This is a very common question. Almost everyone who uses birth control pills has missed a pill at one point or another. So if you have missed a pill, you are not alone. However, you need to know that the most common way women get pregnant while using birth control pills is by starting the pack late.

If you start your pack late:

• 1 day late starting the next package: Take 2 pills as soon as you remember and one pill each day after. Use a backup form of birth control for two weeks.
• 2 days late starting the next package: Take 2 pills per day for 2 days, and then continue as usual. Use a backup form of birth control for two weeks.
• 3 or more days late starting the next package: Call the clinic for instructions.

If you miss pills during the first three weeks of your pack:

• 1 pill missed: Take it as soon as you remember and take your next pill at your usual time. This means that you take two pills in the same day.
• 2 pills missed in a row in the first two weeks: Take two pills on the day you remember and two pills the next day. Finish the rest of the pack as usual. Use a backup form of birth control for one week.
• 2 pills missed in a row in the third week: Keep taking one pill every day until Sunday. On Sunday, set aside the rest of the pack and start taking a new pack of pills. Use a backup form of birth control for one week.
• 3 or more pills missed in a row anytime: Keep taking one pill every day until Sunday. On Sunday, set aside the rest of the pack and start taking a new pack of pills. Use a backup form of birth control for two weeks.

If you missed any of the last 7 pills of a 28-day package:

• Skip the missed pill (or pills). The last seven pills contain no hormones, so missing them will not increase your chance of pregnancy. They are only there in order to keep you in the routine of taking a daily pill. Just be sure to start your next pack on time.

Most people are familiar with contraceptive options such as birth control pills and condoms. However, there are many other options that may fit your needs better. Your decision should take into consideration your general health as well as your preferences for convenience and speed of reversibility. Regardless of which method you choose, please remember that birth control only works to prevent an untimely pregnancy if you use it consistently and correctly.

Birth control pills: (click for more)

The Ring: (click for more)

The Patch: (click for more)

The progestin-containing IUD: (click for more)

The implantable device: (click for more)

The Shot: (click for more)

The male condom: (click for more)

The female condom: (click for more)

The diaphragm: (click for more)

The cervical cap: (click for more)

The sponge: (click for more)

The chance that you will experience an unintended pregnancy while using birth control depends largely on how well you use your chosen method. Since nobody is perfect, the failure rates of various birth control measures are always reported in two ways: “perfect use,” and “typical use.” The chart below gives you an idea about how well your birth control method stacks up to other popular options.

Source: Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive Technology: Nineteenth Revised Edition. New York NY: Ardent Media, 2007.

The Gardasil vaccine is a series of three injections given to girls and women between the ages of 11 and 26 years. The purpose of the vaccine is to prevent cancer and genital warts. Specifically, the vaccine protects against four types of the human papillomavirus (types 6, 11, 16 and 18) which are well recognized causes of genital warts, cervical cancer, vulvovaginal cancer and anal cancer. In scientific trials, the vaccine has demonstrated high effectiveness against the virus while also maintaining an excellent safety record. However, it is important to know this vaccine will not provide protection against any type of the virus that the patient already carries. That means that the vaccine is purely preventative and cannot serve as a treatment for genital warts, abnormal pap tests or cancer of any type. Nevertheless, all women in the recommended age range should be offered the HPV vaccine regardless of whether they have been exposed to the virus or not. This is because there appears to be some degree of cross-protection against other less-encountered types of HPV that are also associated with cancer. As with other childhood vaccines, Gardasil is very well tolerated by most patients and has few side effects. The most commonly reported side effects include pain, swelling, and redness at the injection site. In short, we highly recommend this vaccine to all age-appropriate patients. It is also likely that in the near future the FDA will expand the recommended age range and approve the vaccine for males as well.

At menopause, a woman's body makes less estrogen. Although this is a natural stage in a woman's life, it can bring on troublesome changes such as hot flashes, vaginal dryness, insomnia, mood swings and osteoporosis. Because of this, many women choose to take hormone therapy after menopause. The decision to take hormone therapy should be based on the severity of your symptoms, your personal and family medical history and your risk of bone loss. The current thinking regarding hormone therapy is that you should take the lowest dose required to relieve your symptoms for the shortest period of time needed.

Like most medications, hormone therapy is not without risks. Using a progestin seems to increase the risk for breast cancer. Also, your monthly bleeding may resume. Although bleeding may occur for only a short time, many women do not want to have a period and find this side effect bothersome.

A recent study called the Women's Health Initiative also raised concerns about the risks of hormone use for postmenopausal women. There were two separate parts to this study. Women who still have a uterus were placed on a combination therapy of estrogen and progestin. The progestin is important for women with a uterus because it balances the estrogen and helps prevent uterine cancer. Women in the second segment of the study had undergone a previous hysterectomy and no longer had a uterus. These women did not need the progestin component and received only estrogen.

The group that received estrogen plus progestin were followed for over 5.2 years. For every 10,000 women each year, the combination therapy compared with placebo on average resulted in:

The branch of the study of women receiving combination therapy was stopped early because of an increased risk of breast cancer and clotting episodes, and because the risks seemed to outweigh the benefits (on average).

The group that received estrogen alone was followed for 6.8 years. For every 10,000 women each year, estrogen use compared with placebo on average resulted in:

The estrogen-only part of the study was stopped early due to an increased risk of stroke and other blood clotting problems. Although the risk for breast cancer for women on estrogen only appeared to be lower, this finding was not proven conclusively.

The data from the Women's Health Initiative may sound a little scary, but the risk of negative outcome to any particular individual is low. For example, the study found that among 10,000 women taking estrogen plus progestin for one year, there will be only 8 more cases of breast cancer among the hormone users that if they had not taken the therapy. So, in terms of statistical risk to any one person, the chance that breast cancer would develop as a result of hormone therapy is very low. But, the risk of taking hormones for the overall population was substantial. If you add up all of the extra cases of breast cancer, heart attacks, stroke and blood clots and then subtract out the reductions of colorectal cancer and fractures, you'd still get about 100 extra harmful events among the 10,000 hormone users after 5.2 years (the period the estrogen-plus-progestin part of the study ran). If you consider the millions of women who use hormone therapy and the cost associated with providing medical care to those ladies, the impact on society is substantial.

Please remember that the reports of increased risks do not mean that YOU will develop breast cancer or any other condition associated with hormone therapy. Your personal and family medical history and your lifestyle choices are the major factors in your chances for developing disease.

It is also important for you to know that the Women's Health Initiative has not been well-received by all healthcare providers. The study has been criticized because it included women aged 50 to 79, with the average age being well past menopause. It is possible that these participants were predisposed to the negative outcomes just based on their age and remoteness from menopause. It has been suggested that the study findings might have been different if the participants were more recently menopausal.

If you have questions about whether hormone therapy is right for you, please talk to your doctor. A thorough assessment of your personal risk factors and consideration of the severity of your symptoms will help to determine which path you should take.

Many women are unable to take hormonal therapy for menopausal symptoms because of their personal or family medical history. Fortunately, there are many useful alternatives to medications that contain hormones. There are also several locally-applied hormone products which might not carry the same risks as those that deliver medication throughout the body. We encourage you to ask your doctor what might work best for your needs.

For osteoporosis:

• Raloxifene (Evista) preserves bone density and prevents fractures (although not hip fractures). The down side is that this medication may worsen hot flashes.
• Bisphosphonates (Actonel or Fosamax) preserve bone density, prevent fractures, and can reverse bone loss.
• Teraparatide (parathyroid hormone) may reverse bone loss in some patients.
• Calcitonin (a nasal spray or injectable) is used to treat women who have osteoporosis and may prevent some spinal compression fractures.

For hot flashes:

• Lifestyle changes including dressing in layered clothing (in order to avoid being too warm), sleeping in a cool room, and reducing stress. Avoid spicy foods and caffeine. Consider trying deep breathing and stress reduction techniques like meditation or yoga.
• Phytoestrogens: Soybeans and some soy-based foods contain phytoestrogens, which are estrogen-like compounds. Soy foods include tofu, tempeh, soy milk, and soy nuts. Other plant sources of phytoestrogens include such botanicals such as black cohosh, wild yam, dong quai, red clover, and valerian root. However, there is no solid evidence that phytoestrogens from any source really work to relieve hot flashes. Furthermore, the risks of taking the more concentrated forms of soy phytoestrogens, such as pills and powders, are not known. Dietary supplements with phytoestrogens do not have to meet the same quality standards as do drugs, and little is known about the safety of these products.
• Antidepressants (Effexor). These medications have been proven moderately effective in clinical trials.

For vaginal dryness:

• Vaginal lubricants and moisturizers which are readily available over the counter.
• Products that release estrogen locally (such as vaginal creams, a vaginal suppository (Vagifem), and a vaginal ring (Estring).

For mood swings:

• Lifestyle behaviors including getting enough sleep and being physically active.
• Relaxation exercises and stress reduction.
• Antidepressant or anti-anxiety drugs.

For insomnia:

• Over-the-counter sleep aids.
• Milk products such as a glass of milk or cup of low fat yogurt at bedtime.
• Physical activity in the morning or early afternoon. (Exercising later in the day may increase wakefulness).
• Hot shower or bath immediately before going to bed.

Osteoporosis is a silent disease in which bones become fragile and are more likely to break. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks. Fractures occur typically in the hip, spine, and wrist, although any bone can be affected.

More than 8 million American women have osteoporosis, and many more have such low bone density that they are likely to develop it. Osteoporosis can happen at any age, but the risk increases significantly as you get older. The first noticeable sign of osteoporosis is often loss of height. Other signs can include changes in the curvature of the spine, pain in the middle of the back, and tooth loss.

Some of the major risk factors for osteoporosis include:

• (1) Advanced age.
• (2) Being female.
• (3) Small, thin body type.
• (4) White or Asian race.
• (5) Menopause or causes of low levels of sex hormones.
• (6) Smoking.
• (7) Family history of osteoporosis.
• (8) Physical inactivity.
• (9) Excessive drinking of alcoholic beverages.
• (10) Prolonged use of steroids or some anticonvulsants.

If you think that you're at risk for osteoporosis, you may want to ask your healthcare provider about having a DXA-scan (dual energy x-ray absorptiometry). This painless test measures how solid your bones are. Your doctor can also talk to you about easy ways to prevent osteoporosis if you are at risk or to treat you if you already have this condition.

Sterilization refers to an elective surgical procedure that is performed in order to provide permanent birth control. It should be thought of as lifelong decision, and you must be certain that you do not want children in the future. Because sterilization is a major decision, you should avoid making this choice during times of stress such as during a divorce, after losing a pregnancy or after having a baby. You also should not make this choice under pressure from a partner or others. Studies have shown that women younger than 30 years are much more likely than older women to regret having the surgery. If you have doubts about the procedure at any time—even after you have signed papers giving consent—let your doctor know. It is never too late to choose a less permanent form of birth control.

If you undergo surgical sterilization and later decide that you want another baby, attempts to reverse the procedure only work about 60% of the time. The success of reversal depends on a number of factors such as type of sterilization, health and age of the person, and length of time since the procedure. Reversal also involves a major surgical procedure and significant out-of-pocket expense.

You should also be aware that surgical sterilization involves a small failure rate of less than one percent. Sometimes, a small tract called a fistula can form between the blocked portions of the fallopian tubes, thus allowing sperm to reach an egg. If this happens, you could become pregnant or, even worse, experience an abnormal type of pregnancy called an ectopic pregnancy. This is when a pregnancy implants in an area of the body other than the uterus (such as the fallopian tube, ovary or other abdominal structures). Ectopic pregnancies don't happen very often, but when they do, they can be life-threatening. If you decide to have a sterilization procedure, your doctor should talk to you about the signs and symptoms of ectopic pregnancy.

There are several ways in which surgical sterilization can be performed. The methods used most often are the laparoscopy, mini-laparotomy and hysteroscopy. The decision about which method is appropriate for you should depend on your history of prior abdominal surgeries, your general health and your weight. In considering your options, ask your doctor which procedure would be best for you.

Some women choose sterilization to be done right after giving birth. This is called a “postpartum tubal.” In this procedure, the patient is taken to the operating room and is usually given a regional anesthetic such as an epidural. A small incision is made under the belly button, and the fallopian tubes are accessed through this incision. The doctor may remove a section of each fallopian tube or simply close the tube with loops of suture, clips, elastic-like bands or electric current. Any of these techniques may be used during a cesarean delivery as well. The real bonus to this procedure is that it adds very little additional discomfort during the postpartum period, and in most cases it does not extend the length of hospital stay.

If tubal sterilization is performed remote from delivery of baby, it is called an “interval tubal.” This type of procedure may be performed in the operation room using a laparoscope. In this procedure, general anesthesia is administered. Then, a small incision is made inside the belly button. Through this incision, a small device is inserted into the abdominal cavity and used to fill the belly with air. The air lifts the abdominal wall and allows the doctor to see all of the internal structures. Next, two more tiny incisions are made in the lower abdomen. Special instruments are inserted through these incisions and used to close off the fallopian tubes. Your doctor may choose to use elastic-like bands, clips or electric current to complete the procedure. After the tubes are blocked, all of the instruments are removed from the abdomen and the air is expelled. The patient wakes up in the recovery room with three band aids over the incision sites. That's why laparoscopic procedures are sometimes called “band aid surgery.” Patients usually need a day of two off from work, but the recovery process is usually very quick. A minimal to moderate amount of pain is to be expected.

Another option for tubal sterilization is a hysteroscopic procedure called Essure. During this procedure, a small scope is inserted through the vagina and into the uterus. A tiny spring-like device then is guided into the fallopian tubes. Over time, the fallopian tubes will form scar tissue around the device. The scarring blocks the fallopian tubes and prevents pregnancy by keeping sperm from reaching the egg Some doctors are trained to perform this procedure in the office under mild sedation. Other doctors prefer to perform this type of procedure in the operating room under general anesthesia. This minimally-invasive procedure involves very little pain or recovery time. You should be aware that because this is a relatively new procedure, no studies have been done to evaluate its long term effects. However, the initial opinion is very favorable and the device is completely FDA approved. If you choose the Essure procedure, you should also know that you will need an additional dye-based x-ray about 3 months after insertion of the device. The purpose of the x-ray is to ensure that the tubes have scarred down and that no fluid can pass through them. This means that you will need to continue to use another method of birth control until your doctor has confirmed that your tubes are completely occluded.

As with any surgery, all types of sterilization have some risk. Serious complications, such as infections, bowel injuries, bleeding, burns, or complications from anesthesia are very uncommon. Most of the time, these problems can be easily treated and corrected. We encourage you to familiarize yourself with the risks and benefits of each type of surgical sterilization. You and your doctor may decide that other less permanent forms of birth control are more appropriate for you.