Sharon Edwards

Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial.

OBJECTIVE: To estimate whether young women taking the first pill on the day of prescription had higher continuation rates and lower pregnancy rates than women who waited until menses to start the oral contraceptive pill (OCP). METHODS: We recruited 1,716 women aged younger than 25 years seeking to initiate the oral contraceptive at three publicly funded family planning clinics, and randomly assigned them to conventional initiation of the pill (conventional start) or immediate, directly observed ingestion of the first pill (quick start) during the clinic visit. Women underwent follow-up interviews at 3 and 6 months. RESULTS: Sixty percent of participants discontinued the pill, and 8% became pregnant during follow-up. Women who took the first pill in the clinic were more likely to continue to the second OCP pack (odds ratio 1.5, 95% confidence interval 1.0–2.1.); however, the Quick Start approach did not improve OCP continuation rates at 3 and 6 months. Those assigned to Quick Start were slightly less likely to become pregnant within 6 months from the time they started the pill (hazard ratio 0.90, 95% confidence interval 0.64—1.25). Eighty-one percent of women rated the Quick Start approach as acceptable or preferable to waiting. Rates of serious adverse events were low and similar in the two groups. CONCLUSION: Protocols that require a woman to wait until the next menses to start hormonal contraceptives are an obstacle to contraceptive initiation. Directly observed, immediate initiation of the pill improves short-term continuation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00068848 LEVEL OF EVIDENCE: I

Initiation of Oral Contraceptives—Start Now!

PURPOSE Conventional practice for initiating oral contraceptive (OC) pills involves waiting to start the pills with the next menstrual period. We investigated whether immediate initiation of OCs would lead to improved continuation rates and therefore decreased pregnancy rates in adolescents aged 12-17 years. METHODS Study subjects were recruited from adolescent women presenting to 2 inner city clinics requesting OCs. A total of 539 adolescents between 12 and 17 years old were randomized to conventional initiation of the OC pill (Conventional Start [CS]) versus immediate, directly observed OC pill ingestion in the clinic (Quick Start [QS]). At 3 and 6 months the participants completed interviews that questioned them about their OC continuation and pregnancies. RESULTS In all, 86% of our adolescents completed follow-up interviews at 3 months, and 77% at 6 months. There were 45 pregnancies during the study period. QS was associated with continuing OCs to a second pack (adjusted OR 1.8, 95% CI 1.1-3.3). There was no difference in OC continuation rates at 3 or 6 months. Only 26% of adolescents continued OCs at 6 months and we identified 45 pregnancies during follow-up. CONCLUSION We conclude that directly observed, immediate initiation of oral contraceptives (QS) with adolescents briefly improves continuation although overall continuation rates are discouraging low. Health care providers could use this simple strategy to start adolescents on OCs at the initial visit. The low 6-month OC continuation rates highlight the need to seek novel ways to provide adolescents with the necessary tools to be successful at contraception.

Prior Pill Experiences and Current Continuation Among Pill Restarters

CONTEXT Discontinuation of oral contraceptives often puts women at risk for unintended pregnancies. Understanding why a woman discontinued pill use can provide insight into her risk of discontinuation if she restarts use. METHODS Women younger than 25 obtaining oral contraceptives at three university health centers in 2003-2005 were recruited to participate in a randomized trial; 628 former users were interviewed about their previous experience with the method, and were followed up three months after restarting use. Bivariate and multinomial logistic regression analyses were used to assess the relationship between prior reasons for stopping pill use and method continuation. RESULTS Women who had discontinued using oral contraceptives because of side effects were less likely to be very sure about restarting the pill at baseline (73%) than were those who had stopped for logistical or fertility-related reasons (88-94%). They also were less likely to have been satisfied with the pill in the last use interval (49% vs. 95-98%) and less likely to be satisfied with it in the three months after restarting (76% vs. 89-93%). These women were more likely to report a short duration of use than an intermediate duration or continuous use during follow-up (odds ratios, 2.5 and 4.5). CONCLUSIONS When counseling women who are restarting pill use, providers should ask about their experiences with the method and reasons for discontinuation; counseling for women who discontinued because of side effects should address their risk factors for early discontinuation and informing them about other contraceptive choices.