EXECUTIVE SUMMARY
Many women continue to choose combined hormonal contraceptives. However, these methods are dependent on user behavior, such as taking a pill every day or changing the patch or ring on time.
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Combined oral contraceptives continue to be the most-used of all combined hormonal options. To help women stay consistent in their pill-taking, supply multiple packs of pills.
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Management of forgotten contraceptive patches depends on which patch is missed and for how long.
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If The Contraceptive Vaginal Ring Is Out Of The Vagina For More Than Three Hours During The First Two Weeks, A Woman Might Not Be Protected Against Pregnancy. She Should Reinsert The Ring As Soon As Possible And Use An Extra Method Of Birth Control Until The Ring Has Been Used For Seven Days In A Row.
What are the benefits and disadvantages of such second-tier methods as pills, patches, and rings, and which women can safely use them? These Tier 2 methods, designated by their effectiveness ranking as adapted by the World Health Organization (WHO), depend on user behavior such as taking a pill every day or changing the patch or the ring on time.1
It’s best to use the Effectiveness of Family Planning Methods chart in discussing these contraceptive options with women to give a pictorial-based representation of where these methods fall on the effectiveness chart, says Carrie Cwiak, MD, MP, associate professor of gynecology and obstetrics and division director of family planning at Atlanta-based Emory University. (The chart and contraceptive fact sheets are available at the federal Family Planning National Training Centers site. Go to http://bit.ly/1MKCbp8 to download these resources.)
Combined oral contraceptives (COCs) continue to be the most-used of all combined hormonal options, states Cwiak, who spoke at the 2015 Contraceptive Technology Quest for Excellence conference in Atlanta.2 Despite the pill’s popularity, however, continuation is less than desired, notes Cwiak.
Just 55% of women continued on COCs at 12 months, compared to 86% of LARC users, in the Contraceptive CHOICE Project, a prospective cohort study of reproductive-aged women designed to promote the use of long-acting reversible contraceptives (LARC) by eliminating cost, access, and knowledge barriers.3
One way to help women stay consistent in their pill-taking is to supply multiple packs of pills, says Cwiak. In one California study, women who received a one-year supply were less likely to have a pregnancy (1.2% compared with 3.3% of women receiving three cycles of pills and 2.9% of women receiving one cycle of pills).4
COUNSEL ON ADHERENCE
The efficacy of any combined hormonal method depends on compliance to its correct use. To help prepare women for the eventuality of missed pills, clinicians can use the Family Planning National Training Center’s chart at http://bit.ly/1NpChyM or a simplified explanation from Contraceptive Technology:
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If she is late (less than 12 hours) taking a pill, take it immediately and continue with the other pills at the usual time.
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If she is more than 12 hours late taking the pills, she should take the last missed pill right away and also take the pill she should take on time. She should use emergency contraception (EC) if she has had any unprotected intercourse in the past seven days. She should use condoms or abstain until she has used seven pills in a row.5
Management of forgotten patches depends on which patch is missed and for how long. If forgotten or missed in the first week, women should be provided EC if they have had unprotected intercourse and advised to place a patch immediately. An additional method (such as condoms) or abstinence should be used for seven days. Remind the patient to change the patch each week from now on, beginning on the day she started the new patch.
If missed or forgotten on the second or third week, if the patch is one to two days late, the women can remove the old patch and replace it with a new one immediately. She will need no additional contraceptive method or EC.
However, if the patch is more than two days late, she should remove the old patch, place one immediately, and be provided EC if she has had unprotected intercourse. Advise additional contraception or abstinence for seven days.
If, during the fourth week, a woman recognizes she has forgotten to remove her third patch, she can remove it at that time. She will need no additional contraceptive method or EC. She then should place a new patch on the usual day.5
With the contraceptive vaginal ring, if the ring is out of the vagina for more than three hours during the first two weeks, a woman might not be protected against pregnancy. She should reinsert the ring as soon as possible and use an extra method of birth control until the ring has been used for seven days in a row. If the ring has been out for more than three hours during the third week, she can choose from two options:
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She can insert a new ring immediately. This step begins the next three-week use period. She might not have withdrawal bleeding, but she might experience breakthrough spotting or bleeding.
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Or, she can wait for withdrawal bleeding, and insert a new ring no later than seven days from the time the previous ring was removed or expelled. This option should be chosen only if the ring was used continuously for the preceding seven days. In addition, she must use a barrier method until she has used the ring for seven days in a row.5
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U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Effectiveness of Family Planning Methods. Accessed at http://1.usa.gov/1oOY2Bw.
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Cwiak C. Pills, patches and rings: Update on the 2nd tier methods? Presented at the 2015 Contraceptive Technology Quest for Excellence conference. Atlanta; November 2015.
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Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011; 117(5):1105-1113.
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Foster DG, Hulett D, Bradsberry M, et al. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol 2011; 117(3):566-572.
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Nelson AL, Cwiak C. Combined oral contraceptives (COCs). In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
