Management After Missing Birth Control Pills for One Week
Yes, she can and should start a new birth control method immediately with backup contraception for 7 days, but given her pattern of missing pills for an entire week, she should strongly consider switching to a long-acting reversible contraceptive (LARC) method such as an IUD or implant that doesn't depend on daily adherence. 1
Immediate Next Steps
Start the new contraceptive method today without waiting for the next menstrual period. 2
- The negative pregnancy test provides reasonable assurance to proceed with initiation, though if there's any uncertainty about recent unprotected intercourse, schedule a follow-up pregnancy test in 2-4 weeks. 2
- Use backup contraception (condoms) or avoid intercourse for the first 7 consecutive days after starting the new method. 1, 2
- Seven days of continuous combined hormonal contraceptive use is necessary to reliably prevent ovulation. 1
Critical Consideration: Method Selection
This patient's history of missing pills for an entire week is a red flag that she may not be an ideal candidate for any user-dependent method. 1
- Women who frequently miss combined oral contraceptives should consider an alternative contraceptive method that is less dependent on the user to be effective, such as an IUD, implant, or injectable. 1
- Long-acting reversible contraceptives have failure rates of less than 1% per year, compared to 4-7% per year for oral contraceptives in typical use. 3
- Missing pills for a full week represents a significantly extended hormone-free interval, which creates the highest risk for ovulation and unintended pregnancy. 4
If Continuing with Combined Oral Contraceptives
If the patient insists on continuing with pills despite this adherence issue, prescribe a monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate. 2, 5
- Higher-dose pills (30 μg ethinyl estradiol) provide better ovulation suppression than lower-dose options (20 μg) when pills are missed. 1, 5
- Provide clear, simple written and oral instructions on what to do when pills are missed, as women have documented difficulty understanding complex missed pill instructions. 4, 6
- Consider extended or continuous cycling regimens (84 days of active pills followed by 7 hormone-free days) to reduce the number of hormone-free intervals and provide better ovulation suppression. 7
Counseling on Missed Pill Protocol Going Forward
The patient must understand that missing 2 or more consecutive pills (≥48 hours) requires immediate action: 1, 5
- Take the most recent missed pill immediately and discard other missed pills. 1
- Continue taking remaining pills at the usual time (even if taking two pills on the same day). 1
- Use backup contraception for 7 consecutive days. 1
- If pills are missed in the last week of hormonal pills, omit the hormone-free interval by starting a new pack immediately. 1
Common Pitfalls to Avoid
Do not wait for the next menstrual period to start the new method—same-day initiation is recommended. 2
- The hormone-free interval should never exceed 7 days, as this is when the highest risk of ovulation occurs. 4
- Emergency contraception should have been considered if she had unprotected intercourse during the week of missed pills, particularly if this occurred during the first week of her previous pack. 1
- Even with clear instructions, 15-51% of users forget one to three pills per cycle, and many women who understand missed pill instructions choose not to follow them. 6, 8
Follow-Up Considerations
Schedule a follow-up in 1-2 months to assess adherence, side effects, and satisfaction with the method. 9
- Of women who discontinue oral contraceptives, 46% do so because of side effects, and more than four-fifths either fail to adopt another method or adopt a less effective method. 9
- Blood pressure should be monitored during any routine follow-up visits. 2, 5
- If breakthrough bleeding becomes problematic, NSAIDs for 5-7 days can be offered as treatment. 7, 2
- Provide telephone or electronic resources for reference in case of future missed doses. 4