Smoking and age >35 yr Hypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg) Current or history of venous thromboembolism Ischemic heart disease History of cerebrovascular accident Complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis) Migraine with focal neurologic symptoms Breast cancer (current) Diabetes with retinopathy/nephropathy/neuropathy Severe cirrhosis Liver tumor (adenoma or hepatoma) <1 month postpartum and breastfeeding or <21 days postpartum not breastfeeding Adequately controlled hypertension Hypertension (systolic 140–159 mm Hg, diastolic 90–99 mm Hg) Migraine and age >35 yr Currently symptomatic gallbladder disease Mild cirrhosis History of combined oral contraceptive-related cholestasis History of malabsorptive bariatric surgery procedure 1 Active pill delayed Take 1 active pill as soon as possible. for <24 hours in any Continue taking 1 pill OD until end of week pack.
1 or more active pills Take 1 active pill as soon as possible.
missed (Week 1) Continue taking 1 pill OD until end of pack. Back up contraception for 7 days. Consider emergency contraception.
<3 pills missed (Week Take 1 active pill as soon as possible.
2 or 3) Continue taking 1 pill OD until end of pack. Discard any placebo pills. Start new cycle of COC without an HFI.
3 or more missed pills Take 1 active pill as soon as possible.
(Week 2 or 3) Continue taking 1 pill OD until end of pack. Discard any placebo pills and start new cycle without an HFI. Back up contraception for 7 days. Consider emergency contraception.
COC, Combined oral contraceptive; HFI, hormone-free interval; OD, once daily.
should determine how often pills are forgotten before changingpills. Adolescents should be taught the appropriate responseto missed doses (Table 69-6). Health care providers usuallysuggest the use of additional contraception in the first month.
Although not as widely used as COCs, the progestogen-only (or progestin-only) pill, norethindrone (Micronor), is a safe and effective form of contraception when used consistently. It is supplied in packages of 28 tablets, each containing norethindrone with no hormone-free interval. It prevents pregnancy through reduced volume, increased viscosity, and altered molecular structure of cervical mucus, resulting in little or no sperm penetration. In addition, endometrial changes reduce the potential for implantation, and ovulation is partially or completely suppressed. Approximately 40% of women using progestogen-only contraceptives continue to ovulate. Pro-gestogen-only contraception is indicated for women who have a contraindication to estrogen-based contraceptives (see Table 69-4) or have estrogen-related side effects.
The contraceptive vaginal ring (NuvaRing) is a flexible, Silas-tic ring. The ring releases a constant rate of 15 mg of ethinyl estradiol and 0.120 mg of etonogestrel per day. Each ring is used continuously for 3 weeks and then removed. A new ring is inserted 7 days later. The contraindications and side effects are the same as with COCs.
The contraceptive patch (norelgestromin [Evra]) is a 25-cm2 pink patch that is applied, usually on the buttocks, for 1 week followed by removal and application of a new patch for a total of 3 weeks of patch use, then a patch-free week for a withdrawal bleed. The 4-week cycle is repeated. The daily dose is equivalent to a 35-mg ethinyl estradiol COC. In women weighing 90 kg or more, the contraceptive patch is less efficacious.