Which OC would you choose? Test your skills with these 3 cases

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Applied Evidence

Which OC would you choose? Test your skills with these 3 cases

J Fam Pract. 2011 February;60(2):76-83

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References

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Progestin-only pills. Because progestin-only pills are taken every day with no placebos, women who take them have unpredictable and irregular menstrual bleeding. In addition, patients need to know that progestin-only pills must be taken at the same time every day; even a 3-hour day-to-day variation increases the risk of contraceptive failure.²⁰

What to do about forgotten pills?
Most women occasionally forget a pill, and it is important to tell them what to do about it (TABLE 5).^28,29 Such a discussion is critical to ensure contraceptive effectiveness.

If a patient misses one or 2 pills, she may make them up, using an additional form of contraception for 7 days if she skipped 2 consecutive pills. If she misses 3 consecutive pills, advise her to start a new pill pack, use an additional form of contraception for 7 days, and consider emergency contraception (EC) if she had unprotected sex. A woman who misses 3 pills in a row also needs to be urged to consider a contraceptive method that does not depend on daily compliance²⁹—and to consider EC if she had unprotected intercourse.

The most dangerous pill to forget is the first pill of the next pack. Missing that pill means the patient will have gone 8 days without hormonal treatment—and should use an additional form of contraception until she has taken an active pill for 7 days.

EC should be recommended for patients who forget 2 or more combination OCPs or miss the first pill of the next pack and have unprotected intercourse. Levonorgestrel 0. 75 mg (Plan B) can be taken as 2 doses 12 hours apart or taken together as a single dose (Plan B One Step).³⁰ Patients who are 17 years or older are allowed to buy Plan B over the counter; younger patients require a prescription.

TABLE 5
Forgotten pill(s)? What to tell your patients²⁹

Missed pill(s)	Instructions
Placebo	Skip the pill
Active pill <24 hours (1)	Take the pill as soon as you remember
Active pill >24 hours and <48 hours (1)	Take the missed pill AND the scheduled pill together
Active pills (2)	Take 2 pills on 2 consecutive days, then continue taking 1 pill per day Use additional contraception for 7 days Consider EC if you had intercourse when you missed pills
Active pills (≥3)	Stop that pack and start a new pack Use additional contraception for 7 days Consider EC if you had intercourse when you missed pills Consider other forms of contraception that do not require daily compliance
EC, emergency contraception.

What would you prescribe for our 3 patients?

CASE 1: Mandy

You start by strongly suggesting that she stop smoking, explaining that when she reaches age 35, the oral contraceptives will be contra-indicated if she continues to smoke. Because she had previously used a transdermal contraceptive patch without complications, a generic monophasic 30 to 35 mcg EE combination OCP would be a good choice. You schedule a follow-up visit in 3 months to determine how she is adjusting to the pill.

CASE 2: Julie

Julie is interested in continuous dosing but has no health insurance, so you recommend that she use a generic 21/7 combination OCP. Because of her preference for continuous dosing, however, you recommend that she start a new pack every 3 weeks, without taking any of the placebos, and tell her that this may result in improvements in her acne, as well.

CASE 3: Sandra

You reassure Sandra that combination pills have not been found to be harmful to infants, but suggest she consider a progestin-only formulation instead. You talk to her about the importance of meticulous compliance with a progestin-only OCP, which means taking her pill at the same time every day. You also explain that breakthrough bleeding is common with this type of pill, and that you can discuss a combination OCP when she is no longer nursing or if she cannot tolerate the progestin-only pill.

CORRESPONDENCE
Herbert L. Muncie, Jr, MD, 1542 Tulane Avenue, Room 123, New Orleans, LA 70112; hmunci@lsuhsc.edu