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Contraception - Management
How should a woman who is not using contraception start the progestogen-only pill (POP)?
Women who are starting to use a progestogen-only pill (POP):
- Exclude pregnancy.
- If the woman is not amenorrhoeic and not breastfeeding:
- Start the POP at the beginning of menstruation — ideally on the first day (licensed use), but this can be up to and including day 5 of the cycle (unlicensed use).
- Additional contraceptive protection will not be required.
- If this is not possible:
- Start the POP at any other time in the menstrual cycle, provided that it is reasonably certain that a woman is not pregnant (unlicensed use).
- Advise additional contraceptive protection (such as condoms) for the first 48 hours of pill taking.
- If starting immediately after oral emergency contraception:
- Levonorgestrel emergency contraception used — advise additional contraception (condoms or avoidance of sex) for the first 2 days of use.
- Ulipristal acetate emergency contraception used — advise additional contraception (condoms or avoidance of sex) for the first 9 days of use.
- Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of unprotected sex.
- If the woman is amenorrhoeic:
- If the woman is postpartum and not breastfeeding:
- Contraception is not required before day 21 postpartum.
- Ideally, start the POP on day 21 postpartum for immediate contraceptive protection — this is the only licensed use for postpartum women.
- However, the POP can be started before day 21 if requested.
- If started after day 21, advise additional contraceptive protection (such as condoms) for the first 48 hours of pill taking.
- If the woman is postpartum and breastfeeding:
- Start on or before day 21 postpartum for immediate contraceptive protection.
- If started after day 21, advise additional contraceptive protection (such as condoms) for the first 48 hours of pill taking.
- These are unlicensed uses.
Clarification / Additional information
- Explain to the woman that these recommendations may differ from those provided in the patient leaflet or package insert.
- For details of licensed uses and recommended unlicensed uses, see Table 1.
- 'Breastfeeding' means 'fully or nearly fully breastfeeding' during the day and at night.
Table 1. Advice on starting the progestogen-only pill (POP): recommendations within and outside the terms of the product licence.
Starting time | Licensed use as in the Summary of Product Characteristics (SPC) | Evidence-based use outside the terms of the product licence |
|---|
First use | Start on day 1; additional contraceptive method required for 7 or 14 days (depending on the POP product). | Ideally, start on day 1 of the menstrual cycle; can start up to day 5 without additional contraceptive method. |
After abortion or miscarriage | Start immediately after first-trimester abortion or miscarriage; no advice given for second trimester. | Start on day of surgical or second part of medical abortion (induced or spontaneous < 24 weeks); no additional contraceptive method required. If started > 5 days after abortion, an additional contraceptive method is required for 48 hours. |
Postpartum, not breastfeeding | Start on day 21 postpartum; no additional contraceptive method required. | Contraception is not required before day 21 postpartum; ideally, start on day 21 postpartum for immediate contraceptive protection. Can be started before day 21 if requested. If started after day 21, additional contraceptive method required for 48 hours. |
Breastfeeding | No advice given. Micronor® advice suggests waiting until infant weaned. | Start on or before day 21 postpartum for immediate contraceptive protection. If started after day 21, additional contraceptive method is required for 48 hours. |
Missed pills | > 27 hours since last pill (i.e. > 3 hours late). Additional contraceptive method required for 7 or 14 days. Desogestrel pill is missed if > 36 hours since last pill (i.e. 12 hours late). Additional contraceptive method required for 7 days. | > 27 hours since last pill (i.e. > 3 hours late). The missed pill should be taken as soon as remembered; continue daily pill taking; additional contraceptive method required for 48 hours. Emergency contraception is indicated if unprotected sexual intercourse has occurred in the 48 hours since missing pills. Desogestrel-only pill is 'missed' if > 36 hours since last pill (i.e. 12 hours late). Missed pill should be taken as soon as remembered; continue daily pill taking; an additional contraceptive method required for 48 hours. Emergency contraception is indicated if unprotected sexual intercourse has occurred in the 48 hours since missing pills. |
|
Basis for recommendation
- These recommendations are based on guidance issued by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FFPRHC, 2002; FFPRHC, 2005a; FSRH, 2008b].
- The FFPRHC concluded that:
- The risk of ovulation when starting a progestogen-only pill (POP) within the first 5 days of menstruation is acceptably low because the POP has a rapid contraceptive effect on cervical mucus.
- Suppression of ovulation is less reliable when starting after day 5.
- The recommendations on how long additional contraception should be used if the progestogen-only pill is started immediately after oral emergency contraception is based on the Quick starting contraception guidance issued by the Faculty of Sexual and Reproductive Healthcare (FSRH) [FSRH, 2010e].
- Recommendations in FFPRHC guidelines on 'The use of contraception outside the terms of the product licence' [FFPRHC, 2005a] have been quoted when these differ from recommendations in the FFPRHC guidelines 'Selected practice recommendations' [FFPRHC, 2002]. The differences are minor and related to starting a POP in the postpartum period.
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