
• Follow with 7 inactive/placebo pills (or hormone-free interval) 2
• Start a new pack immediately after finishing the previous pack 2

What to Do If You Miss Pills

One Pill Missed (24 to <48 hours late):

• Take the missed pill as soon as you remember 1, 2
• Continue taking remaining pills at the usual time, even if this means taking two pills on the same day 1, 2
• No backup contraception needed 1
• Emergency contraception usually not needed unless pills were also missed earlier in the cycle 1

Two Consecutive Pills Missed (≥48 hours):

If missed in Week 1 or Week 2:

• Take the most recent missed pill immediately (discard any other missed pills) 1
• Take 2 pills the day you remember and 2 pills the next day 2
• Use backup contraception (condoms) or abstain from sex for 7 consecutive days 1, 2
• Consider emergency contraception if unprotected intercourse occurred in the previous 5 days during Week 1 1

If missed in Week 3 (days 15-21):

• For Sunday start: Keep taking 1 pill daily until Sunday, then discard the rest of the pack and start a new pack that same Sunday 2
• For Day 1 start: Discard the rest of the pack and start a new pack immediately 2
• Use backup contraception for 7 days 1, 2

Three or More Pills Missed:

• Start a new pack immediately 2
• Use backup contraception for 7 consecutive days 1
• Consider emergency contraception if appropriate 1

Pre-Initiation Requirements

Essential Screening Before Starting

• Blood pressure measurement is the only required examination before initiating combined oral contraceptives 1
• Pregnancy test if there is any uncertainty about pregnancy status 1
• No pelvic examination, breast examination, or Pap smear required before starting 1

Medical History Screening

Ensure absence of contraindications, particularly 1:

• Smoking if age ≥35 years
• History of blood clots (deep vein thrombosis or pulmonary embolism)
• Uncontrolled hypertension
• Migraine headaches with aura if age >35 years
• Current or history of breast cancer
• Active liver disease or liver tumors
• Cerebrovascular or coronary artery disease

Important Drug Interactions

Medications That Reduce Effectiveness

Use backup contraception or consider alternative contraceptive methods with 1:

• Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, topiramate, oxcarbazepine)
• Rifampin or rifabutin
• St. John's wort
• Some HIV protease inhibitors and antiretrovirals
• Griseofulvin

Common Pitfalls

• Antibiotics (except rifampin/rifabutin) do NOT reduce oral contraceptive effectiveness 1
• Antifungals and antiparasitics do not affect contraceptive efficacy 1

Expected Effectiveness and Side Effects

Contraceptive Efficacy

• Perfect use: Pregnancy rate of 0.13-1.26 per 100 women-years 5, 6
• Typical use: 9% failure rate in the first year, primarily due to inconsistent use 3
• Effectiveness is completely reversible with no negative effect on long-term fertility 3

Common Side Effects

Most common adverse effects include 1, 5:

• Headache (most common reason for discontinuation at 2%)
• Breakthrough bleeding/spotting (highest in first few cycles, decreases thereafter)
• Nausea
• Breast tenderness
• Mood changes

Serious Risks (Rare)

Monitor for signs of 1:

• Venous thromboembolism (blood clots)
• Stroke or myocardial infarction
• Hypertension
• Liver tumors (very rare)

Follow-Up Care

Ongoing Monitoring

• Blood pressure checks at follow-up visits 1
• Assess adherence and any side effects 3
• No routine laboratory tests required unless clinically indicated 1
• Be prepared to adjust formulation if side effects are problematic 3

Cycle Control Expectations

• Intermenstrual bleeding is most common during the first 3 cycles 5
• Cycle control generally improves with continued use 5, 6
• Predictable withdrawal bleeding occurs during the hormone-free interval 3