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Quick Start, Same Day: Jump-start pills, shot
When it comes to initiating oral contraceptives (OCs), new research indicates that immediate initiation before start of the next menses improves short-term continuation of pill use.1 A second study looking at same-day initiation of depot medroxy-progesterone acetate (DMPA, Depo-Provera) suggests that it is a safe and efficient way of providing women needed effective contraception within seven days of the office visit.2
The Quick Start approach has gained favor since early research indicated that it improved pill continuation rates.3,4 Prescribers once instructed on one of two approaches: the "first-day start," which initiates pill use on the first day of the woman's next period, or the "Sunday start," when pill use begins on the Sunday after the menstrual cycle begins. Now Quick Start is listed as the preferred method of pill initiation in Contraceptive Technology.5
Quick Start leads to better short-term continuation, most noticeable in teens and in those women who might be somewhat ambivalent at the time of starting, says Carolyn Westhoff, MD, MSc, professor of obstetrics and gynecology and professor of epidemiology and population and family health at Columbia University in New York City. Westhoff presented case studies and practical guidelines on Quick Start at the recent Contraceptive Technology conference.6
To perform the current study, Westhoff and fellow investigators recruited 1,716 women ages 25 and younger seeking to initiate pills at three publicly funded family planning clinics. Study participants were randomly assigned to conventional initiation of the pill or the Quick Start method. Women who took the first pill in the clinic were more likely to continue to the second pill pack (odds ratio 1.5, 95% confidence interval 1.0-2.1.); however, the Quick Start approach did not improve pill continuation rates at three and six months. Those assigned to Quick Start were slightly less likely to become pregnant within six months from the time they started the pill (hazard ratio 0.90, 95% confidence interval 0.64-1.25). More than 80% of the women rated the Quick Start approach as acceptable or preferable to waiting.
Protocols that require a woman to wait until the next menses to start hormonal contraceptives are an obstacle to contraceptive initiation, the researchers conclude. Directly observed, immediate initiation of the pill improves short-term continuation, they state. Quick Start is a more direct way of providing contraception, notes Westhoff. Saying, "Take your first pill right now" really elicits all the hidden questions that a patient might otherwise forget to ask, she observes.
"If supplies for the first pack are available, then there is no need to counsel on when to start — just start right now," says Westhoff. "That can save time for other important parts of the visit."
How about DMPA?
Can the same principles of jump-starting contraception be used with the contraceptive injection DMPA?
The new research looked at a study population of 1,056 women who had a total of 3,185 DMPA injections. More than 81% of the initial injections were given in the Same Day format, outside the first five days of menses. At each reinjection, 14-27% of women were late and also benefited from rapid access to DMPA. Continuation rates were low in both groups but were not lower among those who used Same Day injections compared with On Time starters. Six pregnancies were diagnosed, all in the Same Day Start group.2
Nearly 80% of patients who wanted to start DMPA did not have to wait for their first shot with this Quick Start/Same Day start protocol, says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the University of California in Los Angeles (UCLA) and medical director of the women's health care programs at Harbor — UCLA Medical Center in Torrance.
There is a four-step process to administering DMPA in this manner, emphasizes Nelson, who served as lead author for the current study. The first step is for clinicians to obtain a thorough history of unprotected intercourse since the last menstrual period to determine the need for pregnancy testing, she states.
Patients then need to obtain emergency contraception if they have had unprotected intercourse in the last five days, she notes. Counseling must include that when giving DMPA in this manner, condoms must be used for the next seven days, says Nelson.
The fourth step is to counsel patients that they will need to repeat the pregnancy test two to three weeks after the injection if they have had any recent unprotected intercourse, says Nelson.