Switching Contraceptive Methods

Switching is changing from one contraceptive method to another without a gap in protection and without unnecessary delay. The aim is to protect from the first day of the new method, avoid overlapping risks, and reduce the unintended pregnancies that follow discontinuation. The rules depend on the method being stopped and the one being started.

Principles.

• Do not stop the old method until the new one is available.

• Start the new method immediately when pregnancy is reasonably excluded, rather than waiting for menses.

• A patient who has used a hormonal method consistently and correctly is protected until the new method begins, so no extra backup is needed.

• When switching from injectables, time the new method to the date the next injection would have been due.

• When the old method was an IUD, protection continues until it is removed, so remove it only once the new method protects.

Switching to combined pills, patch or ring.

• From another hormonal method used consistently and correctly, or with reasonable certainty of non-pregnancy: start immediately; no backup.

• From an injectable: start when the next injection is due; no backup.

• From a non-hormonal method other than an IUD: start within 5 days of menses, no backup; otherwise start at any time if reasonably certain, with backup for 7 days.

• From an IUD: start within 5 days of menses and remove the IUD at the same time; after 5 days, start the pills, use backup for 7 days and remove the IUD at the next menses.

Switching to progestin-only pills.

• From another hormonal method used correctly: start immediately; no backup.

• From an injectable: start when the next injection is due.

• From a nonhormonal method: within 5 days of menses, no backup; otherwise backup for 2 days.

Switching to injectables (DMPA or norethisterone enanthate).

• From a hormonal method: inject immediately if the method was used correctly; no backup.

• From a non-hormonal method other than an IUD: inject within 7 days of menses with no backup; otherwise at any time if reasonably certain not pregnant, with backup for 7 days.

• From an IUD: inject within 7 days of menses and remove the IUD at that time; after 7 days, inject, keep the IUD and remove it at the next menses.

• Between DMPA and norethisterone enanthate: do not alternate; if a switch is unavoidable (for example a stockout), switch at the time the repeat injection would have been given.

Switching to an implant.

• From a hormonal method used correctly: insert immediately; no backup.

• From an injectable: insert when the next injection is due.

• From a non-hormonal method: within 7 days of menses, no backup; otherwise backup for 7 days.

• From an IUD: insert within 7 days of menses and remove the IUD; later in the cycle, insert, keep the IUD and remove it at the next menses.

Switching to an IUD.

• Copper IUD: insert at any time if reasonably certain not pregnant; no backup.

• Levonorgestrel IUD: from a hormonal method used correctly, insert immediately; from a non-hormonal method, insert within 7 days of menses with no backup, or later with backup for 7 days.

Switching from lactational amenorrhoea method. Start another method when menses return, when the infant is 6 months old, or when breastfeeding is no longer fully or nearly fully, whichever comes first.

Steps.

• Ask why the patient wants to switch; address the cause (bleeding, side effect, cost, access).

• Confirm eligibility for the new method.

• Plan the switch date, backup duration and removal date for any device.

• Give condoms and advise on missed use rules for the new method.

• Document the old method, the date it ends and the new method start.

Enzyme-inducing drugs. For a patient stopping an enzyme inducer, keep the method that was used during treatment (DMPA, IUD or condoms) for 28 days after stopping before returning to pills, patch, ring or an implant.

After emergency contraception. Start the new method on the same day after levonorgestrel emergency contraception, or after 5 days when ulipristal acetate was used, with backup for 7 days.

Common errors.

• Removing an IUD or implant before the new method protects.

• Starting pills a week after a late injection without a pregnancy check.

• Alternating DMPA and norethisterone enanthate routinely.

• Not telling the patient how many days of backup are needed.

Special groups. Postpartum and postabortion switching follows the same principles with the timing limits for each method. Patients switching because of an interaction should have their new method checked against the interacting drug.

Referral and escalation. Refer when the new method needs a procedure not available on site, and provide condoms and the current method until the switch can be made.