Can You Prescribe Progestin-Only Pills (POPs)?
Yes, you can prescribe progestin-only pills to most women of reproductive age without extensive screening, as they have minimal contraindications and do not require pelvic examination, blood pressure measurement, or laboratory testing before initiation. 1
Absolute Contraindications (Do Not Prescribe)
POPs should not be used in women with: 2
- Current breast cancer (U.S. MEC Category 4) 1
- Known or suspected pregnancy 2
- Undiagnosed abnormal genital bleeding 2
- Acute liver disease or benign/malignant liver tumors 2
- Hypersensitivity to any component 2
Conditions Requiring Caution (Generally Should Not Use)
Women with certain severe liver diseases generally should not use POPs (U.S. MEC Category 3), though POPs do not affect disease progression in women with hepatitis, cirrhosis, or benign focal nodular hyperplasia. 1
Special Populations Where POPs Are Strongly Recommended
Breastfeeding Women
- POPs can be initiated at any time postpartum in breastfeeding women (≥1 month postpartum is Category 1) 1, 3
- POPs do not affect milk production, making them ideal for lactating women 3
Women with Estrogen Contraindications
POPs are strongly recommended over combined hormonal contraceptives for: 1
- Antiphospholipid antibody-positive patients (combined estrogen-progestin contraceptives are contraindicated due to thrombosis risk) 1
- Women with SLE and moderate/severe disease activity 1
- History of venous thromboembolism (POPs show no increased VTE risk: RR 0.90,95% CI 0.57-1.45) 1, 3
- Hypertension (even systolic ≥160 or diastolic ≥100 is only Category 2 for POPs vs. Category 3-4 for combined methods) 1
- Cardiovascular disease risk factors 1, 4
No Screening Required Before Initiation
The following tests are Class C (not necessary) before prescribing POPs: 1
- Blood pressure measurement
- Pelvic examination or cervical inspection
- Clinical breast examination
- Liver enzymes
- Glucose, lipids, hemoglobin
- Thrombogenic mutation screening
- STD/HIV screening (though appropriate for other reasons)
Rationale: The conditions that would make POPs unsafe (current breast cancer, severe liver disease) are rare and unlikely to be detected by these screenings, and women with these conditions would likely already have them diagnosed. 1
Prescribing Recommendations
Initial Supply
Provide or prescribe up to a 1-year supply (13 packs of 28-day pills) at the initial visit. 1
- Studies show that providing more pill packs (versus restricting to 1-3 packs) significantly increases continuation rates and reduces unintended pregnancy risk 1
Critical Counseling Points
Patients must understand: 2, 3
- Strict timing requirement: Pills must be taken at the same time every day (within 3 hours for traditional POPs) 3, 2
- If >3 hours late: Take the missed pill immediately, use backup contraception for 48 hours, consider emergency contraception if unprotected intercourse occurred in previous 5 days 3, 2
- Irregular bleeding is common and not harmful, especially in first 3-6 months 1
- Typical use failure rate: Approximately 9 out of 100 women become pregnant in the first year 1
Drug Interactions to Consider
POPs may have reduced effectiveness with: 2
- Rifampin, barbiturates, phenytoin, carbamazepine, felbamate, oxcarbazepine, topiramate, griseofulvin
- Some anti-HIV protease inhibitors
- St. John's Wort (may induce hepatic enzymes)
Common Pitfalls to Avoid
Do not require pelvic exam before prescribing - this creates an unnecessary barrier to contraception access 1
Do not restrict pill pack supply - providing only 1-3 months increases discontinuation and pregnancy risk 1
Do not prescribe POPs as first-line for healthy adolescents - the strict timing requirements and irregular bleeding make them less ideal than IUDs or implants for this population 3
Do not use DMPA (injectable progestin) in antiphospholipid antibody-positive patients - unlike POPs, DMPA may have higher VTE risk (RR 2.67) 1
Counsel extensively about bleeding patterns - failure to prepare patients for irregular bleeding is a major cause of discontinuation 1
Cardiovascular Safety Profile
POPs do not increase cardiovascular disease risk. 4
- No significant increase in myocardial infarction (OR 0.94,95% CI 0.31-2.91) 4
- No significant increase in stroke (OR 1.60,95% CI 0.24-0.72) 4
- No significant increase in VTE (OR 0.68,95% CI 0.28-1.66) 4
This makes POPs particularly valuable for women with cardiovascular risk factors who need effective contraception. 1, 4