Quick Starting Contraception

Menses-dependent start

  • Traditionally, women were told to wait until their next menses to begin hormonal contraception

  • This avoids using contraception during an undetected pregnancy

  • Downside is that the women have additional exposure to pregnancy

  • It may reduce likelihood of actually starting hormonal birth control by up to 25%

  • Impedes access for non-menstruating women


Methods Suitable for Quick Starting
All methods of contraception can be quick started at any time IF it is reasonably certain that there is no risk that the woman could be pregnant.

Criteria for reasonably excluding pregnancy are:


If any one OR more of the following criteria are met AND there are no signs or symptoms of pregnancy:

  1. She has not had intercourse since the start of her last normal (natural) menstrual period, since childbirth, abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease

  2. She has been correctly and consistently using a reliable method of contraception (Barrier method can be considered reliable PROVIDED they had been used consistently and correctly for every episode of intercourse)

  3. She is within the first 5 days of the onset of a normal (natural) menstrual period

  4. She is less than 21 days postpartum (Non-breastfeeding women)

  5. She is fully breastfeeding, amenorrhoeic AND less than 6 months postpartum

  6. She is within the first 5 days after having an abortion, a miscarriage, an ectopic pregnancy or an uterine evacuation for gestational trophoblastic disease

  7. She has not had intercourse for MORE THAN 21 days AND has a Negative high-sensitivity urine pregnancy test (able to detect hCG levels around 20 mIU/ml)

Quick starting Hormonal Contraception

  • Start hormonal contraception immediately

  • Increases women’s access

  • Improves continuation rate for combined contraceptive pills

  • Better adherence at 3 months among adolescents

  • Reduces unintended pregnancies

  • No significant difference in number of bleeding-spotting days or any other bleeding parameter

Quick start approach if pregnancy CAN be Excluded (1)

  • Last menstrual period < 5 days, quick start initiation. No need back up contraception

  • Last menstrual period > 5 days and if no unprotected sex, quick start initiation and use back up contraception or abstain for 7 days for pill, patch, injection or implant.

  • For Levonorgestrel intrauterine system, quick starting on day 8 onwards will need 7 days of additional precaution.

Quick start approach If Pregnancy CANNOT be Excluded (2)

  • Last menstrual period > 5 days and if have unprotected sex, do a pregnancy test

  • If pregnancy test negative, quick start initiation but assess if emergency contraception is needed

  • Use back up contraception or abstain for the first 7 days for pill, patch, injection, LNG-IUS or implant

  • Return in 21 days (3 weeks) and do a pregnancy test.

  • Pregnancy cannot be excluded until it is confirmed 21 days from the last unprotected sexual intercourse (UPSI) via a highly sensitive urine pregnancy (HSUP) test

  • IUD can be used as emergency and ongoing contraception and should only be quick started IF the conditions for EC are met.

  • IUD poses a risk of early unprotected pregnancy (MEC 4) whereas the other quick start methods do not and neither are they teratogenic

Cochrane Review (2012): Immediate start of hormonal birth control (5)


The review aim to evaluate:

  1. whether a quick start of hormonal birth control works as well as the usual start

  2. whether women like the approach

  3. whether a quick start method might improve women's use of hormonal birth control

5 RCTs from year 2003 to 2007 were included in the review based on the following search criterea:

  • RCTs that compared quick start to the usual start of birth control

  • RCTs that compared quick start of different types of hormonal birth control with each other (including COCs and progestogen-only contraceptive)

 

Findings

  • Method discontinuation was similar between groups in all trials

  • Bleeding patterns and side effects similar between quick start vs menses-dependent start

  • Quick start Depo-Provera showed

    • fewer pregnancies (OR 0.36; 95% CI 0.16 to 0.84)

    • more were “very satisfied” (OR 1.99; 95% CI 1.05 to 3.77)

  • Trial of two quick start methods comparing vaginal ring and COCs showed vaginal ring users have

    • Less prolonged bleeding (OR 0.42; 95% CI 0.20 to 0.89)

    • Less frequent bleeding (OR 0.23; 95% CI 0.05 to 1.03)

    • Less side effects eg changes in breast, weight, mood and nausea

    • More women were “very satisfied” (OR 2.88; CI 1.59 to 5.22)

Conclusions

  • Limited evidence that suggest quick start method reduces unintended pregnancies or increases method continuation.

  • Pregnancy rate is lower in women who started depo immediately compared to those who started with other contraceptive methods before depo.

  • Some differences were associated with contraceptive type rather than the start time (i.e. quick start vaginal ring vs quick start COC)

  • More studies on quick start versus the menses-dependent start of the same hormonal are needed

Pregnancy diagnosed after starting contraception


Women should be informed that contraceptive hormones are not thought to cause harm to the fetus and they should NOT be advised to terminate pregnancy on the grounds of exposure.

Pregnancy diagnosed after starting contraception

  • Women who quick start contraception when pregnancy cannot be excluded MUST be informed that a pregnancy test must be taken 21 days after the last episode of UPSI.

  • Women should be made aware that bleeding during or soon after stopping hormonal contraception is NOT the same as a natural period and is not a reliable indicator that a woman is not pregnant.

Women using COC, POP, Implant or DMPA

  • For women who wish to continue with their pregnancy, they should be advised that the methods of contraception should be removed or terminated

 


Women using IUCD

  • Women should be advised that the IUCD should be removed if the intrauterine pregnancy is less than 12 weeks gestation as long as the threads are visible or it can be easily removed from the endocervical canal.

  • Women with intrauterine pregnancy should also be informed that the removal of IUCD could improve pregnancy outcome but is associated with a small risk of miscarriage.

References

  1. Lara-Torre E, Schroeder B. Adolescent compliance and side effects with quick start initiation of oral contraceptive pills Contraception 2002;66:81-5

  2. Association of Reproductive Health Professionals. Choosing a Birth Control Method. Available @ www.arhp.org/publications-and-resources/quick-reference-guide-for-clinicians/choosing Accessed on 26 Feb 2018

  3. Faculty of Sexual & Reproductive Healthcare ( FRSH) Guideline – Quick Starting Contraception, April 2017

  4. Curtis KM, Jatlaoui TC, Tepper NK, et al. US Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-4):1-66.DOI:http://dx.doi.org/10.15585/mmwr.rr6504a1.

  5. Lopez LM, Newmann SJ, Grimes DA, et al. Immediate start of hormonal contraceptives for contraception. Cochrane Database Syst Rev 2012, Oct 2;(12):CD006260

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