What are the guidelines for managing a missed progestin-only pill (POP) and bridging with other contraception?

Management of Missed Progestin-Only Pills (POPs) and Bridging with Other Contraception

If you miss a progestin-only pill (POP) by more than 3 hours, take the missed pill immediately, continue daily pills, use backup contraception for 2 consecutive days, and consider emergency contraception if you had unprotected intercourse. 1

Missed POP Management Protocol

When a POP is considered "missed":

• A POP is considered missed if taken more than 3 hours after the scheduled time (i.e., >27 total hours since the previous dose) 1

Steps to take after missing a POP:

1. Take one pill as soon as possible 1
2. Continue taking pills daily at the same time, even if it means taking two pills on the same day 1
3. Use backup contraception (e.g., condoms) or avoid sexual intercourse until pills have been taken correctly, on time, for 2 consecutive days 1
4. Consider emergency contraception if unprotected sexual intercourse occurred 1

Vomiting or Severe Diarrhea Management

If vomiting or severe diarrhea occurs within 3 hours after taking a POP:

• Take another pill as soon as possible (if able, despite discomfort) 1
• Continue taking pills daily at the same time 1
• Use backup contraception until 2 days after vomiting or diarrhea has resolved 1
• Consider emergency contraception if unprotected intercourse occurred 1

Bridging with Other Contraception

Emergency Contraception Options:

• Copper IUD: Most effective emergency contraception option 1
• Ulipristal acetate (Ella): Can be more effective than levonorgestrel after the first 72 hours 1
• Levonorgestrel (Plan B): Take as soon as possible within 72 hours of unprotected intercourse 1, 2

Long-term Contraceptive Alternatives:

• Consider switching to methods less dependent on user compliance if POPs are frequently missed, such as:
  • IUD
  • Implant
  • Injectable contraceptives 1

Important Considerations

Mechanism of Action and Timing:

• Unlike combined oral contraceptives, POPs inhibit ovulation in only about half of cycles 1
• Peak serum steroid levels are reached about 2 hours after administration 1
• By 24 hours after administration, serum steroid levels are near baseline 1
• An estimated 48 hours of POP use is necessary to achieve contraceptive effects on cervical mucus 1

Newer POP Formulations:

• Some newer POPs (like drospirenone 4mg) may have a longer window of effectiveness due to longer half-life (30-34 hours) 3
• Studies with drospirenone 4mg show that ovulation inhibition is maintained even with a 24-hour delay in taking a pill 3

Common Pitfalls to Avoid:

• Taking POPs at inconsistent times: Inconsistent or incorrect use is a major reason for contraceptive failure 1
• Not using backup contraception after missed pills: This significantly increases pregnancy risk 1, 4
• Not considering emergency contraception when appropriate: Emergency contraception should be considered after unprotected intercourse following missed POPs 1, 4
• Not recognizing when to switch methods: Women who frequently miss POPs should consider methods less dependent on user compliance 1

Follow-Up Recommendations

• No routine follow-up visit is required after initiating POPs 1
• Return at any time to discuss side effects, problems, or to change methods 1
• At routine visits, healthcare providers should assess:
  • Satisfaction with the contraceptive method 1
  • Changes in health status or medications that might affect POP appropriateness 1
  • Weight changes if the woman is concerned 1