Common problems

Missed pill. The following refers to the combined pill (see later for the progesterone-only pill).

• If an omitted dose is remembered within 12 hours it should be taken at once and the next dose at the usual time, and all should be well.

• If more than 12 hours have elapsed, the above procedure should be followed but an additional barrier method of contraception should be used for 7 days (or abstinence). Whereas the protective effect of cervical mucus returns within 48h, this 7-day period is needed to ensure effective suppression of an ovulation that may have been initiated by the missed piU.15

Plainly a regimen in which a pill is taken every day (dummy pills) may confuse the subject who will then need advice.

Intercurrent gut upset. Obviously a patient may vomit the dose; if vomiting occurs more than 3 hours after a pill, behave as for a missed pill (above). The hormones are rapidly absorbed and only severe diarrhoea would interfere significantly with efficacy.16 But if there is doubt, it would be prudent to use a barrier method during and for 7 days after the episode.

15 If these 7 days run beyond the beginning of the routine intended pill-free days, the next cycle (packet) should follow without a gap, thus postponing the menses by a month (Family Planning Association).

16 Orme M et al 1991 Unintended pregnancies and contraceptive use. British Medical Journal 302: 789.

Changing of preparation. If a woman is unhappy on one preparation she may be changed to another containing a different dose of oestrogen and/or progestogen. The new preparation should start the day after she has finished a cycle on the previous preparation. If this is done no extra risk of pregnancy occurs.

Break-through bleeding (bleeding on days of active pill taking) can mean a higher dose of oestrogen or progestogen is required. Note that missed or late pills, drug interaction (see later) or sexually transmitted infection, e.g. due to chlamydia, can also cause breakthrough bleeding.

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