No matter how hyper-organized you are, there’s bound to be a day when taking your birth control pill straight-up slips your mind, or a disruption in your schedule knocks you out of your pill-popping groove. Realizing there’s one too many pills in your pack can send even the most rational woman into a spiral of panic and despair, where the only question you want answered is: Now what?
When you’re on the combination pill, which is made up of estrogen and progestogen, these hormones prevent the monthly fluctuations in hormone secretion that lead to egg development, and in turn, ovulation. “The progestogen component prevents ovulation, while the estrogen component primarily prevents the selection and emergence of the dominant follicle that produces the egg,” says Melissa Peskin-Stolze, M.D., ob-gyn at Stony Brook University Hospital in New York. Meanwhile, the progestogen-only pills work by thickening the cervical mucus (to ward off sperm) and thinning the endometrial lining (which makes it less receptive to a fertilized egg).
“Pills are formulated so that the hormones will be at the therapeutic level for only 24 hours,” says Elicia Harris, M.D., board-certified ob-gyn at Women’s Health Advantage in Indiana. “When you miss a pill, your hormone levels will drop below the therapeutic level, which makes you susceptible to pregnancy if you have intercourse during that time.” You may also notice some slight hormonal changes like nausea, headaches, and some light bleeding.
The best course of action depends on two factors: how many pills have been missed and when in your cycle they were missed. “If one pill is missed, nothing happens and you should take that pill as soon as you remember, then your next pill at the usual time,” says Peskin-Stolze. If it’s close to the time you’d normally take your next pill, take both at the same time. Backup contraception isn’t usually needed in this case, but you may want to consider it if you missed pills earlier in the pack, or in the last week of the previous pack. Continue taking the rest of the pack as usual.
If you miss two pills and miss them early in your cycle (think: the first two weeks), breakthrough ovulation can occur due to the body’s inability to suppress the stimulating hormones, says Peskin-Stolze, in which case you should catch up by taking two pills for the next two days, take the rest of the pack as usual, and use backup contraception for the next seven days.
If you miss two pills in the third week, or if more than two hormonal pills are missed at any time, you should initiate backup contraception right away and start a new pill pack the same day, says Peskin-Stolze. Once the new pack is started, continue with backup contraception for the next seven days.
There are two different types of progestogen-only pills—a 12-hour pill that must be taken within 12 hours of the same time each day, and a three-hour pill that must be taken within three hours of the same time each day. If taken outside of this timeframe, your hormones may fall below the therapeutic window, upping your risk of pregnancy, says Harris.
If you’re less than three hours late taking it—or less than 12, depending on the brand you’re taking—then take the late pill as soon as you remember to, take the next pill when you normally would, and continue with the rest of the pill pack as usual. In most cases, another form of contraception isn’t necessary, but do consider backup protection if you’re a chronic pill-forgetter.
If you’re more than three hours late taking it—or more than 12—take one pill as soon as you remember (even if you’ve missed more than one), then take the next pill when you normally would, and continue with the rest of your pill pack as usual. Once you remember to take your missed pill, use backup contraception for at least the next two days, as it takes 48 hours for the progestogen-only pill to take full effect. No matter where you are in your pill pack, use this strategy.
“If you think you may not be protected because you weren’t taking your pills correctly, you should take emergency contraception,” says Peskin-Stolze. (For example, if you missed two or more pills in the first week of a combo-pill pack and had unprotected s*x during the previous seven days, or during the two days after missing your progestogen-only pill—especially if forgetting pills is a regular thing.) EC is available over the counter for women over 17, as well as with a prescription, and should be taken within 72 hours of unprotected s*x to prevent a pregnancy, says Harris.
These are just general preventative guidelines—different brands of birth control have different hormonal formulations. “Some pills have one continuous level of hormone throughout the pack, and other pills have three levels of hormones throughout,” says Harris. But no matter what pill you’re on, you should take all of the active pills at the same time each day (the only optional pills for skipping are the placebos).
Ultimately, if you’re unsure about what to do and the pamphlet in your pill pack doesn’t cut it, it’s best check in with your doc for a consult. And if you have trouble remembering a daily pill no matter how many alarms you set, consider alternative birth control methods, such as an IUD, says Harris, which doesn’t require day-to-day compliance and is a little more freeing to the mind (and s*x life).