Will ‘Quick Start’ give women jump on pill use?
Will Quick Start’ give women jump on pill use?
You reviewed the instructions for initiating the first pack of oral contraceptives (OCs) with your patient. She elects to use the "Sunday start," beginning pills on the first Sunday after her next period. When she returns for a follow-up visit in a few months, though, you discover she never started the pills and now is pregnant.
How can you combat this problem?
Researchers are evaluating the effectiveness of the "Quick Start" method of initiating pill use, which entails the patient taking the first pill in the office following counseling by the clinician. The rationale for this approach is to improve acceptability and use by eliminating the time period women wait for their menstrual periods.
Results from two small observational studies have found improved pill continuation rates with Quick Start users.1,2 A second paper, scheduled for upcoming publication, shows no adverse impact on bleeding patterns in women using the initiation method.
Researchers at New York City’s Columbia University are following up their initial work and spearheading a randomized clinical trial funded by the Bethesda, MD-based National Institute of Child Health and Human Development. The investigation will evaluate continuation and pregnancy outcomes at six months among 2,000 urban U.S. women younger than age 25 who receive pills at clinics at Mount Sinai Adolescent Health Center and Columbia University in New York City, University of Texas Southwestern Medical Center in Dallas, and Emory University in Atlanta, reports Carolyn Westhoff, MD, MSc, associate professor of OB/GYN and public health at Columbia University.
OCs work — when taken
Oral contraceptives are one of the most effective methods of birth control, but they must be taken consistently and correctly to achieve efficacy. According to A Pocket Guide to Managing Contraception, OCs may be initiated in one of three ways:
- first day of next menstrual period (generally preferred because no routine backup method is needed);
- first Sunday after menstrual bleeding begins;
- immediately, if pregnancy is excluded.3
If the woman is not switching from another hormonal method, instruct her to use backup contraception for seven days for options 2 and 3.3
How does Quick Start differ from the third option?
"Our concept of Quick Start includes directly observed therapy, not simply any-day start, for the positive impact of taking the first pill right there with the encouragement of the provider," offers Westhoff. "’Any-day start’ obviously can have benefits too, but isn’t really what we mean by Quick Start."
Why do patients often return to the clinic having failed to begin their first pack of pills? Some women may become pregnant while waiting for their period and the initiation of the pill pack, while others may encounter confusion about starting instructions when their period finally arrives, she says. Some women have ambivalence over the pill after they leave the clinic, due to discussion with friends and family who emphasize disadvantages and myths about pill use, she notes.
The Quick Start method alleviates these problems, Westhoff notes. By taking the first pill in the office, all the woman has to remember after she leaves is to follow her daily pill schedule. By being on hand when the first pill is taken, the clinician is on hand to answer any questions involving pill use, she notes.
Since pills are initiated during the clinic’s work week, the odds are that office staff will be on hand when patients call in for refills, rather than when women opt for a "Sunday start."2 This availability keeps women from discontinuing the method when they are unable to access health care during the weekend.
Improve OC compliance
In its observational study, Columbia University investigators prospectively evaluated predictors of short-term OC continuation among 250 OC women who requested pill use.1 Telephone follow-up of participants showed that women who swallowed the first OC in the clinic were more likely to continue on their pill schedule until the second package than women who planned to start the pills later.
Staying on schedule with pills is a particular problem with adolescents. While pills are the most popular form of contraception for teens, compliance rates range from 44%-55%.2 A small-scale study suggests better compliance in adolescents at three months with the Quick Start approach while maintaining side effect profile.2
Evaluation of this method of pill initiation is welcomed by family planning providers such as David Archer, MD, professor of obstetrics and gynecology and director of the Clinical Research Center at the Eastern Virginia Medical Center in Norfolk.
"I cannot understand why it takes us so long to do a clinical trial to show efficacy for initiating oral contraceptives immediately in women," comments Archer. "It is important that we think outside of the box more often with such simple, but important, innovations."
References
1. Westhoff C, Kerns J, Morroni C, et al. Quick Start. A novel oral contraceptive initiation method. Contraception 2002; 66:141.
2. Lara-Torre E, Schroeder B. Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills. Contraception 2002; 66:81-85.
3. Hatcher RA, Nelson AL, Zieman M, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation; 2001.
You reviewed the instructions for initiating the first pack of oral contraceptives (OCs) with your patient. She elects to use the Sunday start, beginning pills on the first Sunday after her next period. When she returns for a follow-up visit in a few months, though, you discover she never started the pills and now is pregnant.Subscribe Now for Access
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