Substance use disorder: contraceptive options counseling

What’s New in Contraception?

Contraceptive Technology Conference!

Biologic sexism of STIs

Excess breast cancer deaths after COVID-19

Contraception for patients with medical conditions

Pelvic Floor Dysfunction

Treating vulvodynia

Puzzling Over the Hurt Down-Under

Serious Mental Illness and Contraception

New 13-Cycle Vaginal Contraceptive System

The Future of Family Planning in Post-COVID America

New ASCCP Guidelines: Implications for FP

On the alert: mood disorders during 2020 stressors

Sex in the Time of COVID-19

Challenges old and new during the pandemic

Reproductive health in the time of Covid-19

Talking about toys

Missed Pills: The Problem That Hasn’t Gone Away

Find the “yes! . . . and” rather than “no” or “but”

Digital Family Planning: the Future is Now

Irregular Bleeding Due to Contraceptives

When she’s low on libido…

Ouch! Best approaches to menstrual pain

Contraceptive efficacy: understanding how user and method characteristics play their part

Strategizing treatment for chronic heavy menstrual bleeding


Untangling the literature on obesity and contraception

High tech apps for no-tech FABM

Menstrual exacerbation of other medical conditions

From Princeton University: Thomas James Trussell (1949-2018)

The Short and Long of IUD Use Duration

Selecting a Method When Guidance Isn’t Clear-cut

Healthcare in the Time of Digital Expansion

The Scoop on Two New FDA-Approved Contraceptive Methods

Pregnancy of unknown location—meeting the challenge

Big “yes” (with caveats) to CHCs during perimenopause

The role of IUDs (LNG IUDs, too!) in emergency contraception

Combined pills’ effect on mood disorders

Abortion in the U.S.: safe, declining, and under threat

Hope for ovarian cancer screening test

Breast cancer still a small risk with some hormonal contraceptives

New treatment modality for BV

Record rate of HPV-related throat cancer

Viruses in semen potentially transmissible

Don’t Abstain from Your Role in Abstinence

Teens births declining but geographic ‘hotspots’ defy trend

Online Medical Abortion Service Effective and Safe

Do Women Really Need to Wait That Long?

Reassuring news on depression and OC use

PMDD: Genetic clues may lead to improved treatment

Breast cancer risk when there is a family history

Body weight link to breast and endometrial cancers (and 11 others)

Family Planning in 2017 and Beyond

Make Me Cry: Depression Link (Again)?

Managing implant users’ bleeding and spotting

Zika: Updated guidance for providers

Pharmacist-prescribed contraceptives

Hot off the press! 2016 MEC and SPR

Zika virus fears prompt increased request for abortion in nations outlawing abortions

Opioid use epidemic among reproductive-age women

Good news on the family planning home front!

War Against Planned Parenthood Hurts Women

Win-win for both treatment and prevention

Center of the Storm


Menopause, mood, mental acuity, and hormone therapy

Emergency contraception for teens

Postpartum Contraception: Now, Not Later

Reproductive tract infections, sexually transmitted infections, or sexually transmitted diseases: “a rose by any other name…”

Are we practicing what we preach?

Be alert to VTE in hormonal contraceptive users

LARC among teens increased 15-fold, but not enough

Brain cancer and hormonal contraception

Free tools: Easy access to the US Medical Eligibility Criteria for Contraceptive Use

Alcohol consumption when pregnancy is unwanted or unintended

Latest Data on Contraceptive Use in the United States

LateBreaker sampler from Contraceptive Technology conference

Emergency Contraceptive Pill Efficacy and BMI/Body Weight

Handout on Unintended Pregnancy and Contraceptive Choice

Ask About Withdrawal (Really!)

Rules to Practice By: Safety First and Cleanliness is Close to. . .

What’s Vanity Fair Got Against the NuvaRing?

Promising New Treatment for Hepatitis C

Numbers matter, so make them simple for patients

The Recession’s Effect on Unintended Pregnancies

Lessons Learned from the Contraceptive CHOICE Project: The Hull LARC Initiative

Applying the “New” Cervical Cytology Guidelines in Your Practice

Acute Excessive Uterine Bleeding: New Management Strategies

Medical indications for IUD use in teens

Whatever happened to PID?

Update on Emergency Contraception New and Improved

Missed Pills: The Problem That Hasn’t Gone Away
February 2020


With all the technology available to assist patients in remembering to take their pills, wouldn’t it make sense to think that missed pills are a thing of the past? That, apparently, is not the case, though. According to the National Survey of Family Growth, in 1 month’s time, 15% of oral contraceptive users reported missing 1 pill and another 16% reported missing 2 or more pills.[1] And that is in only one month. Just what do we know about the risk for an unintended pregnancy after pills are missed? According to The Guttmacher Institute, 13% of women receiving abortions had relied on oral contraceptives in the month of becoming pregnancy.[2] But as yet, there’s no direct evidence about the risk of pregnancy following missed pills. Therefore, we look at surrogate measures—such as ovulation, follicular development, and hormone levels—extrapolating from there on what to advise patients.[3] Recent studies have looked at the effectiveness of counseling and reminders in helping users remember to take their pills daily. What practical tips might we learn from those studies? And, as ever, what are the current best missed-pill recommendations to share with your patients?

To estimate the frequency that oral contraceptive users missed their pills, the National Survey of Family Growth surveyed a nationally representative sample of women aged 15 to 49 years through in-person interviews (more sensitive questions are self-administered). Thirty-one percent had missed 1 or more pills in the 4 weeks leading up to the survey. While younger women were about as likely than older women to miss only 1 pill, they were substantially more likely to miss 2 or more pills (21% vs 13%).

Table 1.  Percentage of women who missed taking oral contraceptive pills among women aged 14-44 years who used oral contraceptive pills and had sexual intercourse—National Survey of Family Growth 2013-20151

While there appear to be no studies showing direct evidence on the degree of risk that these missed pills may lead to pregnancy, a 2013 review of multiple studies explored indirect evidence in looking such asthat would indicate the level of ovarian function after missed pills or extended pill-free intervals.[4] The analysis offered some reassurance:

  • Extending the pill-free interval (8-14 days). Few women ovulated and those who did ovulate experienced abnormal cycles
  • Missing 1-4 pills not adjacent to the pill-free interval. Women appeared to have little follicular activity and low risk of ovulation. Those who ovulated had poor cervical mucus quality
  • Missing very low-dose pills. Compared to missing 30 mcg EE pills, missing 20 mcg EE pills resulted in greater follicular activity

These are, of course, surrogate measures, and it is difficult to determine how the risk of pregnancy corresponds to follicular development or ovulation with abnormal hormone levels or cervical mucus. It may be, according to the researchers, that the risk of pregnancy may not actually increase.

Nonetheless, there is that pesky difference in failure rates following perfect use vs. typical use. Perfect use is defined as correct and consistent use. Typical use includes missed pills and extended pill-free intervals, in addition to discontinuation or other imperfect use patterns.

Part of a provider’s responsibility is to help improve adherence and continuation of patients’ chosen contraceptive methods. But how is that working for you? Last year, a Cochrane Systematic Review of 10 randomized controlled trials involving 6,242 women examined the evidence on counseling and reminder systems.3 First the caveat: much of the certainty of the evidence was low due to risks of bias, imprecision, poor reporting, and such. Moreover, intensive counseling practices differ from provider to provider outside of the research setting. But we have what we have. Bottom line?

  • Counseling may improve continuation and reduce discontinuation due to menstrual problems or adverse effects.
  • Reminders may improve continuation but appears to make little or no difference in adherence.

What do we actually know for sure? That COC users will miss pills. So it’s helpful to know the current best recommendations are for managing missed pills.

  • First, know that after patients have taken at least 7 COCs at the correct time, they are at little risk for ovulation until they subsequently miss 7 consecutive pills.[5]
  • Breakthrough ovulation and unintended pregnancy are more likely to occur if the patient missing pills is using a 21/7 formulation.[6]
  • COCs containing 20 mcg or less of EE are associated with more breakthrough ovulation with missed pills.[7]

Because missed pills during the first week of a pill pack pose the greatest risk of pregnancy, having the patient use the LNG emergency contraceptive pills may be appropriate if she had been sexually active around that time. Emergency contraception may also be appropriate when a patient misses too many pills (e.g., 3+ consecutive pills containing 0.03 to 0.035 mg EE or 2+ consecutive ills containing 0.02 mg or less EE.).[8]

When initiating COCs, proactively instruct your patient in what to do after missing 1 or more of her pills. Patients who have vomiting or severe diarrhea within 24 hours of taking their COC should be treated as if they had missed pills.

Managing Missed Pills—Patient Instructions

For 1 late or missed active (hormonal) pill:  

  • Take 1 active pill as soon as possible.
  • Continue taking your pills daily on time, which may mean taking 2 pills in one day.
  • No back-up contraception is needed.
  • Emergency contraception is not typically needed unless pills were also missed earlier in the packet or at the end of the previous packet.

For 2 or more late or missed active (hormonal) pills:   

  • Take 1 active pill as soon as possible.
  • Continue taking your pills daily on time, which may mean taking 2 pills in one day.
  • Use condoms or abstain from vaginal sex until you have taken active pills for 7 days in a row.
  • If pills were missed during the last week of active pills (days 15 through 21 of a packet), finish the active pills in the current packet and start a new packet the next day without using any placebo pills, OR use condoms or abstain from vaginal sex until you have taken active pills in the new packet for 7 days in a row.
  • Use emergency contraceptive pills if you missed COCs during the first week of a packet and you had any unprotected intercourse. You may also need to use emergency contraception if you missed too many pills.

[1] Daniels K. Percentage of Women Who Missed Taking Oral Contraceptive Pills* Among Women Aged 15–44 Years Who Used Oral Contraceptive Pills and Had Sexual Intercourse, Overall and by Age and Number of Pills Missed — National Survey Of Family Growth, United States, 2013–2015. MMWR Morb Mortal Wkly Rep Sep 15;66:965. Published online 2017 Sep 15. doi: 10.15585/mmwr.mm6636a10

[2] Jones R. Reported contraceptive use in the month of becoming pregnant among U.S. abortion patients in 2000 and 2014. Contraception, Volume 97, Issue 4, 309-12.

[3] Mack N, Crawford TJ, Guise J-M, Chen M, Grey TW, Feldblum PJ, Stockton LL, Gallo MF. Strategies to improve adherence and continuation of shorter-term hormonal methods of contraception. Cochrane Systematic Review. Published online 23 April 2019

[4]Zapata LB, Steenland MW, Briahna D, et al. Effect of missed combined hormonal contraceptives on contraceptive effectiveness: a systematic review. Contraception 2013;87:685-700.

[5]Cwiak C, Edelman AB. Oral contraceptives. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018.

[6] Dinger J, Minh TD, Buttmann N, Bardenheuer K. Effectiveness of oral contraceptive pills in a large U.S. cohort comparing progestogen and regimen. Obstet Gynecol 2011;117:33–40.

[7] Gallo MF, Nanda K, Grimes DA, Lopez LM, Schulz KF. 20 μg versus >20 μg estrogen combined oral contraceptives for contraception. Cochrane Database Syst Rev 2013:Cd003989

[8] Trussell J, Cleland K. Emergency contraception. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018.