My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I summarise and review the various NICE guidance on contraception focusing on the oral methods only. I have summarised the guidance from a Primary Care perspective, at times simplifying some of the guidance to make it manageable.

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

The NICE GP YouTube Channel: NICE GP - YouTube 

The various guidelines can be found following these links:

·      Summary of “Contraception – assessment” : https://cks.nice.org.uk/topics/contraception-assessment/

·      Scenario: Assessment for contraception: https://cks.nice.org.uk/topics/contraception-assessment/management/assessment-for-contraception/

·      Scenario: Comorbidities and personal characteristics: https://cks.nice.org.uk/topics/contraception-assessment/management/comorbidities-personal-characteristics/

·      Scenario: Assessment for specific contraceptive methods: https://cks.nice.org.uk/topics/contraception-assessment/management/assessment-for-specific-contraceptive-methods/

·      Contraception - combined hormonal methods: https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/

·      Scenario: Combined oral contraceptive:

https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/

·      Contraception - progestogen-only methods: https://cks.nice.org.uk/topics/contraception-progestogen-only-methods/

·      Scenario: Progestogen-only pill:

https://cks.nice.org.uk/topics/contraception-progestogen-only-methods/management/progestogen-only-pill/

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Transcript 

Hello everyone and welcome. I am Fernando Florido, a GP in the United Kingdom.

Today, we'll be reviewing the various NICE guidelines on contraception focusing on the oral contraception only. I have summarised the guidance from a Primary Care perspective and I have put the relevant links in the episode description.

Please note that this is my interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

If you prefer a video format, there’s also a YouTube version of these episodes. The link is in the episode description.

Covering contraception in general is a vast and challenging task. I must admit that there were moments when I felt overwhelmed, as condensing all the necessary information into a concise video seemed nearly impossible, even when focusing solely on oral hormonal contraception. The NICE guidance can be extremely complex, depending on factors such as the woman's place in her hormonal cycle or whether unprotected sexual intercourse has occurred at a specific time. In situations where complexity became unmanageable, I made an effort to simplify the advice while ensuring that the desired contraceptive effect was maintained.

So, with that said, let's dive in!"

The video consists of three parts: an assessment of suitability for oral contraception, information about the combined oral contraceptive, and details about the progesterone-only pill.

Let’s start with the assessment.

How should we start the assessment of a woman requesting oral contraception?

Well, we will

o  Exclude Pregnancy

o  Take a history and clinical examination. 

o  Assess the risk of sexually transmitted infections (STIs) and

o  Assess for sexual abuse, rape, and non-consensual sex especially in vulnerable women

o  Remember that the legal age of consent to sexual activity is 16 years in the UK and that Sexual activity under this age is an offence, even if consensual.

o  If a girl younger than 16 years of age requests contraception without parental consent, she should be assessed for criteria that she is competent to make this decision. In England and Wales these are the Fraser criteria but in different jurisdictions the advice will be different. I have not covered this here and if you come across such a situation, I would advise you to seek medicolegal advice.

We are now going to look at what methods of contraception are suitable for women with certain comorbidities. These sections cover the UK Medical Eligibility Criteria (UKMEC) for hormonal contraception. 

All oral hormonal contraception, that is, the COC and the POP, can be used in the following cases:

·      past or current pelvic inflammatory disease (PID)

·      history of gestational diabetes or diabetes with no vascular disease

·      a BMI of less than 35 

·      non-migrainous headaches

·      migraine without aura but if migraine without aura develops in a woman already using a COC, we should stop it and give an alternative.

·      Fibroids, previous ectopic pregnancy and menorrhagia but obviously women with unexplained vaginal bleeding should be investigated and

·      perimenopausal women, although we will need to consider possible risk factors

The POP can be used but combined oral contraception is not recommended in the following cases: 

·      diabetes with nephropathy, retinopathy, neuropathy, or other vascular disease

·      migraine with aura or with a history of it

·      multiple risk factors for cardiovascular disease

·      BMI of 35 or more

·      Hypertension, even if it is adequately controlled.

·      Current or History of VTE.

·      Major surgery with prolonged immobilization.

·      Family history of VTE in first-degree relative younger than 45 years of age.

·      Immobility for any reason

·      age 35 years or older and a smoker or stopped smoking less than 1 year ago.

In respect of postpartum and breastfeeding

·      POP can be used from day 1

·      COC can be used from 6 weeks

·      Before 6 weeks:

o  We should never use the COC in the first 3 weeks.

o  We will not use the COC before 6 weeks if breastfeeding or if there are risk factors for VTE

o  But the COC can be used from 3 weeks to 6 weeks if not breastfeeding and there are no risk factors for VTE

In respect of girls aged under 18 years

·      We will avoid regular hormonal contraception if non-menstruating girls and.

·      We will recommend barrier methods for the prevention of sexually transmitted infections 

Finally, in respect of the POP

·      We will check that the cervical screening is up to date and.

·      We will check the additional considerations for drospirenone like:

o  Not to be used in renal failure.  

o  To be avoided in hyperkalaemia or at risk of developing it and

o  To have UEs and BP monitored depending on risk factors

How should we follow up women on oral contraception, both the COC and the POP?

·      We should do a review 3 months after the first prescription, and annually thereafter.

·      At follow up visits we will:

o  Check BP and BMI.

o  Ask about headaches, especially migraine. 

o  Assess for any new risk factors.

o  Address any issues or adverse effects.

o  Check the patient’s knowledge and remind about possible drug interactions and

o  Advise about long-acting reversible contraception

·      We should stop COC at 50 years of age, and switch to and alternative such as the POP.

Before looking at the COC and the POP separately, let’s look at how we would manage a patient taking oral contraception who develops unscheduled bleeding.

·      We need to know that unscheduled bleeding is common in the first 3 months of starting the COC and in women taking the POP

·      We will always need to check for:

o  missed pills, drug interactions, and vomiting or diarrhoea.

o  STIs and as a minimum, we should test for Chlamydia trachomatis.

o  Pregnancy and we should do a pregnancy test and.

o  Gynaecological conditions such as cervical or endometrial cancer.

·      We will consider a speculum and pelvic examination if there are concerns and

·      If all is normal, the bleeding can be assumed to be caused by the COC or POP:

o  If on the COC and the bleeding does not settle, we will consider:

▪       a different COC (with a higher dose of oestrogen, or higher dose of progestogen, or different type of progestogen).

▪       another form of contraception.

o  If on the POP we will advise that

▪       although bleeding may settle with time, there is no evidence to indicate who may become amenorrhoeic, and who may experience persistent irregular bleeding.

▪       If the bleeding is unacceptable to the patient, we will consider changing to:

▪       A different POP, although there is no evidence that changing improves bleeding or

▪       A different type of contraceptive method. 

We are now going to look at the combined oral Contraception

·      Let’s remember that COC inhibit LH and FSH which stops ovulation from occurring.

·      In addition, COCs also have contraceptive effects on cervical mucus and the endometrium

·      The usual 7-day break causes vaginal bleeding mimicking menstruation. However, there is no health benefit from this and women can choose to take fewer, or no, breaks.

·      When used perfectly, there’s a 0.3% failure rate within the first year. But in the real world the failure rate can go up to 9%.

When can a woman start using a combined oral contraceptive?

·      If the COC is started on days 1–5 of the menstrual cycle: 

o  No additional contraception is required unless the woman is starting Qlaira® or Zoely®.

o  If the woman is starting Qlaira® or Zoely®, on day 1 of the menstrual cycle then no additional contraception is required

o  But if the woman is starting Qlaira® or Zoely®, on day 2-5 of the menstrual cycle we should advise a barrier method for the first 9 days (for Qlaira) or the first 7 days (for Zoely).

·      If the COC is started at any other time in the menstrual cycle:

o  We will advise a barrier method for the first 7 days (9 days for Qlaira®).

·      If pregnancy cannot be excluded and the woman wishes to start hormonal contraception without delay:

o  We will prescribe the COC and advise a pregnancy test no sooner than 3 weeks after the last episode of unprotected sexual intercourse (UPSI).

If the woman is starting a COC after oral emergency contraception:

·      For levonorgestrel, we will start the COC immediately and we will advise a barrier method for the first 7 days (9 days if taking Qlaira®).

·      For ulipristal, we will start the COC 5 days after and we will advise a barrier method for this time and the next 7 days (9 days if taking Qlaira®).

If the woman is switching from another COC, the combined contraceptive patch, or the combined vaginal ring:

·      We will start the COC on the day after the last active pill, patch, or vaginal ring. There is no need to wait for the next menstrual period. 

o  No additional contraception is required.

·      If the woman decides to take the usual break before starting the new COC, we will need to assess the need for additional contraception and emergency contraception.

If the woman is switching from a progestogen-only pill (except desogestrel) or levonorgestrel intrauterine system (LNG-IUS):

·      We will start the COC at any time in the menstrual cycle and advise a barrier method for the first 7 days (9 days for Qlaira®).

The advice on how to switch from the drosperidone progestogen-only pill, a progestogen-only implant, or a copper intrauterine device can be fairly complex depending on various factors and these patients may very well be managed by family planning clinics so I will not cover them here. But feel free to check the links in the episode description if you wish to know more. 

If the woman is amenorrhoeic but not pregnant:

·     we can start the combined oral contraceptive at any time, and additional contraception is required for 7 days (9 days for Qlaira®).

If the woman is postpartum:

·     we will advise a barrier method for the first 7 days (9 days for Qlaira®).

If the woman has had a miscarriage or termination of pregnancy:

·      If gestation is less than 24 weeks:

o  If the COC is started within 5 days (except Qlaira® and Zoely® which is 1 day). No additional contraception is required.

o  If the COC is started at any other time, use a barrier method for 7 days (9 days for Qlaira®).

·      If gestation is 24 weeks or more, we will treat them as if they were postpartum.

What types of combined oral contraceptive (COC) are available?

·      Combined oral contraceptives (COCs) contain both an oestrogen and a progestogen.

·      COC preparations differ according to:

o      How the doses vary over the menstrual cycle. For example

▪       In monophasic COCs, the amount of oestrogen and progestogen in each active tablet is constant throughout the cycle.

▪       In phasic COCs, the amounts of oestrogen and progestogen vary over the cycle. Phasic COCs can be biphasic, triphasic, or quadraphasic depending on the number of sets of active pills.

o      They can also vary depending on the dose of the oestrogen. For example

▪       Low-strength COCs contain 20 micrograms of ethinylestradiol. and

▪       Standard-strength preparations contain 30–35 micrograms of ethinylestradiol in monophasic COCs and 30–40 micrograms in phased preparations.

o      They also vary according to the type of progestogen they contain. and

o      The presence or absence of a pill-free interval.

▪       Most COCs are packaged as 21 active tablets to allow for a 7 day break every 4 weeks. However, some products have 7 placebo tablets so that a tablet is taken every day without a break

Which combined oral contraceptive (COC) should we offer first-line?

·      First-line options are monophasic preparations containing 30 micrograms of oestrogen, plus either norethisterone or levonorgestrel. Examples are Loestrin 30, Microgynon 30, Ovranette, Levest and Rigevidon

·      However, any COC can be offered first-line.

·      We should prescribe up to 12 months’ supply for initiating or continuing CHC. And

·      You can check the full availability of brands by looking at the BNF.  

Let’s look at the advice that we should give women taking the COC.

If a woman becomes pregnant while taking the combined oral contraceptive (COC) pill and she wishes to continue with the pregnancy:

o  We will stop the pill.

o  And explain that there is no evidence of harm if pregnancy occurs whilst on the COC. 

What are the advantages and disadvantages associated with combined oral contraceptives (COCs)?

Advantages are that

·      There is a reduced risk of some cancers, including colorectal, ovarian and endometrial cancer. 

·      There is a reduced risk of ovarian cysts and benign ovarian tumours.

·      There is reduced severity of acne in some women.

·      Normal fertility returns immediately after stopping the COC.

·      COCs may also reduce the risk of benign breast disease and osteoporosis, although the available evidence is conflicting.

Disadvantages are that

·      They are less effective than long-acting reversible methods of contraception and that

·      Some women experience adverse effects .

·      The most commonly reported adverse effects are: 

o  Nausea and abdominal pain.

o  Headache.

o  Breast pain and/or tenderness.

o  Menstrual irregularities in up to 20% of COC users

·      Other adverse effects include:

o  Hypertension.

o  Changes in lipid metabolism.

o  there is a very small increase in risk of MI, and two-fold increase in risk of stroke, which is greater in at risk patients.

o  There is an increased risk of VTE, but the absolute risk is very low and lower than the risk of VTE in pregnancy.

o  The risk of VTE depends on the progestogen component and:

▪       levonorgestrel, norethisterone, or norgestimate have the lowest risk

o  There is an increased risk of breast and cervical cancer which returns to normal within 10 years after stopping the COC.

o  depression is a known side effect

o  symptoms of angioedema may be induced or exacerbated by exogenous oestrogens

o  There is no evidence that COCs cause weight gain or loss of libido.

o  In addition, co-cyprindiol should not be used in hepatic disease and meningiomas have been associated with cyproterone.

We also need to be aware of drug interactions and that the effect of COC may be reduced with liver enzyme-inducing drugs like:

o  Antibiotics such as rifampicin and rifabutin.

o  Antiepileptic drugs.

o  Antiretrovirals.

o  St John's wort.

How should we manage them?

·      We should advise not to take products containing St John’s wort.

·      We should always change to an alternative contraceptive method if taking rifampicin or rifabutin. For other liver enzymes drugs the advice may be more complex depending on the duration of treatment and type of COC used. I would recommend that you look up the specific advice depending on the situation

·      We need to be aware that breakthrough bleeding may indicate low serum ethinylestradiol concentrations. If other causes of bleeding have been excluded, we could increase the dose up to a maximum of 70 micrograms.

·      We will consider the need for emergency contraception if sexual intercourse has taken place while the efficacy of the COC may have been reduced.

·      To reduce the risk of contraceptive failure, we can recommend either: 

o      An extended regimen that is, using the COC continuously until breakthrough bleeding occurs for 3 to 4 days or

o      A tricycling regimen with a shortened pill-free interval of 3–4 days, that is taking 3 pill packs continuously without a break.

·      But we need to remember that only monophasic 21-day pill packs containing at least 30 micrograms of ethinylestradiol are suitable for these two options. 

In terms of surgery, we should explain that

·      No precautions are necessary for minor surgery (such as varicose vein surgery, and tooth extraction). But

·      The COC should be stopped: 

o  Four weeks before any major surgery (which includes operations lasting more than 30 minute), all surgery to the legs, or surgery that involves prolonged immobilization of a lower limb or

o  If emergency surgery or immobilization (such as for a leg fracture) is necessary.

o  The COC can then be restarted 2 weeks after full mobilization. 

Let’s now go through what Missed pill advice we should give and 

These missed pill rules apply to all combined oral contraceptives (COCs) except Qlaira® and Zoely®.

·      If it has been 9 completed days or more since the last active pill was taken we will consider emergency contraception if unprotected sexual intercourse (UPSI) has taken place and:

o  We will advise to take the missed pill as soon as possible and to continue taking the remaining pills at the usual time.

o  We will advise a barrier method until 7 consecutive pills have been taken. 

o  We will consider a follow up pregnancy test.

·      If one pill has been missed (that is <72 hours since the last pill was taken), we will advise:

o  That emergency contraception and additional contraceptive precautions are not required if there was otherwise consistent, correct use.

o  To take the missed pill as soon as possible.

o  To continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).

·      If 2–7 pills have been missed (72 hours or more since the last pill in the current pack was taken):

o  We will consider emergency contraception if the missed pills were in week 1 after the break and if UPSI has taken place and we will also consider a follow up pregnancy test.

o  Emergency contraception is not needed if missed pills are in subsequent weeks if there was consistent, correct use in the previous 7 days.

o  We will advise to take the most recent missed pill as soon as possible. Any earlier missed pills should be ignored.

o  We will advise to continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours.

o  If there were two or more missed pills in the 7 days prior to the break, to omit the break.   

o  We will advise a barrier method until 7 consecutive pills have been taken. 

·      If more than 7 consecutive COC pills have been missed in any week of pill-taking:

o  We will Consider emergency contraception and an immediate and follow up pregnancy tests.

o  We will Restart the COC as a new user. And

o  We will advise a barrier method until 7 consecutive pills have been taken.

What advice should we give a woman who has missed pills of Qlaira or Zoely

·      If the pill is taken less than 12 hours late (Qlaira) or 24 hours late (Zoely) we will advise:

o  To take the missed pill immediately.

o  To take further pills at the usual time.

o  That additional contraception is not required.

·      If pill is taken more than 12 hours late (Qlaira) or 24 hours late (Zoely), management will depend on the day of the cycle on which it has been missed. This can get quite complicated so I have not included it here and I recommend that you look it up if you come across this situation. 

How should vomiting or diarrhoea be managed when on the COC?

·      Well, for all combined oral contraceptives (COCs) except Qlaira® and Zoely®:

o  If there is vomiting within 3 hours of taking COC, another pill should be taken as soon as possible.

o  If vomiting or diarrhoea persists for more than 24 hours:

▪       We will follow the instructions for missed pills, counting each day of vomiting and/or diarrhoea as a missed pill.

▪       We will advise a barrier method during the illness and for 7 days afterwards. and

▪       if the illness occurs while taking the last 7 pills, we will recommend not having a break and starting the next cycle immediately.

·      For Qlaira® and Zoely®:

o  If a woman vomits within 3–4 hours of taking an active pill, take the next tablet as soon as possible.

o  If more than 12 hours elapse for Qlaira® or 24 hours for Zoely®, follow the missed pills advice.

We are now going to have a look at the progestogen-only pill:

·      The POP has several independent modes of action, including thickening cervical mucus thereby preventing sperm penetration, delaying ovum transport, inhibiting ovulation, and providing an endometrium hostile to implantation.

·      It should be taken daily with no pill-free interval.

·      When used perfectly, the failure rate is 0.3% within the first year of use but in the real world, the failure rate can go up to 9%.

·      Any licensed progestogen-only pill (POP) may be used first line and we can prescribe 12 months' supply when initiating or continuing a POP. 

How should we start a progestogen-only pill except drospirenone?

·      In women with menstrual cycles:

o  We will start on days 1–5 and no additional precaution is required.

o  If no possibility of pregnancy and starting at any other time we will advise a barrier method for 2 days.

o  If there is risk of pregnancy and starting at any other time, we will:

▪       Recommend an immediate pregnancy test and a follow up test no sooner than 3 weeks after the last episode of unprotected sexual intercourse (UPSI).

▪       consider emergency contraception.

▪       Quick start the POP but delay for 5 days if ulipristal EC was given.

▪       advise a barrier method for 2 days.

▪       And This applies also to women who are amenorrhoeic and have had UPSI in the last 21 days. However,

·      In women who are amenorrhoeic and no UPSI in the last 21 days:

o  We will do a pregnancy test and

o  We will start the POP and advise a barrier method for 2 days

·      The POP can be started at any time after childbirth, including immediately after delivery regardless of breastfeeding. However:

o  If started up to day 21 postpartum no additional precaution is required but

o  After day 21 postpartum, we will ensure that the patient is not pregnant, then start the POP recommending a barrier method for 2 days 

·      In women post first- or second-trimester abortion:

o  The POP should ideally be started on the day or day after a first- or second-trimester abortion but otherwise management is no different to menstruating women.

·      If starting the POP after oral EC, we will:

o      Start the POP immediately if levonorgestrel was given or 5 days after taking ulipristal.

o      We will recommend a barrier method for 2 days. And we will

o      Advise the woman to do a pregnancy test no sooner than 3 weeks after the last episode of UPSI.

How should we switch to the progestogen-only pill (except drospirenone) from other methods of contraception?

·      If we are switching from combined oral contraceptive:

o  If we are starting on days 1–2 of the break then no additional precaution is required.

o  If we are starting on days 3–7 of the break or week 1 following the break and if there is no risk of pregnancy, then:

▪       We should advise a barrier method for 2 days.

o  If we are starting on days 3–7 of the break or week 1 following the break but unprotected sexual intercourse (UPSI) has occurred after in that time:

▪       We will restart or continue the COC until 7 consecutive pills are taken after the break then switch.

▪       No additional precautions are required.

▪       If COC cannot be continued, we will start the POP immediately and we will consider the need for emergency contraception (EC) and a pregnancy test as well as recommending a barrier for 2 days.

o  If we are starting on weeks 2–3 of COC use, no additional precaution is required providing the method has been used consistently and correctly.

·      If we are switching from a POP to another POP:

o  We will start the new POP at any time in the menstrual cycle.

▪       If switching to drospirenone, advise a barrier method for 7 days but 

▪       For all other POPs, no additional precaution is required.

o  If we are switching from drospirenone, to a different POP, the guidance is complex depending on when in the cycle the switch takes place. I have not included it here and I recommend that you look this up if considering this option. 

·      If we are switching from a progestogen-only injectable to a POP other than drosperinenone:

o  If it is 14 weeks or less since the last injection then no additional precaution is needed.

o  If it is more than 14 weeks since the last injection and no risk of pregnancy we will recommend a barrier method for 2 days.

o  If it is more than 14 weeks since the last injection and there is a risk of pregnancy then we will consider the need for EC and a pregnancy test.

·      The advice on how to switch from a progestogen-only implant and intrauterine contraception can be fairly complex depending on various factors and these patients may very well be managed by family planning clinics so I will not cover them here. But feel free to check the links in the episode description if you wish to know more.

The advice above does not include drospirenone. However, if we are giving drospirenone we need to be aware that:

·      It needs to be started on day 1 of the normal menstrual cycle so that no additional precaution is required.

·      Any barrier method advice needs to be for 7 days as opposed for 2 days for other POPs

What are the possible risks and adverse effects of progestogen-only pills?

·      Well, Menstrual irregularities are common.

·      Other possible risks and adverse effects of the POP include: 

o  Ectopic pregnancy (with the exception of desogestrel), but the absolute risk is lower than if not using contraception.

o  Breast tenderness (which is usually transient). 

o  Ovarian cysts (which may be persistent).

o  Depression and changes in mood and libido.

o  Panic attacks (with the desogestrel pill).

o  Headache and migraines.

o  Weight changes.

·      The Breast cancer risk cannot be completely excluded. Any increased risk is likely to be small and to reduce with time after stopping. 

·      In terms of Cardiovascular disease (CVD) risk,  The POP is generally appropriate for women with cardiac disease and is useful as a bridging method while specialist advice is being sought about contraceptive options.  

Drug interactions of the progestogen-only pill (POP) include: 

·      Liver enzyme-inducing drugs (such as rifampicin and carbamazepine) can reduce the efficacy of POPs. Therefore, we will:

o      change to an alternative contraceptive method for as long as she is on these drugs and for 28 days after. 

o      If this is not possible and she is on short-term treatment (2 months or less), we will continue the POP but we will advise a barrier method while taking, and for 28 days after stopping, the liver enzyme-inducing drug. and

o      We will Consider emergency contraception (EC) if unprotected sexual intercourse has taken place while the efficacy of the POP may have been reduced.

o      Other examples of liver enzyme inducing drugs include:

▪       Antibiotics such as Rifampicin and Rifabutin.

▪       Antiepileptics

▪       Antiretrovirals:

▪       St John's Wort.

·      Griseofulvin may also reduce the contraceptive effect of POPs and therefore we will recommend an alternative

·      Lamotrigine may increase plasma levels of progestogen so we should monitor side effects.

·      POPs may reduce the ability of ulipristal to delay ovulation and therefore after ulipristal the patient should:

o      wait 5 days (at least 120 hours) before continuing or starting the POP, with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure.

o      We should recommend additional contraception until the POP is started and for 48 hours after, that is, for a week after Ulipristal. 

If a woman is found to be pregnant whilst using the progestogen-only pill (POP) and she wishes to continue with the pregnancy, we will:

·      stop the POP.

·      We will Inform her that there is no evidence of harm if pregnancy occurs while using the POP. and

·      We will Be alert to the possibility of an ectopic pregnancy.

Let’s look at the Missed pill advice for the POP

·      A pill is missed if the patient is: .

o  12 hours or more late (that is, more than 36 hours since the last pill) if on the desogestrel pill

o  24 hours or more late (that is 48 hours or more since the last pill) if on the drospirenone pill or

o  More than 3 hours late (that is, more than 27 hours since taking the last pill) if on any other progestogen-only pills

·      If the patient has missed a pill, we will advise:

o  To take a pill as soon as possible. If more than one pill has been missed, only one should be taken.

o  To take the next pill at the normal time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).

o  To use a barrier for 7 days if taking drospirenone, or 2 days for all other POPs.

·      We will consider prescribing emergency contraception if unprotected sexual intercourse has taken place after the missed pill and within 48 hours of restarting the POP. For drospirenone, we will consider prescribing emergency contraception in wider circumstances and I recommend that you look up the details in this case if you need to.

Let’s now look at the information and advice that we should give in the event of vomiting or diarrhoea

·      If there is vomiting within 2 hours of pill taking, another pill should be taken as soon as possible.

o  If the subsequent pill is taken more than 3 hours late (or 12 hours late for a desogestrel pill or 24 hours late for drospirenone), we will advise the missed pill rules.

o  If vomiting continues or very severe watery diarrhoea develops, we will advise the missed pill rules (counting each day of vomiting and/or diarrhoea as a missed pill) and use a barrier method during the illness and for 48 hours afterwards.

How long should the progestogen-only pill be used for?

·      If a woman aged over 50 years with amenorrhoea wishes to stop contraception before the age of 55 years:

o  We will check FSH levels on two occasions, with an interval of 6 weeks between tests.

o  If both FSH levels are more than 30 IU/L, the progestogen-only pill (POP) can be discontinued after a further year.

o  If the FSH level is in the premenopausal range, we will continue the POP and recheck the FSH level after 1 year.

·      Once a woman reaches 55 years of age, contraception can be stopped even if she is still experiencing menstrual bleeding.

o  However, if a woman aged 55 years or over does not wish to stop a particular method, consider continuing the method provided individual benefits and risks are assessed and discussed with her. 

·      The POP can be used concurrently with hormone replacement therapy (HRT) to provide effective contraception, but it should not be relied on as the progestogen component of HRT.

In conclusion, the management of oral contraception requires a comprehensive approach and it can become complex.

Please keep in mind that this is only a summary and my interpretation of the guideline. 

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye