Initiating Combined Hormonal Contraception
Initiation timing decides whether protection is immediate or needs backup. Ovulation is reliably suppressed after 7 consecutive days of active hormone, so any combined method started after the first 5 days of menses needs 7 days of backup. Starting within 5 days of the start of menses gives immediate protection because follicular development is not yet established. The combined injectable allows a start within 7 days of the start of menses without backup.
| Method | Start without backup | Backup if started later |
|---|---|---|
| Pill, patch, ring | Within 5 days of the start of menses | 7 days |
| Combined injectable | Within 7 days of the start of menses | 7 days |
Backup methods. Condoms or abstinence. Condoms also give protection against HIV and other sexually transmitted infections.
Effectiveness. First-year pregnancies: 8 in 100 women with typical use and 0.3 in 100 with perfect use for pill, patch and ring; 3 and 1 in 100 for the combined injectable.
Return to fertility. Without delay after pill, patch or ring; about 5 months on average after the injectable.
Eligibility before starting. Confirm the patient has no category 4 condition and review any category 3 condition.
- Category 4: breastfeeding under 6 weeks; blood pressure 160/100 or more; ischaemic heart disease, stroke or complicated valvular disease; migraine with aura; current or past breast cancer; current or past deep vein thrombosis or pulmonary embolism, or thrombogenic mutation; diabetes with vascular disease; smoker 35 years or more with 15 or more cigarettes daily; lupus with positive or unknown antiphospholipid antibodies; decompensated cirrhosis; liver adenoma or malignancy.
- Category 3: breastfeeding 6 weeks to under 6 months; not breastfeeding under 21 days postpartum; blood pressure 140/90 to 159/99; rifampicin; rifabutin; enzyme-inducing antiseizure medicines.
Pregnancy exclusion. Pregnancy is reasonably excluded when there has been no intercourse since the last menses, a reliable method has been used correctly and consistently, menses began within the past 7 days, the patient is within 7 days of an abortion or miscarriage, or the patient is within 4 weeks of childbirth and not breastfeeding. When none holds, a urine pregnancy test is done.
A negative test within 2 weeks of unprotected sex does not exclude early pregnancy, so a quick start needs 7 days of backup and a repeat test in 2 to 4 weeks. If pregnancy cannot be excluded and the patient is otherwise eligible, issue packs to start with the next menses.
Interactions that defeat backup planning. Rifampicin, rifabutin, enzyme-inducing antiseizure medicines, griseofulvin and St John’s wort lower hormone levels, and backup does not correct this; choose another method. Efavirenz, nevirapine and ritonavir-boosted regimens need consistent condom use.
Counselling points for the clinician. State the exact backup period, the date protection begins and what to do after a missed dose. Consent, no coercion, assent from under 18 years.
Special groups. Adolescents: same rules. Postpartum and breastfeeding: timing is set in the start table. Perimenopause: category 2 from 40 years. HIV: dolutegravir, tenofovir and related backbones do not change timing. Postabortion: immediate start.
Regimen line for the pill. Ethinylestradiol 20 to 35 micrograms with a progestin, oral, one tablet daily; 21 active tablets then 7 hormone-free days. Grace: missing 1 or 2 pills, or a new pack 1 or 2 days late, needs no backup. Missing 3 or more pills needs 7 days of backup. Enzyme inducers: do not use.
Regimen line for the patch. Norelgestromin 6 mg with ethinylestradiol 0.6 mg, transdermal, weekly for 3 weeks then 1 patch-free week. Grace: patch change up to 48 hours late. Weight of 90 kg or more: another method is preferred.
Regimen line for the ring. Etonogestrel 11.7 mg with ethinylestradiol 2.7 mg, vaginal, 3 weeks in then 1 week out. Grace: insertion up to 48 hours late; ring out up to 48 hours.
Regimen line for the injectable. Medroxyprogesterone acetate 25 mg with oestradiol cypionate 5 mg, or norethisterone enanthate 50 mg with oestradiol valerate 5 mg, deep intramuscular every 30 days. Grace: 7 days early or late.
Start timing.
| Situation | Pill, patch, ring | Combined injectable |
|---|---|---|
| Within 5 days of the start of menses | Start now; no backup | Start now; no backup |
| 6 to 7 days after the start of menses | Start now; backup 7 days | Start now; no backup |
| After day 7 of menses, pregnancy excluded | Start now; backup 7 days | Start now; backup 7 days |
| Amenorrhoea, not pregnant | Start now; backup 7 days | Start now; backup 7 days |
| Not breastfeeding, 21 days or more postpartum, amenorrhoeic | Start now; backup 7 days | Start now; backup 7 days |
| Not breastfeeding, menses returned | Start within 5 days of menses with no backup; later with 7 days of backup | Start within 7 days of menses with no backup; later with 7 days of backup |
| Not breastfeeding, under 21 days postpartum | Not advised | Not advised |
| Breastfeeding, under 6 months | Not advised | Not advised |
| Breastfeeding, 6 months or more | Start by menses timing, or at any time with pregnancy excluded and 7 days of backup | Start by menses timing, or at any time with pregnancy excluded and 7 days of backup |
| After first or second trimester abortion | Start immediately; no backup within 7 days | Start immediately; no backup within 7 days |
| After levonorgestrel emergency contraception | Start immediately; backup 7 days | Start immediately; backup 7 days |
| After ulipristal emergency contraception | Wait 5 days, then start; backup 7 days | Wait 5 days, then start; backup 7 days |
Switching.
| From | Action |
|---|---|
| Another hormonal method used correctly | Start at once; no gap and no backup |
| Progestin-only injectable | Start when the next injection is due |
| Non-hormonal method | Start within 5 days of menses; otherwise any time if pregnancy is excluded with 7 days of backup |
| Intrauterine device, copper or hormonal | Start within 5 days of menses and remove the device then; if later, start with pregnancy excluded, use backup for 7 days and remove the device at the next menses |
| Implant | Start at once while the implant is in place; no gap |
| Another combined pill | Start the next pack the day after the last active tablet, or after the usual hormone-free interval |
Late or missed use during the first 7 days. Starting a pack, patch or ring late by 3 or more days, or missing 3 or more pills in the first week, restarts the backup period. Reset the 7 days from the day the method is correctly in place.
Follow up. Review at about 3 months and then yearly: blood pressure, weight, smoking, medicines. Up to 3 cycles may be issued at a visit. At about 50 years a change to a progestin-only or non-hormonal method is usual practice.
Initiation failures. Pregnancy after starting is most often from a late start without backup, missed pills in the first week or an interacting medicine. Exclude interactions, confirm the start date and review the backup used.
Unprotected sex during the backup period. Give emergency contraception. Levonorgestrel 1.5 mg orally as a single dose (two 750 microgram tablets together) as soon as possible within 120 hours; no adjustment for kidney or liver disease; acceptable in breastfeeding; not needed if pregnant. Ulipristal 30 mg orally as a single dose within 120 hours, where available; avoided in severe liver disease; hormonal contraception is started 5 days later with backup. A copper intrauterine device inserted within 5 days is the most effective option.
Expected effects of a quick start. Irregular bleeding and nausea in the first cycles; reassure and give ibuprofen 800 mg orally three times daily for 5 days with food if bleeding is unacceptable (maximum 2.4 g daily; avoid in renal impairment, active peptic ulcer or significant liver disease; not used in pregnancy).
Pregnancy on a combined method. Stop the method, confirm the pregnancy and its location, and refer for antenatal care or ectopic evaluation. Combined hormones are not known to harm the foetus.
Red flags. Severe abdominal pain, chest pain or breathlessness, severe or new headache, eye problems, severe calf pain. Stop the method and arrange urgent evaluation.
Referral and escalation. Emergency transfer for suspected thrombosis, stroke or myocardial infarction or suspected ectopic pregnancy. Refer for category 4 diagnoses found at initiation.
