For a patient with a history of OCP use, a pill that was previously used successfully is a reasonable starting point. For OCP-naïve patients, physicians may want to prescribe the least costly pill that is compatible with the patient’s health insurer and her preference, as well as your knowledge and comfort level.
How many pill packs to prescribe?
Most women receive 3 pill packs at a time from the pharmacy, although some get only one at a time.21 Yet evidence suggests that dispensing a 12-month supply of hormonal contraceptives at one time significantly increases patient continuation and use of preventive services (Pap smear screening and chlamydia testing, for example), decreases the need for pregnancy testing, and significantly cuts health care costs.21Keep in mind, however, that each pack of traditional pills contains medication for 4 weeks, while a year contains 13 4-week blocks of time. So any prescription written for 12 OCP packs will be insufficient to cover the entire year.
Variation in number and type of placebo
Another consideration: OCPs traditionally come in 28-day pill packs, with the last 7 pills being placebos. The number of active and placebo pills has been modified in some OCPs, in an attempt to decrease the risk of ovulation and unintended pregnancy.
Because some patients develop hormonal withdrawal side effects during the period of time when they’re taking placebos, several OCP formulations have added a small amount of estrogen to some, or all, of the placebos. One variation combines both concepts, featuring 24 active pills (rather than 21, to decrease the risk of ovulation) and 4 placebo pills containing 10 mcg EE (in an attempt to prevent withdrawal effects). Other variations are available, as well.
Although these pills have a greater inhibition of the pituitary-ovarian axis, they do not have better contraceptive efficacy compared with traditional dosing.22 Still, OCPs with such nontraditional regimens may be considered for any patient, and prescribed for women who have had prior success with this type of OCP.
Getting started: What to tell patients
For many years, combination OCPs were started on the Sunday after the onset of the next menses—a method known as conventional start. But there were 3 disadvantages to this: Patients needed to use an additional form of contraception during the first month of OCP therapy, had an increased risk of pregnancy in the first month, and often misunderstood the instructions, frequently starting the pills the Sunday after their period ended, instead of the Sunday after menstrual bleeding began.
The “first day” start came next. Patients were routinely told to begin their pills on the first day of their next menses. This was easily understood and eliminated the need for an additional form of contraception in the first month, but theoretically, a woman could get pregnant while waiting for her next menstrual cycle to start the OCPs.
To address these problems, the newest option is known as the “visit day” or “quick start. “ Advise patients to start the pills on the day of their office visit, either with a sample package or by picking up the OCPs at the pharmacy on the same day. This results in better short-term continuation rates and does not disrupt menstrual bleeding patterns.23,24
Pregnancy test. Prior to the quick start, however, women should have a documented negative pregnancy test (or receive emergency contraception if they have had unprotected intercourse in the last 72 hours). If the patient had unprotected intercourse in the prior 2 weeks, the pregnancy test should be repeated 2 weeks after she starts taking the pill.
OCP timing after a pregnancy
Women who have had a spontaneous or therapeutic abortion <20 weeks’ gestation can start taking combination OCPs immediately. A patient whose pregnancy ended >20 weeks and who is not breastfeeding can use combination OCPs, as well. Because of an increased risk of VTE during the initial postpartum period, however, women should delay the start date until >3 weeks postpartum.25
Breastfeeding considerations. Some women, and some clinicians, fear that combination OCPs reduce both the quantity and quality of breast milk. In fact, low-quality evidence suggests that the pills reduce the quantity of breast milk but do not impair infant growth.26 Studies of OCPs and breastfeeding, although of limited quality, have failed to show specific harm to the infant.
According to ACOG, women who are nursing can begin combination OCPs >6 weeks’ postpartum if breastfeeding is well established and no other form of contraception is acceptable.27 To address concerns about decreased breast milk associated with combination OCPs, however, progestin-only pills are frequently recommended for nursing mothers—and can be started immediately postpartum without any effect on breast milk.25