Combined_Oral_Contraceptive_Pill_Missed_Pill_Flashcards
What is the recommendation if 1 pill is missed at any time in the cycle?
Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection needed.
What is the recommendation if 2 or more pills are missed?
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day. Use condoms or abstain from sex until taking pills for 7 days in a row.
What should be done if pills are missed in week 1 (Days 1-7)?
Emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1.
What should be done if pills are missed in week 2 (Days 8-14)?
After seven consecutive days of taking the COC, there is no need for emergency contraception.
What should be done if pills are missed in week 3 (Days 15-21)?
Finish the pills in the current pack and start a new pack the next day, thus omitting the pill-free interval.
What is the theoretical protection pattern for taking the COC?
Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off.
summarise cocp missed pill
Combined oral contraceptive pill: missed pill
The advice from the Faculty of Sexual and Reproductive Healthcare (FSRH) has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
A 22-year-old woman presents to her GP regarding her contraception. She is currently on the combined oral contraceptive pill however has accidentally omitted her last 2 pills and is unable to remember the correct advice regarding missed pills. Her last unprotected sexual encounter was 3 days ago and she finished her pill-free interval 5 days ago. Before this, she was very consistent in taking her pills. You advised her to take the most recent missed pill.
What additional advice must you give regarding her contraception?
Offer emergency contraception and use additional contraception for the next 7 days
Simply continue from the next pill as normal
Take the additional missed pills and continue as normal
Use additional contraception for the next 5 days
Use additional contraception for the next 7 days
Offer emergency contraception and use additional contraception for the next 7 days
COCP: If 2 pills are missed in week 1, consider emergency contraception if she had unprotected sex during the pill-free interval or week 1
Offer emergency contraception and use additional contraception for the next 7 days is the correct advice in this scenario of missed pills. If you miss more than one pill during the pill-free interval or at the start of a cycle, then you are at risk of becoming pregnant. The Faculty of Sexual and Reproductive Healthcare therefore advises that in this scenario ‘the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row’. The use of emergency contraception is also recommended if there was an episode of unprotected sexual intercourse (UPSI) during the pill-free interval or week 1 of the cycle, as in this case. The additional recommendation would be to advise the patient to take the most recent missed pill (as was done in this case) and continue subsequent pills as normal.
Simply continue from the next pill as normal is incorrect because there is a risk of pregnancy in this situation. This would warrant emergency contraception in the case of an episode of UPSI. Additionally, you should advise her to use additional contraception for the next week.
Take all the missed pills and continue as normal is incorrect. In this case, pregnancy is a large risk so needs to be addressed. If 2 or more COCP pills are missed then it is correct to take the most recent missed pill only (including if this means taking two pills in one day), however here it is pertinent to add extra precautions e.g. emergency contraception. It is incorrect to simply take all the missed pills as this is not effective contraception and can cause adverse effects from taking too many at once.
Use additional contraception for the next 5 days is incorrect. It is recommended to use additional contraception e.g. barrier contraception, however, this should be for the next 7 days. Additionally, in the case of a recent episode of UPSI during the pill-free interval or week 1 of her cycle, emergency contraception should be offered.
Use additional contraception for the next 7 days is incorrect. If the patient was in week 2 or 3 of her cycle, then the recommendation would simply be to use additional contraception for the next 7 days. However, because she is in week 1 of her cycle, and she had an episode of UPSI, then emergency contraception should be offered.
A 42-year-old woman contacts her GP for advice after forgetting to take her combined oral contraceptive pills during a holiday. She reports that she had consistently taken the first nine pills of the pack correctly but missed days 10 and 11 - it is now the end of day 12 and she has not yet taken her today’s pill. She had unprotected intercourse with her husband the previous evening and is now concerned about the need for emergency contraception. Her medical history includes asthma, and she has never been pregnant or had children.
What is the most appropriate management?
Copper coil
Levonorgestrel pill
No emergency contraception, take 2 pills today, then continue as normal
No emergency contraception, take 2 pills today, then omit the pill-free interval
Ulipristal pill
No emergency contraception, take 2 pills today, then continue as normal
If two pills are missed, between days 8-14 of the cycle, no emergency contraception is required, as long as the previous 7 days of COCP have been taken correctly
No emergency contraception, take 2 pills today, then continue as normal is correct. This patient has missed taking the pill on days 10 and 11 and is yet to take a pill on day 12, meaning that she has missed 2 pills in week 2 of her pack. In this situation, the FSRH guidelines recommend that one missed pill should be taken straight away, and then today’s pill should be taken at the normal time, even if this means taking 2 pills in one day. Emergency contraception is not required as prior to this, the patient has adhered to the contraceptive pill regimen correctly for more than seven consecutive days. Therefore, they are not at risk of pregnancy because there has not been enough time for ovulation to occur. It is advisable, however, to recommend additional precautions such as barrier methods until the patient has taken the contraceptive pill for a further seven consecutive days. There is no need to skip the pill-free interval at the end of this pack since they will have taken the pill for over seven days before this interval; hence, ovulation is unlikely during this period.
Copper coil is incorrect. The patient’s consistent and correct use of the contraceptive pill for more than seven consecutive days protects against pregnancy due to insufficient time for ovulation to occur. Consequently, there is no requirement for any form of emergency contraception.
Levonorgestrel pill is incorrect. This patient is protected as they have taken the contraceptive pill for seven consecutive days, which leaves insufficient time for ovulation to have occurred. Therefore, emergency contraception is unnecessary.
No emergency contraception, take 2 pills today, then omit the pill-free interval is incorrect. Although, indeed, emergency contraception isn’t needed in this case, there’s no necessity to omit the pill-free interval at the end of this pack. The patient will have taken seven consecutive days of pills before this break commences and thus will not be at risk of ovulating during that time. If this had occurred after days 15-21 of the packet, then this would be appropriate advice.
Ulipristal pill is incorrect. As with previous explanations, due to consistent and correct usage of the contraceptive pill over more than seven days consecutively by the patient, there hasn’t been adequate opportunity for ovulation; hence no form of emergency contraception is required.
A 32-year-old woman presents with concerns related to her contraception. She currently takes rigevidon (a combined oral contraceptive pill) and is usually good at remembering to take it. Unfortunately, she has realised that she has forgotten to take the past 2 pills, as she has misplaced her medication. There is concern about her risk of pregnancy.
On further questioning, her pill-free break started 10 days ago. She tells you that she had unprotected sexual intercourse 2 days ago.
What is the most appropriate next management step?
Consider emergency contraception
Continue as normal
Continue as normal with 2 days of additional precautions
Continue as normal with 7 days of additional precautions
Continue as normal with 7 days of additional precautions and omit the pill-free interval
Consider emergency contraception
COCP: If 2 pills are missed in week 1, consider emergency contraception if she had unprotected sex during the pill-free interval or week 1
This patient is currently in the first pill-taking week with an episode of unprotected intercourse during this time whilst missing 2 pills. The guidance, therefore, is to consider emergency contraception due to the high risk of pregnancy.
Restarting the pill and continuing as normal with or without additional precautions, is not appropriate here in isolation as there is a high chance of pregnancy, so emergency contraception should be considered.
Continuing as normal and omitting the pill-free interval with 7 days of additional precautions, would only be appropriate during the final week of pill taking (week 3), just before the usually expected pill-free interval.
A 21-year-old woman comes to see you because she has missed a dose of her combined oral contraceptive pill (COCP). She is on day 10 of her current packet and missed the pill yesterday, around 26 hours ago. She has taken all other pills on time and has not had any recent diarrhoea or vomiting. Her last episode of unprotected sexual intercourse was 12 hours ago. The patient calls to ask whether she needs emergency contraception.
What would be the most appropriate management option for this woman?
No emergency contraception required
Offer the Depo-Provera (medroxyprogesterone) contraceptive injection
Perform a pregnancy test and offer emergency contraception
Prescribe emergency contraception
Suggest she has a copper coil inserted
No emergency contraception required
COCP: If 2 pills are missed in week 1, consider emergency contraception if she had unprotected sex during the pill-free interval or week 1
Patients who are on the combined oral contraceptive pill need to be offered emergency contraception if they have missed two or more pills and have had unprotected sexual intercourse during the pill-free period or week 1 of the pill packet. This woman has missed only one pill on day 9 and therefore does not require emergency contraception. Emergency contraception would be required if she had unprotected sex during the pill-free interval or during week 1 (days 1-7) of the pill packet and had missed two pills.
As this woman has missed only one pill, she does not require a pregnancy test at this point. However, if she had missed two pills and there was a history of erratic pill-taking then it would be sensible to carry out a pregnancy test prior to prescribing emergency contraception.
If this woman had missed 2 pills during days 1-7 of her pill packet and also had unprotected sex over this time period, then she should be offered emergency contraception. There are various different forms of emergency contraception available and the choice of agent depends on the timing of the unprotected intercourse event, other medications the woman may be taking, and her preferences. EllaOne (ullipristal acetate) is licensed for use up to 120 hours after unprotected intercourse, and Levonelle (levonorgestrel) is licensed for use up to 96 hours after unprotected intercourse.
Offering to insert a copper coil to prevent pregnancy would be inappropriate this patient does not require emergency contraception. If she was having trouble remembering to take her pill correctly and wished to consider a long-acting contraceptive, then you could use this opportunity to counsel her on her options, which would include intrauterine devices, subnormal contraceptive implants, and the contraceptive injection.
The contraceptive injections are used for long term contraception but can not be used as a form of emergency contraception and is therefore not an appropriate choice in this case.
A 23-year-old woman who uses the combined oral contraceptive pill (COCP) called the surgery after missing 1 dose. She usually takes one tablet at 10 pm each day, however, she missed the dose and remembered the next morning. Her last menstrual period was 10 days ago.
What is the most appropriate advice to give this patient?
Copper intrauterine device (IUD)
Discard the missed pill and take the next pill at 10 pm
Take the missed dose immediately and then take the next pill at 10pm
Take the missed pill and start the next pack without the 7 days break
Ulipristal
Take the missed dose immediately and then take the next pill at 10pm
COCP: if 1 pill is missed, take the last pill ASAP but no further action is needed
Important for meLess important
This woman has missed 1 pill, thus, the advice would be to take the missed pill immediately, and then take the next pill at the usual time which is 10 pm in this case. She can take the 7-day pill-free break as normal it is only 1 missed pill.
Copper IUD could be used as emergency contraception after unprotected intercourse in those who are not on contraception; this woman does not need an IUD as she is on the COCP and has missed 1 dose only.
Discarding the missed pill is inappropriate as would be her at risk of an unwanted pregnancy.
Starting the next pack without the 7-day break is wrong as she has only missed one dose and can take the 7-day break as usual. If she missed 2 pills and there were fewer than 7 pills left in the pack, she would have to start the next pack without a break.
Ulipristal is also used as emergency contraception within 120 hours of unprotected sexual intercourse. It is not needed in this woman as taking the missed pill would be sufficient.
A 17-year-old girl presents to the GP. She is taking the combined oral contraceptive pill and believes she has missed a dose. She last took the pill 3 days ago. She started the current pack 19 days ago. There has been no unprotected sexual intercourse over the last month.
What advice do you give the patient?
Discard the current pack of pills and then cease the oral contraception
Discard the missed doses and continue as normal
Finish the pills in the current pack and start the new pack the next day
Finish the pills in the current pack and then start the pill-free interval as normal
Take no more pills and start a 7-day pill-free interval now
Finish the pills in the current pack and start the new pack the next day
COCP: If 2 pills missed in week 3, finish the pills in the current pack and start new pack immediately, omitting pill-free interval
Important for meLess important
Finish the pills in the current pack and start the new pack the next day is correct. This rule applies to those taking the combined pill who miss at least two pills in week 3 (days 15-21).
Discard the current pack of pills and then cease oral contraception is incorrect. There is no reason to cease oral contraception entirely when having missed multiple doses.
Discard the missed doses and continue as normal is incorrect. When missing two or more doses within week 3 the patient should finish the current pack and not discard any missed doses.
Finish the pills in the current pack and then start the pill-free interval as normal is incorrect. When missing two or more doses within week 3 the patient should omit the pill-free interval and begin a new pack the next day.
Take no more pills and start a 7-day pill-free interval now is incorrect. The pill-free interval should always be omitted when missing two or more doses within a week.
A 27-year-old woman visits her general practitioner for advice. She currently takes the combined oral contraceptive pill (COCP) nightly and is sexually active. She had sexual intercourse with her boyfriend two days ago and did not use a condom. The patient commenced week 1 of a new pack of the COCP six days ago. However, she missed yesterday night’s pill and also missed the pill from the night before.
What advice should she be given?
Skip the missed pills and take tonight’s pill; no emergency contraception needed
Take the two missed pills and tonight’s pill; no emergency contraception needed
Take yesterday’s missed pill and tonight’s pill; advise emergency contraception
Take yesterday’s missed pill and tonight’s pill; no emergency contraception needed
Take yesterday’s missed pill and tonight’s pill; skip the pill-free interval at the end of this pack
Take yesterday’s missed pill and tonight’s pill; advise emergency contraception
COCP: If 2 pills are missed in week 1, consider emergency contraception if she had unprotected sex during the pill-free interval or week 1
COCP can appear somewhat confusing and advice has changed over recent years. If the patient had missed just one pill, at any stage of the cycle, she would be advised simply to take the missed pill and tonight’s pill, with no further need for emergency contraception. However, if having missed two or more pills, as is the case here, in week 1 of the pill cycle, she should be advised to take yesterday’s missed pill and tonight’s pill and to advise emergency contraception. Any earlier missed pills should be ignored.
Advising her to skip the missed pills and take tonight’s pill and that no emergency contraception is needed is incorrect. She should take the most recently missed pill, rather than skipping them all, and emergency contraception is needed here.
Taking the two missed pills and tonight’s pill and stating that no emergency contraception is needed is incorrect. She should not take more than one missed pill (in addition to tonight’s pill). She should also be advised to consider emergency contraception.
Taking yesterday’s missed pill and tonight’s pill but advising no emergency contraception is needed is incorrect. Emergency contraception is warranted here, as the sexual intercourse occurred in week 1 of the pill cycle. If this had occurred during week 2, the advice regarding no need for emergency contraception would be correct.
Taking yesterday’s missed pill and tonight’s pill and skipping the pill-free interval at the end of this pack is incorrect. This would be the advice give if the pills had been missed in week 3 of the pill cycle.
