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Advice on missed pills

In this occasional series, the Faculty of Family Planning and Reproductive Health Care answers GPs' questions

In this occasional series, the Faculty of Family Planning and Reproductive Health Care answers GPs' questions

What should women who miss combined oral contraceptives containing 30-35µg or less of ethinylestradiol do?

Missed ONE or TWO pills
•She should take a pill as soon as possible and then continue taking pills daily, one each day. (If a woman misses more than one pill, she can take the first missed pill and then either continue taking the missed pills or discard them to stay on schedule.)
•She does not need any additional contraceptive protection.

Missed THREE or more pills
•She should take a pill as soon as possible and then continue taking pills daily, one each day. (Depending on when she remembers that she missed a pill or pills, she may take two pills on the same day – one at the moment of remembering, and the other at the regular time, or even at the same time.)
•She should also use condoms or abstain from sex until she has taken pills for seven days in a row.
•If she missed the pills in the third week, she should finish the pills in her current pack and start a new pack the next day. She should not have a pill-free interval. If the pill-free interval is avoided in this way, she does not need to use emergency contraception.
•If she missed the pills in the first week (effectively extending the pill-free interval) and had unprotected sex (in week one or in the pill-free interval), she may wish to consider the use of emergency contraception.

For everyday pill regimens
•If a woman misses any inactive pills, she should discard the missed inactive pills and then continue taking pills daily, one each day.

What should women who miss combined oral contraceptives containing 20µg or less of ethinylestradiol do?

Missed ONE pill
•She should take a pill as soon as possible and then continue taking pills daily, one each day at her usual time.
•She does not require additional contraceptive protection.

Missed TWO or more pills
•She should take a pill as soon as possible and then continue taking pills daily, one each day. (Depending on when she remembers that she missed a pill or pills, she may take two pills on the same day – one at the moment of remembering and the other at the regular time, or even at the same time.)
•She should be advised to use condoms or abstain from sex until she has taken pills for seven days in a row.
•If she missed the pills in the third week, she should finish the pills in her current pack and start a new pack the next day. She should not have a pill-free interval. If the pill-free interval is avoided in this way, she does not need to use emergency contraception.
•If she missed the pills in the first week (effectively extending the pill-free interval) and had unprotected sex (in week one or in the pill-free interval), she may wish to consider the use of emergency contraception.

For everyday pill regimens
•If a woman misses any inactive pills, she should discard the missed inactive pills and then continue taking pills daily, one each day.

The pill and St John's wort

For women who start using the Pill immediately after stopping St John's wort (Hypericum perforatum), is contraceptive efficacy reduced?

Liver enzyme-inducers increase the metabolism of ethinylestradiol and progestogen. Ethinylestradiol and progestogen have a narrow therapeutic range, and therefore increased metabolism may lead to a reduction in contraceptive efficacy. St John's wort induces liver enzymes but is less potent than other liver enzyme-inducers such as rifampicin.

It can take up to four weeks for liver enzymes to return to normal after the discontinuation of rifampicin. It is unclear how long it takes for liver enzymes to return to normal after St John's wort is stopped.

The WHO Selected Practice Recommendations for Contraceptive Use and the FFPRHC UK Selected Practice Recommendations for Contraceptive Use state that in general, the combined pill can be started at any time in the menstrual cycle. If started up to day five, additional contraception is not required. If started after day five, additional protection, such as condoms, is advised for seven days.

For women using a combined oral contraceptive pill and a liver enzyme-inducer, a contraceptive pill regimen containing at least 50µg ethinylestradiol daily is required with additional protection until four weeks after the liver enzyme-inducer is stopped.

For women who discontinue St John's wort and start combined oral contraception, the CEU advises that a regimen containing at least 50µg of ethinylestradiol daily is required with additional contraceptive protection until four weeks after St John's wort is stopped. After this time, a standard 30µg ethinylestradiol regimen may be used.

Length of intrauterine system use

For women using the levonorgestrel containing intrauterine system (LNG-IUS), is the device safe and effective for use fore longer than five years?

Randomised trials have shown that the LNG-IUS has contraceptive efficacy for up to seven years of continuous use. About 40% of the levonorgestrel load is still present in the LNG-IUS after five years of use and one study has shown that the LNG-IUS is safe for up to 12 years (with device replacement every five years).

Guidance from the clinical effectiveness unit of the Faculty of Family Planning and Reproductive Health on the LNG-IUS recommends that women should be informed that the LNG-IUS is licensed for five years of use. It is good practice that all women using the LNG-IUS should be advised to return for review after five years of use, to discuss the need for removal and replacement.

Despite evidence from the randomised trials mentioned above, the CEU and the expert group that contributed to the development of this guidance decided to endorse the Summary of Product Characteristics recommendation that women using the LNG-IUS for contraception have the device replaced after five years.

In the absence of evidence to suggest otherwise, this recommendation also applies to women aged over 40 years at the time of insertion. However, women using the LNG-IUS for menorrhagia only and whose symptoms are well controlled, may continue with the LNG-IUS beyond its licensed duration particularly if they are amenorrhoeic.

Condoms and spermicide
Which are more effective at preventing pregnancy: condoms lubricated with nonoxynol-9 or non-spermicidally lubricated condoms ?

The World Health Organization reviewed the safety and effectiveness of nonoxynol-9 in the family planning setting (spermicide alone, spermicide with diaphragms and cap, and spermicidally lubricated condoms).

No evidence was identified that showed that spermicidally lubricated condoms provide additional protection against pregnancy compared with non-spermicidally lubri-cated condoms. Nonoxynol-9 lubricated condoms should not be promoted over non-spermicidally lubricated condoms.

The CEU recommends that, based on current evidence, non-spermicidally lubricated condoms are as effective in preventing pregnancy as nonoxynol-9 lubricated condoms.

These questions and answers are from Family Planning Masterclass: evidence-based answers to 1,000 questions, edited by Gillian Penney, Susan Brechin and Anna Glasier, published by RCOG press, priced £48. ISBN 1-904752-33-0. To order a copy go to www.rcogbookshop.com

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