`Quick start' of pills promising.

Starting oral contraceptives (OCs) while being supervised by a health care provider during the first clinic visit, regardless of the time in a woman's menstrual cycle--an initiation method called Quick Start--may improve OC continuation rates without increasing menstrual side effects.

OCs have traditionally been initiated during or shortly after menses, in part to make sure a woman is not pregnant when she starts taking her pills. However, waiting until menses to start OCs may not be successful if women lose motivation, are confused about when to start taking pills, or become pregnant while waiting for their menses. In fact, up to a quarter of women waiting to initiate OCs may never even take their first pill. (1) "We thought that starting the pill while the patient was in the clinic asking for it might address all of these issues to some degree," says Dr. Carolyn Westhoff, a professor of obstetrics and gynecology at Columbia University in New York, USA, and one of the developers of the Quick Start approach.

One common objection to Quick Start is that a woman who starts her pills mid-cycle may be pregnant. But pregnancy can usually be ruled out using a simple urine pregnancy test. Where such tests are not available, a simple six-question checklist has been created by FHI (based on criteria developed by the U.S. Agency for International Development and the World Health Organization) to help providers be reasonably sure that a woman is not pregnant. (The checklist is available in English, Spanish, and French at http://www.fhi.org/en/fp/ checklistse/chklstfpe/index.html.) In addition, research has shown that OC use during early pregnancy does not harm a developing fetus. (2)

At family planning clinics in New York, Dr. Westhoff and colleagues recently evaluated three-month OC continuation rates among 227 Hispanic women, 58 of whom used Quick Start to initiate OC use and 169 who planned to initiate OCs at other times after they left the clinic) Taking all variables associated with continuation into account, women who took their first pill at the clinic were nearly three times more likely to start their second pack of pills than were women who planned to start their pills later.

Another Quick Start study was conducted by researchers at Case Western Reserve School of Medicine, Cleveland, Ohio, USA, and Allegheny General Hospital, Pittsburgh, Pennsylvania, USA, among nearly 200 women ages 22 and younger. (4) Nearly three-quarters of Quick Start initiators, compared with just more than half of the young women who were instructed to initiate their pills on the first Sunday after their next menses, were still using OCs after three months. The study also showed no differences between groups in nausea, vomiting, or breakthrough bleeding up to one year after OC initiation. Dr. Westhoff and colleagues also conducted a randomized trial to specifically compare bleeding patterns of women using Quick Start with those of women using a traditional start, and they found no differences in the number of bleeding or spotting days or the duration of bleeding and spotting episodes between groups. (5)

Although these studies have all been conducted in the United States, Dr. Kavita Nanda, an associate medical director at FHI, reports that she and fellow researchers are evaluating potential sites for an upcoming study to examine continuation rates and bleeding patterns for women in the developing world who use Quick Start initiation versus traditional initiation using an advance-provision strategy.

Advance provision of OCs--providing nonmenstruating women with one or more packets of pills they can take home and initiate once menstruation has occurred--is the standard alternative to Quick Start. But even advance provision is not available in many countries. "Quick Start has great potential for the developing world," says Dr. John Stanback, an FHI senior associate who has studied advance provision of OCs in sub-Saharan Africa. (6) "But we also need to make sure that providers know that advance provision is a safe alternative, for example, when pregnancy cannot be ruled out or for women who wish to wait until their next menses to begin pill taking."

REFERENCES

(1.) Oakley D, Sereika S, Bogue EL. Oral contraceptive use after an initial visit to a family planning clinic. Faro Plann Perspea 1991;23(4):150-54.

(2.) Bracken MB. Oral contraception and congenital malformations in offspring: a review and meta-analysis of prospective studies. Obstet Gynecol 1990;76(3 Pt 2):552-57.

(3.) Westhoff C, Kerns J, Morroni C, et al. Quick Start: a novel oral contraceptive initiation method. Contraception 2002;66(3): 141-45.

(4.) Lara-Torre E, Schroeder B. Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills. Contraception 2002;66(2):81-85.

(5.) Westhoff C, Morroni C, Kerns J, et al. Bleeding patterns after immediate versus conventional contraceptive initiation: a randomized controlled trial. Fertil Steril 2003;79(2):322-29.

(6.) Stanback J, Janowitz B. Provider resistance to advance provision of oral contraceptives in Africa. J Faro Plann Reprod Health Care 2003; 29(1):35-36.