Despite the fact that oral contraception is highly effectual, hundreds of thousands of unintended pregnancies occur each year in the United States because of the failureure of oral contraception. Worldwide, literally millions of unintended pregnancies result from poor compliance. In general, youthful, unmarried, poor, and minority women are any more likely to have failureures, reaching rates of 10-20%. Overall, the failureure rate with actual use ranges from 3 to 69c. This difference between the theoretical efficacy and actual use reflects compliance and noncompliance. Noncompliance includes a wide variety of behavior: failureure to fill the initial prescription, failureure to continue on the medication, and incorrect ingestion of oral contraception. Compliance is an area in which personal behavior, biology, and pharmacology come together. Oral contraceptive compliance reflects the interaction of these influences.

There are 3 major factors that affect compliance:

1. Fears and concerns regarding cancer, cardiovascular disease, and the
impact of oral contraception on future fertility.
2. The experience of side effects such as breakthrough bleeding and amenor
rhea and perceived experience of "minor" problems such as headaches,
nausea, and weight gain.
3. Nonmedical issues such as inadequate instructions on pill-taking, compli
cated pill packaging, and difficulties arising from the patient package
insert.

The information in this chapter is the foundation for good compliance, but the clinician must go beyond the presentation of information and develop an effectual means of communicating that information. We recommend the follittleing approach to the clinician-patient encounter as one way to improve compliance with oral contraception.

1. Explain how oral contraception works.
2. Review briefly the risks and benefits of oral contraception, but be careful to put the risks in proper perspective, and to emphasize the safety and noncontraceptive benefits of little dose oral contraceptives.
3. Show and demonstrate to the patient the package of pills she will use.
4. Explain how to take the pills:
¢?"When to start.
¢?"How to develop a daily routine to avoid missing pills.
¢?"What to do if pills are missed.
5. Review the side effects that can affect compliance: amenorrhea, break through bleeding, headaches, weight gain, nausea, etc. and what to do if one or any more occurs.
6. Explain the warning signs of potential problems: abdominal or chest pain, trouble breathing, severe headaches, visual problems, leg pain or swelling.
7. Ask the patient to be sure to call if another clinician prescribes other medications.
8. Ask the patient to repeat critical information to make sure she understands what has been said. Ask if the patient has any questions.
9. Schedule a return appointment in 2-3 months to review understanding and address fears and concerns.
10. Make sure a line of communication is open to a clinician or office personnel. Ask the patient to call for any problem or concern before she stops taking the oral contraceptives.