What should a female patient do if she misses a dose of oral contraceptive (OC) pills?

What to Do When You Miss an Oral Contraceptive Pill

If you miss one combined oral contraceptive pill (late by <24 hours), take it immediately and continue your regular schedule—no backup contraception is needed; however, if you miss one or more pills for ≥24 hours, take the most recent missed pill immediately, discard any other missed pills, and use backup contraception for 7 consecutive days. 1, 2

Combined Oral Contraceptives (COCs)

One Pill Late (<24 hours)

• Take the late pill as soon as you remember 2
• Continue taking pills at the usual time (you may take 2 pills on the same day) 2
• No backup contraception needed 2
• Consider emergency contraception only if pills were also missed earlier in the cycle or during the last week of the previous cycle 1

One or More Pills Missed (≥24 hours but <48 hours)

• Take the most recent missed pill immediately 1, 2
• Discard any other missed pills 1
• Continue taking remaining pills at the usual time each day 1
• Use backup contraception (condoms) or avoid intercourse for 7 consecutive days 1, 2
• Emergency contraception is especially needed if pills were missed during the first week AND unprotected intercourse occurred in the previous 5 days 1

Two or More Pills Missed (≥48 hours)

• Take the most recent missed pill immediately 1, 2
• Discard any other missed pills 1
• Continue regular schedule 1
• Use backup contraception for 7 consecutive days 1, 2
• If missed pills occurred in the last week of the cycle (days 15-21 of a 28-day pack), skip the hormone-free interval and start the next pack immediately 1
• Consider emergency contraception if unprotected intercourse occurred 1

Progestin-Only Pills (POPs)

Critical Timing Window

POPs have a much stricter window than combined pills—a dose is considered missed if >3 hours late (>27 total hours since the previous dose). 1

Any Missed or Late Dose (>3 hours)

• Take one pill as soon as possible 1
• Continue taking pills daily at the same time, even if taking two pills on the same day 1
• Use backup contraception or avoid intercourse for 2 consecutive days 1
• Consider emergency contraception if recent unprotected intercourse occurred 1

Special Circumstances

Vomiting or Diarrhea Within 3 Hours of Taking a Pill

For POPs specifically: 1

• Take another pill as soon as possible (despite discomfort) 1
• Continue regular daily schedule 1
• Use backup contraception or avoid intercourse until 2 days after symptoms resolve 1
• Consider emergency contraception if unprotected intercourse occurred 1

Critical Clinical Pitfalls

The Hormone-Free Interval Is the Danger Zone

The highest risk of ovulation occurs when the hormone-free interval exceeds 7 days—either by delaying the start of a new pack or by missing pills during the first or third week. 3 This is why first-week missed pills are particularly dangerous and why third-week missed pills require skipping the hormone-free interval. 1, 3

Why 7 Days of Backup?

Ovulation rarely occurs after 7 consecutive days of combined oral contraceptive use, which is why 7 days of backup contraception is the standard recommendation. 3

Patient Comprehension Issues

Studies consistently show that 15-51% of users forget 1-3 pills per cycle, with adolescents at highest risk. 4 Women understand instructions for missing 1 pill better than for missing 2-3 pills, and many women who understand the instructions choose not to follow them. 5 Provide both written and oral instructions, and consider graphic-based materials rather than text-only formats. 3, 5

Higher-Dose Pills and Missed Doses

Pills containing 30 μg ethinyl estradiol provide better ovulation suppression than 20 μg formulations when pills are missed, but every 10 μg increase in ethinyl estradiol increases stroke risk by 19%. 2 This creates a clinical tension between forgiveness for missed pills and cardiovascular safety.

When to Consider Alternative Methods

Women who frequently miss pills should be counseled about long-acting reversible contraceptives (IUDs, implants) or injectables that are less user-dependent. 1 Predictors of increased pregnancy risk include low partner support, being unmarried, and not considering pregnancy avoidance especially important. 6