What is the appropriate quick‑start prescription and counseling for a premenopausal woman with no contraindications who wants to start a low‑dose combined oral contraceptive (ethinyl estradiol 20 µg/levonorgestrel 150 µg) today?

Quick-Start Combined Oral Contraceptive Prescription

Start ethinyl estradiol 20 µg/levonorgestrel 150 µg today using the "quick-start" method, with mandatory backup contraception (condoms or abstinence) for the first 7 consecutive days. 1, 2

Immediate Prescription Protocol

Day 1 Instructions

• Prescribe up to 1 year supply of the medication at once to improve adherence and access 1
• Instruct the patient to take the first pill today, regardless of menstrual cycle timing 1, 2
• Emphasize that backup contraception is absolutely required for the first 7 days because seven consecutive days of pill-taking is necessary to reliably prevent ovulation 1, 2
• This 7-day backup requirement is particularly critical for 20 µg formulations, as studies show more follicular activity when pills are missed compared to 30 µg formulations 1

Daily Adherence Counseling

• Strict adherence is essential with 20 µg formulations - the patient must take one tablet at the same time every day 1, 3
• Missing pills with this lower-dose formulation carries higher ovulation risk than with 30-35 µg formulations 1
• Counsel on what to do if pills are missed (use backup contraception and refer to package insert for specific instructions) 3

Pre-Prescription Safety Assessment

Required Before Prescribing

• Measure blood pressure - this is the only required clinical assessment 2
• A pelvic examination is NOT required before starting COCs 2
• Rule out pregnancy if there is any possibility (though quick-start can proceed if pregnancy test is negative) 1, 2

Absolute Contraindications to Screen For

• Severe uncontrolled hypertension (≥160/100 mm Hg) 1, 2
• Current or history of thromboembolism or thrombophilia 1, 2
• Migraines with aura or focal neurologic symptoms 1, 2
• Complicated valvular heart disease 1, 2
• Ongoing hepatic dysfunction 1, 2
• Complications of diabetes (nephropathy, retinopathy, neuropathy, vascular disease) 2
• Smoking in women ≥35 years old 1, 3

Critical Safety Counseling

Thromboembolism Risk

• Inform the patient that VTE risk increases from 1 per 10,000 to 3-4 per 10,000 woman-years with COC use 1, 2
• The highest VTE risk occurs when initially starting or restarting after a ≥4-week break 3
• This risk remains significantly lower than the 10-20 per 10,000 risk during pregnancy 1, 2

Smoking Warning

• Cigarette smoking increases the risk of serious cardiovascular events from COC use 3
• Women over 35 who smoke should not use COCs 3
• For women under 35, smoking should be discouraged but is not an absolute contraindication 1

STI Protection

• Counsel that this product does not protect against HIV or other sexually transmitted infections 3
• Recommend condom use for STI prevention even after the 7-day backup period 3

Expected Side Effects and Management

Common Transient Effects

• Breakthrough bleeding is the most common side effect, especially in the first few cycles 1, 4, 5
• Headache and nausea may occur but typically improve with continued use 1, 2
• Reassure that these effects usually resolve and enhanced counseling about expected bleeding patterns reduces discontinuation 2

Effects NOT Reliably Linked to COCs

• Weight gain has not been reliably linked to COC use 1, 2
• Mood changes have not been reliably linked to COC use, though women with history of depression should be counseled that depression may recur 1, 3

Drug Interactions to Review

Medications Requiring Alternative Contraception

• Rifampin and rifabutin significantly reduce effectiveness - use alternative contraception 1
• Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine) reduce effectiveness 1
• Griseofulvin lessens effectiveness 1
• Some antiretroviral agents (ritonavir-boosted protease inhibitors, nevirapine, efavirenz) reduce hormonal levels 1

Medications That Do NOT Interact

• Tetracycline-class antibiotics (doxycycline, minocycline) do not reduce effectiveness 1
• Broad-spectrum antibiotics do not affect effectiveness 1
• Antifungals and antiparasitics show no clinically significant interactions 1

Follow-Up Monitoring

Ongoing Requirements

• Blood pressure monitoring is the primary safety requirement during long-term use 1
• Blood pressure can be obtained in nonclinical settings to facilitate monitoring 1
• No routine laboratory monitoring is required beyond blood pressure checks 1

Common Pitfalls to Avoid

• Do not substitute therapeutically equivalent generic products without counseling - differences in bioavailability may interfere with efficacy and increase breakthrough bleeding 4
• Do not extend the hormone-free interval beyond 7 days - this increases ovulation risk 2
• Do not discontinue COCs prematurely due to breakthrough bleeding - this is the most common reason for discontinuation and often leads to less effective contraception or unintended pregnancy 4
• Do not require a pelvic exam before prescribing - this creates an unnecessary barrier to access 2