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Contraception - Management
Which progestogen-only pill (POP) should I offer first-line?

  • Any licensed progestogen-only pill (POP) may be used first-line.
    • However, rules about missed pills differ between products, and this may affect their acceptability.
    • If the woman weighs more than 70 kg, then consider the desogestrel-only pill, Cerazette®, as the first line option.
    • Irregular bleeding (particularly in the first few months) may be more of a problem with the desogestrel-only pill than with other POPs.
Basis for recommendation
  • There has been some debate over whether the desogestrel-only contraceptive pill (Cerazette®) should be preferred over older progestogen-only pills [DTB, 2003]. However, the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC), has not recommended that any one POP be preferred over another [FFPRHC, 2003]. The FFPRHC concluded that:
    • One randomized trial found that a 75-microgram desogestrel pill inhibited ovulation in 97% of cycles. Thus, on theoretical grounds, we would expect the desogestrel pill to be more effective than existing progestogen-only pills (POPs). Although Pearl indices (measures of contraceptive failure rates) from a clinical trial comparing desogestrel to a levonorgestrel POP were not significantly different, the study was small and statistically underpowered. Therefore, an evidence-based recommendation cannot be made that the desogestrel-only pill differs from other POPs in terms of efficacy, nor that it is similar to combined oral contraceptives (COCs) in this respect.
    • In the same randomized trial above, incidence of adverse effects was similar in desogestrel and levonorgestrel users. Overall discontinuation rates were high: 44.8% for the desogestrel group and 39.4% for the levonorgestrel group. Discontinuation rates due to abnormal bleeding however were similar: 22.5% for desogestrel and 18% for levonorgestrel. However, variable bleeding was almost twice as common in desogestrel users than levonorgestrel users in the first 2-4 months of use. Bleeding problems decreased with increasing duration of use. By 11-13 months of use, almost 50% of women using desogestrel had infrequent bleeding or amenorrhoea compared to 10% in the levonorgestrel group.
    • An evidence-based recommendation can be made that the desogestrel-only pill is similar to other POPs in terms of adverse effects and acceptability.
    • The desogestrel-only pill is not recommended as an alternative to COCs in routine practice, but it provides a useful alternative for women who require or wish oestrogen-free contraception.
  • Previously, the FFPRHC on reviewing the available evidence concluded that POPs may be less effective in women who weigh more than 70 kg (except for the desogestrel-only pill, Cerazette®) [FFPRHC, 2007c]. However, a more recent review of the data concluded that current evidence does not support the unlicesend use of two traditional progestogen-only pills per day for women weighing more than 70 kg [FSRH, 2008b].
  • The Scottish Medicines Consortium advises that the use of Cerazette® should be restricted to those individuals who cannot tolerate oestrogen containing contraceptives or in whom those preparations are contraindicated [Scottish Medicines Consortium, 2003b].

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