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Practice Algorithm

Quick-Start/ Same-Day-Start Contraception: Breaking Down Barriers for Women

Anita L. Nelson, MD

Continuation rates for women using hormonal contraception are dismal. Whether the patient is given the medication for free1 or fills a prescription at a pharmacy with a copay or at full cost,2 studies show that 3-month continuation rates rarely exceed 70% and 12-month rates are 30% or less. These numbers only reflect the percentage of prescriptions that are refilled; more than 50% of women who do refill their prescriptions miss more than two pills in each cycle.3

Given these realities, researchers have tried to find ways to enhance correct, consistent use of hormonal contraceptive methods. New, long-acting (ie, “forgettable”) methods that require virtually no action by the patient—eg, intrauterine contraception, implants—provide a very attractive approach. For women who prefer combined hormonal contraception, longer-acting options such as the transdermal patch and vaginal contraceptive ring promote better adherence. For those who want oral contraceptives (OCs), providing several months' worth of medication either directly or by prescription has been asso-ciated with higher short-term continuation rates.4,5

Regardless of the method chosen, the first step is to facilitate the patient’s access to her initial supply. Failure to start the method guarantees that the patient will not succeed. Up to 25% of teenagers who are given a prescription or pill pack with instructions to start with the next menses never use the method. The reasons vary, but include pregnancy, confusion about initiation instructions, and bad advice from friends and family.6,7

To overcome this substantial barrier to successful OC use, Westhoff et al8 developed the quick-start/same-day-start protocols, which have been tested extensively. In a study of more than 1700 women, second-pack continuation of pill use was 50% higher using the quick-start protocol compared with conventional protocols.8 Somewhat surprisingly, bleeding patterns are no different between those 2 groups.9,10 Over time, the same-day-start approach has proven safe and effective for women using transdermal patches,11 vaginal rings,12 and depot medroxyprogesterone acetate (DMPA) injections.1,13 It has been estimated that without the quick-start protocols, nearly 80% of women seeking to start DMPA injections would have experienced delayed efficacy, and 10% to 15% of women seeking reinjection would have had to return for subsequent visits.1,13

The quick-start/same-day-start protocols for each of these methods are very similar because they all work on the same principle. Three issues must be addressed:

• Is the patient pregnant now?
• Has she had unprotected intercourse in the last 5 days?
• What will she use as a back-up method until the hormonal method takes effect?

The risk of current pregnancy can generally be assessed from the patient's history, but a urine test should be administered in all cases as indicated by coital history. A woman who has engaged in unprotected intercourse within the last 120 hours should be given 2 emergency contraception (EC) tablets immediately. She can start the ongoing method (eg, DMPA, ring, patch) at the same time, but it is prudent to delay OC initiation for 12 to 18 hours to avoid nausea that the patient could incorrectly attribute to her hormonal method.

In general, the patient should start with the first pill in the pack or the first patch in a 3-week cycle. She needs to understand that her next scheduled bleeding episode will not occur until she uses all 21 or 24 days of her combined hormonal method. A back-up method (abstinence, condoms) should be used for 7 days with quick-start OCs, rings, and injections until the cervical mucus is sufficiently thickened to block sperm entry into the upper genital tract. Because it takes 2 days for the transdermal patch to reach therapeutic serum levels, women following the quick-start protocol with the patch should use back-up contraception for 9 days.

Patients should be instructed to return for pregnancy testing only if they have pregnancy symptoms or do not have bleeding during their next hormone-free interval. The only exception to this rule is the quick-start DMPA user who receives EC; these women should be routinely instructed to obtain a pregnancy test 2 to 3 weeks postinjection, because they may attribute any amenorrhea to DMPA use and substantially delay a pregnancy diagnosis. The algorithm in the Figure highlights the steps to follow when using DMPA on the date of the patient°s visit, which can easily be adapted for use with any combined hormonal method.

Click to enlarge

FIGURE. Depot medroxyprogesterone acetate quick-start protocol. DMPA = depot medroxyprogesterone acetate; LMP = last menstrual period; IC = intercourse; UCG = urine chorionic gonadotropin; EC = emergency contraception.

The logic of the quick-start/same-day-start approach is undeniable. Women come to the health care provider seeking contraception because they are at risk for pregnancy. Requiring them to use a less effective method until their next menses is not in their best interest. Helping a woman to immediately initiate her method of choice not only promotes better protection and patient education, but also sends a clear message to the patient that the health care provider recognizes the importance of contraception to her health, reinforcing her commitment to correct and consistent use.

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Anita L. Nelson, MD, is Professor, Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, Torrance, CA.

References

1. Nelson AL, Katz T. Initiation and continuation rates seen in two-year experience with same day injections of DMPA: a retrospective chart review. Contraception. 2007;75(2):84-87.
2. Nelson AL, Westhoff C, Schnare SM. Evaluation of 91-day extended regimen oral contraceptive continuation rates. Contraception. 2007;76(2):172.
3. Potter L, Oakley D, de Leon-Wong E, Canamar R. Measuring compliance among oral contraceptive users. Fam Plann Perspect. 1996;28(4):154-158.
4. Foster DG, Parvataneni R, de Bocanegra HT, Lewis C, Bradsberry M, Darney P. Number of oral contrceptive pill packages dispensed, method communication, and costs. Obstet Gynecol. 2006;108(5): 1107-1114.
5. Nelson AL, Pietersz D, Nelson LE, Aguilera L. Documented short-term continuation rates for combined hormonal contraceptives in an indigent population with ready access to contraceptive supplies. Am J Obstet Gynecol. 2007;168(9):599.e1-6.
6. Oakley D, Sereika S, Bogue EL. Oral contraceptive use after an initial visit to a family planning clinic. Fam Plann Perspect. 1991;23(4):150-154.
7. Polaneczky M, Slap G, Forke C, Rappaport A, Sondheimer S. The use of levonorgestrel implants (Norplant) for contraception in adolescent mothers. N Engl J Med. 1994;331(18):1201-206.
8. 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(6): 1270-1276.
9. Westhoff C, Morroni C, Kerns J, Murphy PA. Bleeding patterns after immediate vs. conventional oral contraceptive initiation: a randomized, controlled trial. Fertil Steril. 2003;79(2): 322-329.
10. Lara-Torre E, Schroeder B. Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills. Contraception. 2002; 66(2):81-85.
11. Murthy AS, Creinin MD, Harwood B, Schreiber CA. Same-day initiation of the transdermal hormonal delivery system (contraceptive patch) versus traditional initiation methods. Contraception. 2005;72(5):333-336.
12. Westhoff C, Osborne LM, Schafer JE, Morroni C. Bleeding patterns after immediate initiation of an oral compared with a vaginal hormonal contraceptive. Obstet Gynecol. 2005;106(1):89-96.
13. Sneed R, Westhoff C, Morroni C, Tiezzi L. A prospective study of immediate initiation of depo medroxyprogesterone acetate contraceptive injection. Contraception. 2005;71(2):99-103.

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