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Contraception - Management
Missed combined oral contraceptive (COC) pills: what should be done?

  • Restart/catch up with the pill cycle.
    • When seven or fewer active COC pills have been missed, the woman should resume taking her pills as soon as possible.
      • Restarting. If pills are missed in weeks 1, 2, or 3 of the pack: she should take the last missed pill as soon as possible and continue with the usual pill-taking schedule. Depending on when she remembers, she may take two pills at different times (the moment of remembering and her regular time), or two pills at the same time. For users of everyday COCs: if inactive pills are missed in week 4, she should throw away the missed inactive pills and continue the usual pill-taking schedule.
      • Skipping the pill-free interval. If pills are missed in week 3 of the pack: she should finish the active pills in the current pack and then immediately start a new pack (omitting the pill-free interval or discarding any inactive tablets).
    • When more than seven active COC pills have been missed, the woman needs to restart the COC as if she had not used it before.
  • Assess if contraceptive protection has become unreliable.
    • Loss of contraception is most likely if missed pills extend the pill-free (or inactive pill) interval to more than 7 days.
    • The fpa (Family Planning Association) and the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC), regard contraception as becoming unreliable if:
      • Two or more 20-microgram ethinylestradiol pills (Loestrin 20®, Mercilon®, Femodette®) are missed — mnemonic: 'Two for twenty'.
      • Three or more 30- or 35-microgram ethinylestradiol pills (all other COCs) are missed — mnemonic: 'Three for thirty'.
    • The BNF (British National Formulary) regards:
      • Contraception as unreliable if the delay is >= 24 hours (especially the first in the packet).
      • Lost if more than 2 COC tablets are missed from the first 7 tablets in a packet.
  • If contraceptive protection has become unreliable:
    • Advise additional protection, such as condoms or abstinence, until the woman has taken her COC for 7 days in a row.
    • Consider emergency contraception. If contraceptive protection has become unreliable and the woman has been sexually active without taking other precautions, consider the possibility of pregnancy and whether emergency contraception would be appropriate — see the CKS topic on Contraception - emergency.

In depth

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