Progestogen_Only_Pill_Counselling_Flashcards
What is the most common problem with the progestogen-only pill (POP)?
Irregular vaginal bleeding is the most common problem.
When does the POP provide immediate protection?
If commenced up to and including day 5 of the cycle, or if switching from a combined oral contraceptive (COC) and continued directly from the end of a pill packet (i.e., Day 21).
What should be done if the POP is started after day 5 of the cycle?
Additional contraceptive methods (e.g., condoms) should be used for the first 2 days.
How should the POP be taken?
The POP should be taken at the same time every day, without a pill-free break (unlike the COC).
What should be done if a POP pill is missed and it is less than 3 hours* late?
Continue as normal.
What should be done if a POP pill is missed and it is more than 3 hours* late?
Take the missed pill as soon as possible, continue with the rest of the pack, and use extra precautions (e.g., condoms) until pill-taking has been re-established for 48 hours.
What should be done if the user has diarrhoea and vomiting while on POP?
Continue taking the POP but assume pills have been missed and follow the missed pill protocol.
Do antibiotics affect the effectiveness of the POP?
Antibiotics generally have no effect on the POP unless they alter the P450 enzyme system, for example, rifampicin.
Do liver enzyme inducers affect the effectiveness of the POP?
Yes, liver enzyme inducers may reduce the effectiveness of the POP.
What should be included in counselling about the POP?
Discussion on STIs should be included.
summarise
Progestogen only pill: counselling
Women who are considering taking the progestogen-only pill (POP) should be counselled in a number of areas:
Potential adverse effects
irregular vaginal bleeding is the most common problem
Starting the POP
if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. condoms) should be used for the first 2 days
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
Taking the POP
should be taken at the same time every day, without a pill-free break (unlike the COC)
Missed pills
if < 3 hours* late: continue as normal
if > 3 hours*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Other potential problems
diarrhoea and vomiting: continue taking POP but assume pills have been missed - see above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce the effectiveness
Other information
discussion on STIs
*for Cerazette (desogestrel) a 12 hour period is allowed
**unless the antibiotic alters the P450 enzyme system, for example, rifampicin
A 36-year-old female starts Cerazette (desogestrel) on day 7 of her cycle. How long will it take before it can be relied upon as a method of contraception?
Immediately
2 days
5 days
7 days
Until first day of next period
2 days
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
A 27-year-old woman visits her general practitioner asking for emergency contraception. She recently commenced the progesterone-only pill on day 10 of her menstrual cycle and has since had unprotected sexual intercourse with a new partner 4 days later. She is worried as they did not use barrier contraception at the time.
What is the most appropriate management for this patient?
Intrauterine device
Intrauterine system
Levonorgestrel
Reassurance and discharge
Ulipristal acetate
Reassurance and discharge
The progestogen-only pill takes 48 hours before it becomes effective
Unless commenced up to and including day 5 of the menstrual cycle (in which case cover is immediate), the progesterone-only pill takes 48 hours until it becomes effective. During this time additional barrier methods of contraception should be used. As this patient is currently on day 10 of her menstrual cycle, it will take 48 hours until the POP becomes effective. Therefore, having unprotected sexual intercourse on day 14 of her menstrual cycle would be considered safe and emergency contraception is not indicated.
The intrauterine device is a method of emergency contraception that can be used within 5 days of unprotected sexual intercourse. However, as the POP has become effective, it is not indicated.
The intrauterine system is not a method of emergency contraception and is not indicated for this patient.
Levonorgestrel is a form of emergency contraception that must be taken within 72 hours of unprotected sexual intercourse. Ulipristal acetate (also known as EllaOne) is a form of emergency contraception that must be taken within 5 days of unprotected sexual intercourse. However, this patient has been taking the POP for 4 days, meaning that it has taken full effect.
A 24-year-old woman presents to her general practitioner seeking an oral contraceptive pill. Her past medical history is significant for migraine headaches and asthma.
She is in a monogamous relationship with a regular male partner and they currently rely on barrier contraception.
Following a discussion on the merits of different types of contraception, the woman opts to trial a progestogen-only pill.
What is the most common adverse effect of this form of contraception?
Acne vulgaris
Breast tenderness
Irregular vaginal bleeding
Mood dysregulation
Weight gain
Irregular vaginal bleeding
Progestogen-only pill: irregular vaginal bleeding is the most common adverse effect
Irregular vaginal bleeding is the correct answer. Irregular vaginal bleeding is the most common adverse effect caused by the progestogen-only pill, caused by disruption of the negative feedback loop controlling endometrial proliferation and shedding. Troublesome irregular vaginal bleeding may be improved by using a formulation with ‘placebo pills’ to allow monthly shedding of the endometrium.
Acne vulgaris is incorrect. In contrast to the combined oral contraceptive pill, the progestogen-only pill may worsen acne in some women. This is a less-common adverse effect than irregular vaginal bleeding.
Breast tenderness, mood dysregulation, and weight gain are incorrect. Although these are all adverse effects experienced by women taking the progestogen-only pill, these are less common than irregular vaginal bleeding.
A 27-year-old visits her GP with irregular vaginal bleeding, reporting 4-weeks of intermittent light ‘spotting’. She denies pelvic pain, vaginal discharge, dyspareunia or post-coital bleeding. A pregnancy test is negative and a pelvic and speculum examination is normal.
The patient had a smear test 2-years ago which was HPV negative and is sexually active with one partner. They have both been screened for sexually transmitted infections. She started taking desogestrel for contraception one and a half months ago.
What is the most appropriate action?
Advise the patient switches to a combined oral contraceptive pill
Advise the patient switches to the levonorgestrel intrauterine system
Reassure and re-assess in 2 months
Refer for transvaginal ultrasound
Repeat cervical smear
Reassure and re-assess in 2 months
Progestogen-only pill: irregular vaginal bleeding is the most common adverse effect
Reassure and re-assess in 2 months is the correct answer. This is because irregular vaginal bleeding is the most common side effect of progestogen-only pills (POPs), which is the class that desogestrel belongs to. NICE advises that further investigation is not needed if this bleeding is present in the first 3-months, so long as a pregnancy and sexually transmitted infections are excluded, there is an up-to-date smear and there are no symptoms suggesting another underlying disease. This patient meets all these criteria and has normal examination findings, so can continue her contraception with reassurance if she desires.
Advise the patient switches to a combined oral contraceptive pill is incorrect. As above, initial bleeding is common with the progestogen-only pill and does not necessarily mean a different contraceptive is required.
Advise the patient switches to the levonorgestrel intrauterine system (IUS) is incorrect. There is no clinical need to change contraception so long as the patient is tolerating the bleeding. Irregular bleeding is common with the POP and is likely to settle with time. Furthermore, unscheduled bleeding is also common in the first 3-6 months of IUS usage.
Transvaginal ultrasound is incorrect. It is not required at this stage, as the patient has no other symptoms and a normal examination. If the bleeding continued beyond 3 months, differentials such as endometrial cancer would be considered, and hence an ultrasound may be warranted.
Repeat cervical smear is incorrect. This patient has an up-to-date smear which is negative for HPV. Cervical smears are screening tests and are not appropriate for suspected cervical cancer. If the patient did have a history concerning for cervical cancer, she would warrant a gynaecology referral. However, this patient has had a normal speculum examination.
