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Contraception - Management
How should a woman start using a combined oral contraceptive (COC) - de novo, or switching from another method or COC?
- If the woman could be pregnant, delay starting combined oral contraceptives (COCs) until the next menstrual period, or until pregnancy has been ruled out.
- Women not currently using hormonal or intrauterine contraception:
- Start COCs at the beginning of menstruation; ideally on the first day of bleeding, but this can be up to and including day 5 of the cycle.
- Additional contraceptive protection will not be required.
- If this is not possible:
- Start COCs at any other time in the menstrual cycle provided that it is reasonably certain that the woman is not pregnant.
- Advise additional contraceptive protection (such as condoms) for the first 7 days of pill taking.
- Inform the woman that medical advice may differ from that included in the packet of pills.
- Specific advice for women who are amenorrhoeic, postpartum and breastfeeding, postpartum and not breastfeeding, or post-abortion is summarized in Table 1.
- Starting immediately after oral emergency contraception:
- Levonorgestrel emergency contraception used — advise additional contraception (condoms or avoidance of sex) for the first 7 days of pill taking.
- Ulipristal acetate emergency contraception used — advise additional contraception (condoms or avoidance of sex) for the first 14 days of pill taking.
- Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of unprotected sex.
- Women who have been using a different COC, combined contraceptive patch, or progestogen-only pill:
- The new COC can be started immediately. There is no need to wait for the next menstrual period.
- However, the woman may want to complete the cycle of her current hormonal method, omitting any hormone-free interval (or the inactive pills of 'every day' preparations), before starting the new COC.
- No additional contraceptive protection is needed.
- Women who have been using a progestogen-only injectable:
- The COC should be started when the repeat injection would have been given.
- No additional contraceptive protection is needed if the COC is started less than 14 weeks (98 days) after the injection (outside the terms of the product licence).
- Women who have been using copper intrauterine devices (IUDs) or the levonorgestrel-releasing intrauterine system (IUS):
- The COC is most conveniently begun within 5 days of the start of menstrual bleeding. No additional contraceptive protection is needed. The IUD or IUS can be removed at that time.
- The COC can be started at any other time in the menstrual cycle, provided it is reasonably certain that she is not pregnant. She will need to abstain from sex or use additional contraceptive protection for the next 7 days.
- To provide the extra protection removal of the IUD or IUS could be delayed for at least 7 days.
- The IUD or IUS can be removed immediately unless she has had sexual intercourse in the past 7 days. In which case it should be left in until she has taken at least 7 pills sequentially.
Clarification / Additional information
- Explain to the woman that these recommendations may differ from those detailed in the patient leaflet or package insert:
- Manufacturers of combined oral contraceptives (COCs) advise that additional contraceptive protection is required if started between day 2 and day 5 of the menstrual cycle.
- Starting a COC at other times times in the cycle is outside the terms of manufacturers' licences.
- Starting hormonal contraception postpartum: general principles.
- No hormonal method should be started before day 21 unless there are good reasons to do so.
- If a hormonal method is to be used post birth, it can be started on day 21 without the need for any additional contraception.
- If started after day 21, then additional contraception (such as condoms) should be used for 7 days (inconsistency in current FFPRHC guidance with regard to requiring additional contraception between day 21 or 28 will be removed by the end of 2007 [Brechin, Personal Communication, 2007]).
- Table 1 outlines how to start a COC for women who are amenorrhoeic, postpartum, post-abortion or post-miscarriage.
Table 1. How to start combined oral contraception (COC) in different circumstances for women not currently using hormonal or intrauterine contraceptive methods.
Circumstances for starting COC | When to start COC | Additional contraceptive protection required |
|---|
Women having menstrual cycles | Start COC up to and including day 5. | None |
At any other time if it is reasonably certain that the woman is not pregnant. | For 7 days |
Women who are amenorrhoeic | COC can be started at any time, if it is reasonably certain the woman is not pregnant.* | For 7 days |
Postpartum (not breastfeeding) | Start COC on day 21 postpartum if vaginal delivery and no additional risk factors for venous thromboembolism. | None |
If > 21 days postpartum and menstrual cycles have returned, COC can be started as for other women having menstrual cycles (see above). | None if COC started on days 1–5; for 7 days if COC started after day 5 |
If > 21 days postpartum and menstrual cycles have not returned, treat as amenorrhoeic. | For 7 days |
Postpartum (breastfeeding) | Between 6 weeks and 6 months COC can be started as for women who are postpartum and not breastfeeding (see above). (Women breastfeeding and < 6 weeks postpartum should not use COCs). | None if COC started on days 1–5; for 7 days if COC started after day 5 or if amenorrhoeic |
Post-abortion or post-miscarriage | Gestation < 24 weeks: start COC within 7 days of surgical or medical abortion. Gestation > 24 weeks: as for postpartum. | None |
COC = combined oral contraceptive * If the cause of the amenorrhoea is uncertain, the ideal would be to use a non-hormonal method of contraception for 6 months and, if still amenorrhoeic, to then investigate for secondary causes — see the CKS topic on Amenorrhoea. For many women, this is not practical, and they will want to start a COC immediately. |
|
Basis for recommendation
- These recommendations are based on expert opinion from a World Health Organization (WHO) expert working group [WHO, 2004b] and are supported by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FFPRHC, 2005a; FFPRHC, 2007b].
- The WHO expert working group concluded that [WHO, 2004b]:
- The risk of ovulation within the first 5 days of menstruation is acceptably low.
- Ovulation is less reliably suppressed when combined oral contraceptives (COCs) are started after day 5.
- A COC must be used for 7 days to reliably prevent ovulation.
- When switching to a COC from another hormonal method, the need for additional contraceptive protection depends on that method.
- The risk of pregnancy after removal of copper intrauterine devices (IUDs), when there has been intercourse in the current menstrual cycle, is sufficiently high to recommend that the device be left in place until the next menstrual period.
- The recommendations on how long additional contraception should be used if combined hormonal contraception is started immediately after oral emergency contraception is based on the Quick starting contraception guidance issued by the Faculty of Sexual and Reproductive Healthcare (FSRH) [FSRH, 2010e].
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