Quick Start: Why put off what you can do today?
By Anita Brakman, MS
Senior Director of Education, Research & Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, FAAP
Clinical Professor of Pediatrics
University of Pittsburgh School of Medicine
University of Pittsburgh Student Health Service
For the last 15 years, emerging evidence has encouraged clinicians who prescribe hormonal contraception to "quick start" patients on their chosen contraceptive method on the day of the visit, instead of waiting until after menses begins. For patients using combined oral contraceptives, contraceptive patch, vaginal ring, or injection, Quick Start is a way to ensure that protection against unintended pregnancy begins as soon as possible. Adolescents are most likely to rely on oral contraceptive pills (OCPs) and other combined hormonal methods to prevent pregnancy,1 so it is especially important that adolescent health professionals are aware of this option for initiating contraception. Proponents of Quick Start believe that this initiation method might improve continuation rates and enhance consistency of pill use among younger patients.
To utilize Quick Start with OCPs, the contraceptive patch, vaginal ring, or injection, a clinician takes a few short steps. First, the clinician identifies the date of last menstrual period (LMP). If it was five or fewer days before the visit, the patient can go ahead and start the method that day. If LMP was more than five days before the visit, clinicians should ask if unprotected sex has occurred during this window to assess if emergency contraception (EC) is appropriate.
If no unprotected sex has occurred since LMP, the patient can start the new method immediately but should abstain from sex or use a backup method such as condoms for one week. If unprotected sex has occurred at any time since the last menstrual period, a urine pregnancy test should be given. Provided the test is negative, the clinician should offer EC if appropriate and at the same time start the patient’s new ongoing method the same day. Backup protection is still needed for a week, and the patient should follow up two weeks later for another pregnancy test to rule out the possibility of a pregnancy occurring just before the method initiation visit.
Is Quick Start safe?
Clinicians who recommend a "Sunday start" or conventional initiation timing such as first day of menses start might have concerns about the safety and efficacy of starting hormonal contraception without confirming that the patient is not pregnant by having her menses. This concern is unfounded, as hormonal contraceptives will not harm an early pregnancy.2 Additionally, a 2013 review in Contraception reported patients who use Quick Start are equally likely to conceive prior to starting contraception compared to counterparts relying on a conventional start.3 The same systematic review also found there is limited evidence that Quick Start initiation prevents more pregnancies than a conventional start.
The review examined four studies which reported on pregnancy risk after starting a hormonal method using quick or conventional start. Two studies found no pregnancies in either group other than those that occurred before contraception was initiated. One study of 1,716 women under age 25 found 138 pregnancies occurring over six months, but there was no significant difference in the number of pregnancies reported among Quick Start groups compared to conventional start groups (8.2% and 9.1%, respectively).
The final study examined data from 539 females ages 12-17. This study had the most encouraging support for Quick Start, finding more pregnancies in the conventional start group than the Quick Start group; 6.5% of those using Quick Start became pregnant, compared to 10.5% of those using a conventional start. This study and all four of studies reported in the review were not powered to detect differences in pregnancy rates, Further and larger studies are needed to assert a true benefit to Quick Start in decreasing unintended pregnancy.3
Check continuation rates
Evidence also is lacking on the long-term benefits for using Quick Start to improve contraceptive continuation rates.
Studies have demonstrated that women who Quick Start oral contraceptives, patches, or rings report higher continuation rates at early follow-up visits, but these rates fall over time. After one year, rates of continuation are similar between quick and conventional starters.3 One study that focused on method continuation among adolescents affirmed these findings, reporting that while Quick Start patients were more likely to start a second pack of pills than conventional starters, continuation rates were similar across both groups at three and six months.4
To truly improve continuation rates and decreased unintended pregnancy, clinicians caring for adolescents (and adults) should consider offering more effective long-acting reversible contraceptives (LARCs). Looking at the widely reported findings of the St Louis Contraceptive CHOICE Project, 81% of LARC users ages 14-19 continued their method for at least 12 months, and 67% continued for 24 months.5 Peers using non-LARC methods (such as pills, patches, or rings) had lower continuation rates of 49% and 37% at one and two years, respectively. Additionally, adolescents enrolled in the study had a birth rate of 6.3 compared to a national teen birth rate of 34.3 per 1,000 women ages 15-19.6
Regardless of a patient’s method of choice, there is no negative effect to a Quick Start initiation, and benefits in terms of continuation rates are seen, at least in the short term. Clinicians should counsel patients to use the most highly effective method available to them and start that method as soon as possible, contraceptive experts agree.
- Jones J, Mosher WD, Daniels K. Current Contraceptive Use In The United States, 2006-2010, and Changes in Patterns of Use Since 1995. Accessed at http://1.usa.gov/1qAjac7.
- Bracken MB. Oral contraception and congenital malformations in offspring: A review and meta-analysis of the prospective studies. Obstet Gynecol 1990; 76(3 Pt 2):552-557.
- Brahmi D, Curtis KM. When can a woman start combined hormonal contraceptives (CHCs)? A systematic review. Contraception 2013; 87:524-538.
- Edwards SM, Zieman M, Jones K, et al. Initiation of oral contraceptives — Start now! J Adolesc Health 2008; 43:432-436.
- O’Neil-Callahan M, Peipert JF, Zhao Q, et al. Twenty-four month continuation of reversible contraception. Obstet Gynecol 2013; 122(5):1,083-1,091.
- Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012; 120(6):1,291-1,297.