Recommended Actions After Incorrect Use of Combined Hormonal Contraception

Overview

This Guidelines summary guides management for when a woman has made a mistake using combined oral contraceptive (COC) pills, a combined vaginal ring (CVR), or a combined transdermal patch (CTP). 

Missing combined hormonal contraception (CHC) removes the suppressive effects of contraceptive steroids on ovarian follicle growth, thereby risking ovulation and conception. Women using CHC who miss COC or make mistakes with their CVR or CTP are at increased risk of pregnancy compared with women who use CHC perfectly.

For further information, please refer to the full guideline. 

Combined Hormonal Contraception

• CHC that is designed to be used in the standard way (that is, COC in 21/7 regimens with 21 active pills followed by a 7-day pill-free interval; ring in place for 21 days followed by a 7-day ring-free interval; patch replaced weekly for 3 weeks followed by 7 patch-free days) can be used with the standard 7-day hormone-free interval (HFI), with a shortened HFI or with omission of the HFI. This guidance is designed to apply if mistakes are made with any of these regimes. For further information, see the FSRH clinical guideline: Combined hormonal contraception
• If a woman uses CHC incorrectly, she should be made aware that contraceptive effectiveness depends on reliable use. Offer alternative effective contraceptive methods (including long-acting reversible contraception)
• When emergency contraception (EC) is being considered, see the FSRH clinical guideline: Emergency contraception, section, What should women be advised regarding future contraception? to support decision-making on type of EC and recommendations for follow-up actions such as CHC method restart, additional protection, and pregnancy testing
• It should be noted that if CHC is not used correctly there is a potential risk of pregnancy, even if these recommended actions are followed.

Combined Oral Contraceptive Pills

This guidance applies only to monophasic ethinyloestradiol (EO) COC containing 20–35 mcg EO and designed to be taken as a 21/7 regime without placebo pills. It does not apply to Eloine® (24/4 regimen EO+drospirenone), Zoely® (24/4 regimen oestradiol+nomegestrol acetate), Qlaira® (oestradiol valerate+dienogest), or oestetrol-containing COC.

Algorithm 1: Guidance on Actions After Incorrect Use of COC (Monophasic Ethinylestradiol COC Without Placebo Pills Only)

• If a woman took her last pill before an HFI at 9am on Monday, so long as she restarts before 9am on Wednesday of the following week (just less than 9 days later), she does not need to take additional action. If she starts at or after 9am on the Wednesday of the following week (9 days or more later), additional action is required. For pills, the HFI is considered to start 24 hours after the last pill is taken.

Combined Vaginal Ring 

Algorithm 2: Guidance on Actions after Incorrect Use of the CVR

• If a woman removed her ring or patch before a HFI at 9am on Monday, so long as she inserts the new ring or applies the new patch by 9am on Tuesday of the following week (just less than 8 days later), she does not need to take additional action. If she restarts after 9am on Tuesday of the following week (8 days or more later), additional action is required. For the ring or patch, the HFI is considered to start at the time the ring or patch is removed.

Combined Transdermal Patch

Algorithm 3: Guidance on Actions After Incorrect Use of the CTP