How do you use pills? Check these strategies

When counseling a woman on when to start her first pack of oral contraceptives (OCs), what is your strategy for pill initiation? Most participants in the 2007 Contraceptive Technology Update Contraception Survey say they are using the Quick Start method.

Recent research indicates that immediate initiation of pills before start of the next menses improves continuation of pill use.1-3 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.4

"I feel especially in teenage girls who are sexually active, it is a good way to protect them from pregnancy rather than waiting for menses," says Eileen Britton, RNC, WHNP, a physician extender at Beaufort County Health Department in Washington, NC. Using Quick Start cuts down on the chance of unintended pregnancy by getting patients started on a method in a timely manner, agrees Wendy Hearn, MSN, FNP-C, a nurse practitioner at the Jefferson County Department of Health and Environment in Lakewood, CO. Clinicians at the facility used to require women to abstain for two weeks and return for a pregnancy test and then start them on pills if the test was negative. Quick Start cuts out this unnecessary delay, says Hearn.

Smoking, OCs don't mix

When it comes to women who smoke and the Pill, about 79% of survey participants say they will not write prescriptions for women ages 35-39 who smoke 10 cigarettes a day. For women ages 40 and older who smoke, about 90% say they will not prescribe OCs.

How can you help women to stop smoking? Try the "Five A's" approach developed by the federal Public Health Service5:

  • Ask. Check tobacco use at every visit. When discussing tobacco use, avoid yes/no questions such as, "Do you smoke?" Opt for multiple-choice questions that will yield more information.
  • Advise. Use clear, strong, and personal recommendations to help women quit. Statements such as, "Your hair and breath will smell better," may help patients respond to the smoking cessation message.
  • Assess. Where is your patient in her path to smoking cessation? If she isn't ready to stop now, review the benefits that will be achieved when she is, such as saving money and improving health. Repetition is crucial for patients who are struggling to stop smoking. Keep delivering the message.
  • Assist. Help your patient devise a plan to stop smoking. Look at options such as nicotine patches, gum, inhalers, and other nicotine replacement products, because only 5% of women who go "cold turkey" are successful.6
  • Arrange for follow-up. The first attempt may not be successful; on average, it takes five attempts before a woman actually quits smoking.

What pill for nausea?

Many women may experience nausea when beginning use of a new OC. Which pill do survey participants prescribe for women who have experienced nausea on previous combined pills?

Alesse, a monophasic 20 mcg pill from Wyeth Pharmaceuticals, Collegeville, PA, continues to lead in this category. About 56% of 2007 participants named the pill as top choice, compared to 44% in 2006. Alesse was followed by Loestrin, a 20 mcg pill from Warner-Chilcott of Rockaway, NJ, and Ortho Tri-Cyclen Lo, a multiphasic 25 mcg pill from Ortho-McNeil Pharmaceutical in Raritan, NJ. The two were named by 19% and 20% of respondents, respectively.

If a woman is in her 40s, healthy, and a nonsmoker, she is a potential candidate for combined oral contraceptives. When it comes to pill options for older women, 2007 survey participants again named Alesse (44%) as their preferred choice, followed by Loestrin (19%) and Ortho Tri-Cyclen Lo (11%).

When do you use pills?

While oral contraceptives provide reliable birth control, they also offer noncontraceptive benefits. Use of combined OCs can lead to reduced risk of ovarian cancer and endometrial cancer.4 About 40% of 2007 survey participants says they specifically prescribed the Pill in the last year to help women decrease their risk of cancer of the ovary.

When it comes to initiating combined OC use in postpartum women who are not breast-feeding, about 46% of 2007 survey participants say they will begin pill use four to six weeks after delivery. About 22% say they start pills one to three weeks postpartum, while about 11% begin OC use upon hospital discharge.

For breast-feeding women who wish to use progestin-only pills, about 42% indicate they will initiate pill use four to six weeks postpartum, while about 24% say they begin pill use one to three weeks following delivery. About 23% state they start minipills upon hospital discharge.


  1. Westhoff C, Heartwell S, Edwards S, et al. Initiation of oral contraceptives using a Quick Start compared with a conventional start: A randomized controlled trial. Obstet Gynecol 2007; 109:1,270-1,276.
  2. Westhoff C, Kerns J, Morroni C, et al. Quick Start. A novel oral contraceptive initiation method. Contraception 2002; 66:141.
  3. Lara-Torre E, Schroeder B. Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills. Contraception 2002; 66:81-85.
  4. Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 18th revised edition. New York City: Ardent Media; 2004.
  5. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Rockville, MD: U.S. Department of Health and Human Services; 2000.
  6. Sullivan MG. Smoking cessation. OB/GYN News 2005; 40:31.