Contraception Guidelines

Introduction to Progestin-Only Pills (POPs)

• The American College of Obstetricians and Gynecologists recommends norethindrone (0.35mg) and drospirenone as available progestin-only pills (POPs) for contraception, with norethindrone being the most commonly used traditional mini pill in the US 1
• The World Health Organization and the American College of Cardiology support the use of progestin-only pills for women with contraindications to estrogen, women with cardiovascular risk factors, and women with hypertension 2, 3

Mechanism of Action and Efficacy

• POPs work through multiple mechanisms, including thickening cervical mucus, inhibiting ovulation in approximately 50% of users, slowing ovum transport through fallopian tubes, and altering the endometrium 1
• The perfect use failure rate of norethindrone POPs is 0.5%, but the typical use failure rate is higher (5-8%) 1
• Drospirenone 4mg (Slynd) has a 24-hour missed pill window, making it more forgiving than traditional POPs 1
• The effectiveness of progestin-only pills varies based on user compliance, with a perfect use failure rate of 0.3-0.5% and a typical use failure rate of 8% 4, 5, 6
• The following table compares the failure rates of different contraceptive methods:

5, 7

Safety and Contraindications

• POPs are safe for women with contraindications to estrogen, can be used during breastfeeding, and have no increased risk of thromboembolism or stroke 1
• The American College of Rheumatology recommends POPs for patients with stable or inactive Systemic Lupus Erythematosus (SLE) 8
• POPs are preferred over combined hormonal methods for patients with antiphospholipid antibodies due to lower thrombotic risk 8
• Progestin-only pills should not be used in women with current breast cancer, severe cirrhosis, or unexplained vaginal bleeding 2
• Estarylla has a higher cardiovascular risk due to its estrogen component, including increased risk of venous thromboembolism (VTE) and stroke, especially with higher estrogen doses, smoking, hypertension, and age over 35 years 6, 9
• Micronor has no increased risk of thromboembolism or stroke 9

Initiation and Management

• POPs can be started anytime during the menstrual cycle if reasonably certain the patient is not pregnant, but backup contraception is needed if started >5 days after menses began 1
• If a dose is missed, backup contraception is needed for 2 days with norethindrone or norgestrel, and for 7 days with drospirenone 1
• The Centers for Disease Control and Prevention recommends that traditional progestin-only pills (POPs) must be taken at the same time every day, within a 3-hour window, and if a dose is missed by >3 hours, the user should take one pill as soon as possible, continue taking pills daily at the same time, use backup contraception for 2 consecutive days, and consider emergency contraception if unprotected intercourse occurred 10
• If vomiting or severe diarrhea occurs within 3 hours of taking a pill, the user should take another pill as soon as possible, continue regular schedule, and use backup contraception until 2 days after vomiting/diarrhea resolves, as recommended by the Centers for Disease Control and Prevention 10

Patient Selection and Counseling

• Patient selection is crucial, considering the patient's ability to adhere to strict timing requirements 1
• Counsel patients about bleeding changes, as irregular bleeding is common and a major reason for discontinuation 1
• Consider alternatives for patients who frequently miss pills, such as long-acting reversible contraceptives 1
• The American Academy of Pediatrics suggests that progestin-only pills are not typically recommended as first-choice contraceptives for healthy adolescents due to the need for strict adherence to timing 2
• The American Academy of Pediatrics recommends that for sexually active individuals, condoms should be used concurrently with hormonal contraceptives to provide protection against sexually transmitted infections, and to consider the patient's ability to adhere to regimen, desired duration of contraception, bleeding pattern preferences, and medical contraindications when selecting a progestin-only method 7, 11
• The Centers for Disease Control and Prevention states that no routine follow-up visit is required specifically for POP use, but at routine visits, providers should assess satisfaction with the method, evaluate any changes in health status or medications, and consider assessing weight changes if the patient is concerned 10