Progestogen
Progestogen-only contraception includes progestogen-only pills, implants, and injectables. The LNG IUD is also a type of progesterone, but will be discussed in the IUD section.
POP’s currently available include levonorgestrel, norethisterone, desogestrel, and drospirenone. The implant is Nexplanon, usually reviewed every three years. With pills, there is typically no pill-free interval. Nexplanon is given every three years, while injectables are usually given every 13-14 weeks, depending on the type (DepoT injections).
Advantages
- POPs: Can be used while breastfeeding, no delayed infertility once stopped.
Desogestrel POPs may help with dysmenorrhoea and mid-cycle ovulatory pains.
- Implants: Given every three years, alleviates dysmenorrhoea and endometriosisassociated pains.
- Injectables: Treats heavy painful bleeds, endometriosis pain, and premenstrual pains. Used for patients with BMI over 35 and those with sickle cell anaemia.
Disadvantages
- All: Unscheduled bleeding.
- Injectables: Delayed fertility up to one year after stopping, associated with weight gain and osteoporosis with long-term use.
- Drospirenone: Specific contraindications include renal insufficiency in AKI, uncontrolled high potassium, and requires U&E and BP checks before prescribing to those over 50 or with certain cardiac/CKD risk factors.
Starting Methods
- Drospirenone must be started on day 1, others can be started on days 1-5.
- If started outside these periods, additional contraception is needed for 7 days (drospirenone) or 2 days (others).
- If pregnancy is considered, start as soon as possible with additional protection.
- After emergency contraception: Start immediately if levonorgestrel is used; delay 5 days if UPA is used. Repeat pregnancy test within 3 weeks.
- Amenorrhoea: do a pregnancy test, if negative and no UPISI in the last 21 days then start POP with a barrier. If negative but has had UPSI in the last 7 days consider EC, quick start POP and additional barrier contraception with a repeat Pregnancy test within 3 weeks
- Postpartum (breastfeeding/non-breastfeeding): Start immediately if less than 21 days, no additional contraception is needed. If more than 21 days with no pregnancy risk, start POP with additional protection. If pregnancy risk, consider emergency contraception and quick start POP with additional protection.
Switching Contraception
- CHC to POP: Day 1 is optimal. Other days need additional protection.
- POP to POP: Can switch anytime, no additional protection needed (except for drospirenone, which needs 7 days).
- Implant to POP: If less than 3 years, switch immediately. If more than 3 years old, a pregnancy test is required.
- Injectable to POP: If less than 14 weeks, switch immediately. If more than 14 weeks, additional protection may be needed.
- LNG IUD to POP: Depends on recent intercourse and IUD status.
- Copper IUD to POP: Depends on timing and recent intercourse.
General Advice
- Follow missed pill advice: 3 hours for most POPs, 12 hours for desogestrel, and 24 hours for drospirenone.
- Take missed pills ASAP and use additional contraception if needed.
- Consider emergency contraception if unprotected intercourse occurs within 48 hours of restarting POP.
Follow-Up
- Usually, @ 3 months and then annually.
- For those over 50 with amenorrhoea wishing to stop contraception. FSH checks (2 checks at 6-week intervals) are required for discontinuation, if >30IU/L, can be discontinued after 1 year. If in the perimenopausal range, then continue and recheck in 1 year.
- Can stop >55 years old
- Can be used alongside HRT to provide contraception if needed.