Immediate start of hormonal contraception may reduce unintended pregnancies and increase method continuation, but the evidence is limited, according to the findings of an intervention review conducted by the Cochrane Fertility Regulation Group.1
In the United States, 49% of all pregnancies and 80% of pregnancies in women 19 years or younger are unintended.2 It has been suggested that a simple way to help decrease the rate of unintended pregnancies and improve continuation of hormonal contraception is through immediate initiation, which was introduced with combined oral contraceptives (COCs) but has since expanded to other types of hormonal contraceptives. With this method, the patient begins using the contraceptive immediately, regardless of her menstrual cycle; to safeguard against pregnancy, backup contraception must be used for the first 7 days.
To avoid any potential risks of hormonal contraceptive use during an undetected pregnancy, many clinicians advise women to wait until the first day of their next menses to begin hormonal contraception. However, evidence has shown that combined hormonal contraceptives do not cause birth defects and that hormonal contraceptives do not increase the risk of miscarriage or fetal growth problems when used early in pregnancy.3 Appropriate use of urine pregnancy tests and consideration of emergency contraception, in addition to use of backup contraception for 7 days, are ways to manage concerns about an undetected pregnancy and the quick start method.
To determine whether quick start hormonal contraception is associated with any differences in effectiveness, continuation, and patient acceptability, researchers identified and analyzed data from 5 randomized controlled trials that compared immediate with conventional start of hormonal contraceptives or that compared immediate start with various hormonal contraceptives.1
Overall, discontinuation rates were similar between all study groups. In studies comparing quick start with conventional start, bleeding patterns and adverse effects were similar between groups. In a trial of immediate versus conventional start of depot medroxyprogesterone acetate (DMPA), fewer pregnancies occurred in and patient satisfaction was higher in the immediate start group. In a comparison of quick start COCs with quick start vaginal ring, the vaginal ring group had less prolonged bleeding, less frequent bleeding, fewer adverse effects, and higher satisfaction ratings.
Based on these results, there is little evidence that immediate initiation of hormonal contraceptives is associated with fewer pregnancies or with less continuation. However, immediate start of DMPA was associated with lower pregnancy rates than the conventional start method, and quick start vaginal ring was preferred over quick start COCs. The conclusion: more studies are needed.
- Immediate start of specific types of hormonal contraceptives was associated with fewer unintended pregnancies and higher patient satisfaction ratings.
- The available evidence showing that quick start hormonal contraception is associated with fewer pregnancies and longer continuation than conventional start hormonal contraception is insufficient to claim one method superior to another.
1. Lopez LM, Newmann SJ, Grimes DA, et al. Immediate start of hormonal contraceptives for contraception. Cochrane Database Syst Rev. 2012;12:CD006260. DOI: 10.1002/14651858.CD006260.pub3.
2. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84:478-485.
3. Lesnewski R, Prine L. Initiating hormonal contraception. Am Fam Physician. 2006;74:105-112.