BNF for Children 2011-2012

BNFC 2011–2012 7.3.2 Progestogen-only contraceptives 4037.3.2 Progestogen-onlycontraceptives7.3.2.1 Oral progestogen-only contraceptives7.3.2.2 Parenteral progestogen-onlycontraceptives7.3.2.3 Intra-uterine progestogen-only deviceThe Faculty of Sexual and Reproductive Healthcarerecommends emergency contraception (see p. 408) ifone or more progestogen-only contraceptive tablets aremissed or taken more than 3 hours (12 hours forCerazette c ) late and unprotected intercourse hasoccurred before 2 further tablets have been correctlytaken.7.3.2.1 Oral progestogen-onlycontraceptivesOral progestogen-only preparations may offer a suitablealternative when oestrogens are contra-indicated(including those patients with venous thrombosis or apast history or predisposition to venous thrombosis),but have a higher failure rate than combined preparations.They are suitable for heavy smokers, and for thosewith hypertension, valvular heart disease, diabetes mellitus,and migraine. Menstrual irregularities (oligomenorrhoea,menorrhagia) are more common but tend toresolve on long-term treatment.Interactions Effectiveness of oral progestogen-onlypreparations is not affected by antibacterials that do notinduce liver enzymes. The efficacy of oral progestogenonlypreparations is, however, reduced by enzyme-inducingdrugs and an alternative contraceptive method,unaffected by the interacting drug, is recommendedduring treatment with an enzyme-inducing drug andfor at least 4 weeks afterwards—see p. 398 and Appendix1 (progestogens). For a short course of an enzymeinducingdrug, if a change in contraceptive method isundesirable or inappropriate, the progestogen-only oralmethod may be continued in combination with additionalcontraceptive precautions (e.g. condom) for theduration of treatment with the enzyme-inducing drugand for 4 weeks after stopping.Surgery All progestogen-only contraceptives (includingthose given by injection) are suitable for use as analternative to combined oral contraceptives beforemajor elective surgery, before all surgery to the legs,or before surgery which involves prolonged immobilisationof a lower limb.Starting routine One tablet daily, on a continuousbasis, starting on day 1 of cycle and taken at the sametime each day (if delayed by longer than 3 hours (12hours for Cerazette c ) contraceptive protection may belost). Additional contraceptive precautions are notnecessary when initiating treatment.Changing from a combined oral contraceptive Start onthe day following completion of the combined oralcontraceptive course without a break (or in the case ofED tablets omitting the inactive ones).After childbirth Start any time after 3 weeks postpartum(increased risk of breakthrough bleeding if startedearlier).Missed pill The following advice is now recommendedby family planning organisations:‘If you forget a pill, take it as soon as you remember andcarry on with the next pill at the right time. If the pill wasmore than 3 hours (12 hours for Cerazette c ) overdue you arenot protected. Continue normal pill-taking but you must alsouse another method, such as the condom, for the next 2days.’Diarrhoea and vomiting Vomiting and persistent,severe diarrhoea can interfere with the absorption oforal progestogen-only contraceptives. If vomitingoccurs within 2 hours of taking an oral progestogenonlycontraceptive, another pill should be taken as soonas possible. If a replacement pill is not taken within 3hours (12 hours for Cerazette c ) of the normal time fortaking the progestogen-only pill, or in cases of persistentvomiting or very severe diarrhoea, additional precautionsshould be used during illness and for 2 days afterrecovery (see also under Missed pill above).ORAL PROGESTOGEN-ONLYCONTRACEPTIVES(Progestogen-only pill, ‘POP’)Cautions arterial disease; sex-steroid dependent cancer;past ectopic pregnancy; malabsorption syndromes;active trophoblastic disease (until return tonormal of urine- and plasma-gonadotrophin concentration)—seekspecialist advice; systemic lupuserythematosus with positive (or unknown) antiphospholipidantibodies; functional ovarian cysts;history of jaundice in pregnancy; interactions: seenotes above and Appendix 1 (progestogens)Other conditions The product literature advises caution inpatients with history of thromboembolism, hypertension,diabetes mellitus and migraine; evidence for caution in theseconditions is unsatisfactoryContra-indications undiagnosed vaginal bleeding;severe arterial disease; acute porphyria (section9.8.2); history of breast cancer but can be used after 5years if no evidence of disease and non-hormonalcontraceptive methods unacceptableHepatic impairment caution in active liver disease;and recurrent cholestatic jaundice, avoid in livertumourPregnancy not known to be harmfulBreast-feeding progestogen-only contraceptives donot affect lactation; see also After Childbirth aboveSide-effects menstrual irregularities (see also notesabove); nausea, vomiting, headache, dizziness, breastdiscomfort, depression, skin disorders, disturbance ofappetite, weight changes, changes in libidoBreast cancer There is a small increase in the risk of havingbreast cancer diagnosed in women using, or who haverecently used, a progestogen-only contraceptive pill; thisrelative risk may be due to an earlier diagnosis. The mostimportant risk factor appears to be the age at which thecontraceptive is stopped rather than the duration of use; therisk disappears gradually during the 10 years after stoppingand there is no excess risk by 10 years. A possible smallincrease in the risk of breast cancer should be weighedagainst the benefitsLicensed use consult product literature for thelicensing status of individual preparations7 Obstetrics, gynaecology, and urinary-tract disorders