Management of Missed Hormonal Contraceptive Pills

General Guidelines

If a dose of either a progestin-only pill (POP) or combined hormonal pill is missed, take the missed pill as soon as possible and follow specific backup contraception guidelines based on the type of pill and duration of delay, as recommended by the Centers for Disease Control and Prevention (CDC) and the American Academy of Family Physicians 1, 2

If a POP is missed for more than 3 hours, take one pill as soon as remembered, continue taking pills daily at the same time, and use backup contraception until 2 consecutive days of correct pill taking, according to the CDC 1, 3
If vomiting or severe diarrhea occurs within 3 hours of taking a POP, take another pill as soon as possible, continue taking pills daily at the regular time, and use backup contraception until 2 days after vomiting or diarrhea has resolved, as recommended by the CDC 1, 4
POPs inhibit ovulation in only about half of cycles, making consistent timing crucial, with peak serum levels reached about 2 hours after taking the pill, followed by rapid elimination, and near baseline serum steroid levels by 24 hours after administration, according to the CDC 1

If a combined hormonal pill is missed for less than 48 hours and only one pill is missed, take the missed pill as soon as possible, continue taking remaining pills at the usual time, and no backup contraception is needed, as recommended by the American Academy of Family Physicians 2
If a combined hormonal pill is missed for 48 hours or more, or two or more pills are missed, take the most recent missed pill as soon as possible, discard other missed pills, continue taking remaining pills at the usual time, and use backup contraception for 7 consecutive days, according to the American Academy of Family Physicians 2, 4

Consider emergency contraception if unprotected intercourse occurred after missing pills, with the copper IUD being the most effective option, and ulipristal acetate (Ella) may be more effective than levonorgestrel formulations after the first 72 hours and for women who are overweight or obese, as recommended by the American Academy of Family Physicians and the CDC 1, 2, 3

Inconsistent or incorrect use is a major reason for contraceptive failure, and not using backup contraception after missed pills significantly increases pregnancy risk, according to the CDC and the American Academy of Family Physicians 1, 3
Women who frequently miss pills should consider a less user-dependent method, such as an IUD, implant, or injectable, as recommended by the CDC 1, 4