Quick Start Contraception

Quick start is starting a contraceptive method on the day of the visit, at any point in the menstrual cycle, once pregnancy is reasonably excluded, rather than waiting for the next menses. It increases uptake and continuation, shortens the unprotected interval, and does not raise the risk of foetal harm.

Principles.

• Pregnancy exclusion is by the checklist or a test, not by menses.

• Add backup contraception where the method needs time to protect.

• Offer emergency contraception when unprotected sex occurred in the last 5 days.

• Quick start applies to all methods, but IUD insertion and sterilisation need stricter exclusion of pregnancy.

Quick start by method.

After emergency contraception.

• Levonorgestrel 1.5 mg: start the chosen hormonal method the same day; backup for 7 days (2 days for progestin-only pills).

• Ulipristal acetate 30 mg: wait 5 days before starting a hormonal method, then use backup for 7 days (2 days for progestin-only pills); use condoms during the 5 days.

• Copper IUD as emergency contraception: no further method is needed; the device continues as the method.

When pregnancy cannot be excluded. Provide a method other than an IUD or sterilisation, advise backup, and repeat a pregnancy test 3 weeks after the last unprotected sex or if menses have not occurred within 4 weeks.

Hormonal methods in unrecognised early pregnancy. There is no evidence of foetal harm. A positive test after quick start is not an indication to terminate the pregnancy.

Steps.

• Confirm reasonable certainty of non-pregnancy.

• Check eligibility category for the chosen method.

• Administer or dispense the method at the visit.

• State the backup requirement in days, and the date it ends.

• Give condoms.

• Set the date for a repeat pregnancy test when certainty was incomplete.

Postpartum quick start.

• Combined methods: from 21 days in non-breastfeeding patients with no other VTE risk factors; from 6 months in breastfeeding patients.

• Progestin-only pills, injectables and implants: from 6 weeks in breastfeeding patients; immediately in non-breastfeeding patients; backup for 7 days when more than 21 days after delivery and amenorrhoeic (2 days for progestin-only pills).

• IUDs: within 48 hours of delivery or from 4 weeks.

Postabortion quick start. Start any method immediately, including an IUD when there is no infection. No backup is needed when the method starts within 7 days of the abortion.

Common errors.

• Sending patients away to return during menses.

• Omitting backup after starting later in the cycle.

• Giving a hormonal method immediately after ulipristal acetate.

• Inserting an IUD without excluding pregnancy.

• Not telling the patient how long backup is needed.

Special groups. Adolescents benefit most from same-day provision because of high loss to follow up. Patients on enzyme-inducing drugs should start DMPA, an IUD or condoms rather than pills or an implant.

Referral and escalation. Refer for ectopic pregnancy suspected on a positive test with pain or bleeding. Refer patients who need a method not available on site, and provide condoms and emergency contraception meanwhile.