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). It should be noted that if combined hormonal contraceptive (CHC) is not used correctly there is a potential risk of pregnancy, even if these recommended actions are followed. For further information, please refer to the full guideline

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Introduction

Missing 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.

Introduction

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 combined oral contraceptive pills (COC) or make mistakes with their combined vaginal ring (CVR) or combined transdermal patch (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 (i.e., COC in 21/7 regimens with 21 active pills followed by a seven-day pill-free interval; ring in place for 21 days followed by a seven-day ring-free interval; patch replaced weekly for three weeks followed by seven patch-free days) can be used with the standard seven-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 regimens. For further information, see 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 (LARC)).

When emergency contraception (EC) is being considered, see FSRH clinical guideline: emergency contraception section 18 (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 ethinylestradiol (EE) COC containing 20–35 mcg EE and designed to be taken as a 21/7 regimen without placebo pills. It does not apply to Eloine® (24/4 regimen EE+drospirenone), Zoely® (24/4 regimen estradiol+nomegestrol acetate) or Qlaira® (estradiol valerate+dienogest).

Algorithm 1: Guidance on actions after incorrect use of COC (monophasic ethinylestradiol COC without placebo pills only)

Guidance on actions after incorrect use of combined oral contraception

If a woman took her last pill before a HFI at 9am on Monday, so long as she restarts before 9am on Wednesday of the following week (just less than nine days later) she does not need to take additional action. If she starts at or after 9am on the Wednesday of the following week (nine 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

Guidance on actions after incorrect use of the combined vaginal ring

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 eight days later) she does not need to take additional action. If she restarts after 9am on Tuesday of the following week (eight 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

Guidance on actions after incorrect use of the combined transdermal patch

Full guideline available from fsrh.org/standards-and-guidance. Reproduced with permission from the Faculty of Sexual and Reproductive Healthcare (FSRH). March 2020. Copyright © FSRH.

Recommended actions after incorrect use of combined hormonal contraception (e.g. late or missed pills, ring and patch). FSRH, 2020. Available from: www.fsrh.org/documents/fsrh-ceu-guidance-recommended-actions-after-incorrect-use-of/

First published: March 2020.