gynecology and obstetrics
Oral Contraceptives
Initiation of Oral Contraceptives
Before oral contraceptives are started, clinicians should take a thorough medical, social, and family history to check for potential contraindications to use. Blood pressure is measured, and a urine pregnancy test is done. OCs should not be prescribed unless blood pressure is normal and results of the urine pregnancy test are negative. A physical examination, although often done when OCs are started, is not required. However, a physical examination is recommended within 1 year of OC initiation. A follow-up visit in 3 months may be useful for discussing potential adverse effects and for rechecking blood pressure. OCs can be prescribed for 13 months at a time. OCs may be started on the same day as the contraceptive visit (often called the quick-start method). The day of the week and time in the menstrual cycle are not important to when OCs are started. However, if OCs are started > 5 days after the first day of menses, women should use a backup contraceptive method (eg, condoms) for the first 7 days of OC use. Progestin-only OCs must be taken every day, at the same time every day. If > 27 hours elapse between doses of aprogestin-only OC, women should use a backup contraceptive method for 7 days in addition to taking the OC daily. For combination OCs, timing is not as stringent. However, if combined OC users miss taking a pill one day, they are advised to take 2 pills the next day. If they forget to take a pill for 2 days, they should resume taking the OC each day and should use a backup contraceptive method for 7 days. If they forget to take a pill for 2 days and have had unprotected sex in the 5 days before forgetting to take the pill, they can consider taking emergency contraception. The timing for starting combination OCs after pregnancy varies: After a 1st-trimester spontaneous or induced abortion: Started immediately For deliveries at 12 to 28 weeks gestation: Started within 1 week if women have no other significant risk factors for thromboembolism After a delivery at > 28 weeks: Not started until > 21 days postpartum because risk of thromboembolism is additionally increased during the postpartum period (however, should be delayed 42 days if women are exclusively breastfeeding [feeding on demand including night feedings and not supplementing with other foods] or if their risk of venous thromboembolism is increased [eg, because of a recent cesarean delivery] In 98% of women who are exclusively breastfeeding and in whom menses does not resume, pregnancy does not occur for 6 months postpartum even when no contraception is used. However, these women are often advised to start using contraception within 3 months after delivery. Progestin-only OCs may be used immediately postpartum. If women have a history of a liver disorder, tests to confirm normal liver function should be done before OCs are prescribed. Women at risk of diabetes (eg, those who have a family history, who have had gestational diabetes, who have had high-birth-weight infants, or who have physical signs ofinsulinresistance such as acanthosis nigricans) require plasma glucose screening and a complete serum lipid profile annually. Use of low-dose OCs is not contraindicated by abnormal glucose or lipid test results, except for triglycerides>250 mg/dL (2.8 mmol/L). Most women with diabetes mellitus may take combination OCs; exceptions are those who have vascular complications (eg, neuropathy, retinopathy, nephropathy) and those who have had diabetes for > 20 years. 