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Contraception - Management
What are the advantages, disadvantages, and risks of using a progestogen-only pill (POP)?

  • Advantages:
    • The progestogen-only pill (POP) is very effective when taken correctly and is more effective than barrier methods of contraception. See Effectiveness of contraceptives.
    • Sex need not be interrupted to use contraception.
    • There are no serious adverse effects.
    • It can be used by women for whom the combined oral contraceptive (COC) is not suitable:
      • Women who are breastfeeding.
      • Older women (35 or more years of age).
      • Heavy smokers (15 or more cigarettes daily).
      • Hypertension.
      • Valvular heart disease.
      • Diabetes mellitus with complications, or duration of diabetes greater than 20 years.
      • Migraine without aura, or history of migraine with aura.
      • Major surgery, as well as surgery affecting the legs.
    • Normal fertility returns when the POP is stopped.
  • Disadvantages:
    • For contraceptive cover to be reliably maintained, pills must be taken at the same time each day: within 3 hours, except for the desogestrel-only pill, Cerazette®, which must be taken within 12 hours.
    • Temporary adverse effects are experienced by some women when they first start a POP (e.g. spotty skin, headaches) [BNF 53, 2007]. Women may be advised that there is no evidence of a causal association between progestogen-only pill use and weight change or depression [FSRH, 2008b].
    • Menstrual irregularities (oligomenorrhoea and menorrhagia) are common [BNF 53, 2007]. Although they tend to resolve with time, there is no way of predicting who will continue to have erratic bleeding, and who will become amenorrhoeic. As a general guide [FSRH, 2008b]:
      • 20% of women will become amenorrhoeic.
      • 40% will bleed regularly.
      • 40% will have erratic bleeding.
    • May be less effective in women who weigh more than 70 kg (except for the desogestrel-only pill, Cerazette®) [FFPRHC, 2007c].
    • Functional ovarian cysts develop in some women. POP use is associated with a roughly 30% higher risk of developing spontaneously reversible ovarian retention cysts — risk is lower for Cerazette® [Robinson and Kubba, 1997].
    • The POP does not protect against sexually transmitted infections; people at risk for sexually transmitted infections are advised to use condoms as well.
  • Risks of some rare but serious conditions are increased:
    • Ectopic pregnancy: small increased risk (for POPs excluding Cerazette®) [Furlong, 2002]. But the absolute risk is lower than that if not using contraception.
    • Breast cancer: the risk of breast cancer may be increased in POP users. A meta-analysis of cohort and case-control studies showed a trend similar to that for COCs, but the results were not statistically significant, possibly because the studies had small sample sizes and were under-powered [Collaborative Group on Hormonal Factors in Breast Cancer, 1996a; Collaborative Group on Hormonal Factors in Breast Cancer, 1996b]. The Committee on Safety of Medicines has advised that the possible small increase in the risk of breast cancer should be weighed against the benefits [CSM, 1998].
  • Adverse effects which have been claimed for POPs, but for which supporting data are inadequate:
    • Loss of libido:
      • Reviews of the literature find studies in which libido was increased, decreased, or unchanged when taking oral contraceptives. Results differ according to study design (retrospective and uncontrolled, prospective and controlled, or randomized controlled) [Davis and Castano, 2004; Schaffir, 2006].

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