Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694842076858.pdf (Pakistan)
Progestin-Only Pills Effectiveness  Effectiveness depends on the user.

For women who have monthly bleeding, risk of pregnancy is greatest if pills are taken late or missed completely.

For breastfeeding women: As commonly used, about 1 pregnancy occurs per 100 women using POPs over the first year.

This means that 99 of every 100 women will not become pregnant.

When pills are taken every day, less than 1 pregnancy occurs per 100 women using POPs over the first   year (3 per 1,000 women).
For women not breastfeeding, they are less effective:  As commonly used, about 3-10 pregnancies occur per 100 women using POPs over the first year.

This means that 90-97 of every 100 women will not become pregnant.

 When pills are taken every day at the same time, less than 1 pregnancy occurs per 100 women using POPs over the first year (9 per 1,000 women).

               Advantages Protect against pregnancy.

Very effective when used correctly.


No need to do anything at the time of sexual intercourse.

Increased sexual enjoyment because no need to worry about pregnancy.

Monthly periods are regular; lighter monthly bleeding and fewer days of bleeding; milder and fewer menstrual cramps.

Can be used for as long as a woman wants to prevent pregnancy.

No rest period needed.

Can be used at any age from adolescence to menopause.

User can stop taking pills at any time.

Fertility returns soon after stopping.


Can be used as an emergency contraceptive after unprotected sex.

Can be used by nursing mothers starting 6 weeks after childbirth.

Do not affect quantity and quality of breast milk.

No oestrogen-related side effects.

Do not increase risk of oestrogen-related complications such as heart attack or stroke.

Women take one pill every day with no break.

Easier to understand than taking 21-day combined pills.
page 130 Oral Contraceptive Pills 8  Can be very effective during breastfeeding.
Limitations Some users report the following: „ Changes in bleeding patterns, including: „ For breastfeeding women, longer delay in return of monthly bleeding after childbirth (lengthened postpartum amenorrhoea) „ Irregular menstrual bleeding „ Amenorrhoea „ Headaches „ Dizziness „ Mood changes „ Breast tenderness „ Abdominal pain „ Nausea „ For women not breastfeeding, enlarged ovarian follicles Client Assessment as per World Health Organization Medical Eligibility Criteria for 1.
Does the client have or has she ever had breast cancer?

Progestin-Only Contraceptive Pills If yes, do not provide POPs.

Help her choose a method without hormones.

2.

Does the client have jaundice, severe cirrhosis of the liver, a liver infection, or tumour?

Perform physical exam or refer.

If she has serious active liver disease (jaundice, painful or enlarged liver, active viral hepatitis, liver tumour), do not provide POPs.

Refer for care.

Help her choose a method without hormones.

3.


Is the client breastfeeding a baby younger than 6 weeks old?

You can give her POPs now, with instructions on when to start—when the baby is 6 weeks old.

4.

Does the client have serious problems with her blood vessels?

If so, what problems?

Do not provide POPs if she reports blood clots (except superficial clots).

Help her choose another effective method.

5.

Is the client taking medicine for seizures?

Taking rifampicin or griseofulvin?


If she is taking phenytoin, carbamezapine, barbiturates, or primidone for seizures or rifampicin or griseofulvin, provide condoms or spermicide or another contraceptive.

If she prefers, or if she is on long-term treatment, help her choose another effective method.

6.

Does the client think she is pregnant?

Assess whether pregnant.

If she might be pregnant, give her condoms or spermicide to use until reasonably sure that she is not pregnant.

Then she can start POPs.


page 131 8 Oral Contraceptive Pills Method of Use Starting Time POPs may be given to breastfeeding women: „ As early as 6 weeks after childbirth and at any time after confirmation that she is not pregnant.

„ If menstrual periods have returned, she can start POPs at any time it is reasonably certain that she is not pregnant.

POPs may be given to non-breastfeeding women: „ Within 3 weeks of childbirth.
Technique The client should always take one pill each day at approximately the same time for maximum efficacy, until the pill packet is finished.

The more pills she misses, the greater her risk of becoming pregnant.

„ When she finishes one pack, she should take the first pill from the next pack on the very next day.

„ It is very important to start the next pack on time.

Starting a pack late risks pregnancy.


Missed Pills Instructions If a Woman Forgets to Take a Pill or Pills It is easy to forget a pill or to be late in taking it.

POP users should know what to do if they forget to take pills.

If a woman is 3 or more hours late in taking a pill or misses one completely, she should follow the instructions below: For breastfeeding women, whether missing a pill places her at risk of pregnancy depends on whether or not her monthly bleeding has returned.
„ Take a missed pill as soon as possible.

„ Keep taking pills as usual, one each day.

(She may take 2 pills at the same time or on the same day.)

If the client has regular monthly bleeding: „ Use a backup method for the next 2 days.

„ Also, if she had sex in the past 5 days, she can consider taking ECPs.

If she vomits within 2 hours after taking a pill: „ Take another pill from her pack as soon as possible, and keep taking pills as usual.
page 132 Oral Contraceptive Pills 8 „ If vomiting or diarrhoea continues, follow the instructions above for making up missed pills.

Table 8-2.
Table 8-2.

Progestin-Only Pills: Side Effects and Their Management Side Effect Nausea or dizziness Breast tenderness • Women not breastfeeding Amenorrhoea • Breastfeeding women • Women not breastfeeding Irregular bleeding • If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons Take POPs at bedtime and with food.
Management • Advise her to wear a supportive bra (including during strenuous activity and sleep).

• Use hot or cold compresses.

• Give her:  Tab.

aspirin (325-650 mg), SOS but not more than three times a day  Tab.

ibuprofen (200-400 mg), 1BD  Tab.

paracetamol (325-1,000 mg), 1TDS The number of tabs will depend on the formulation.

The dosage can vary with the severity of the problem.

Reassure her that this is normal during breastfeeding.

It is not harmful.
It is not harmful.

Reassure her that it is not harmful; in fact, lack of menstruation will help improve her anaemia.

• Reassure her that it is not harmful.

• Breastfeeding itself may cause irregular bleeding.

• Many women using POPs experience irregular bleeding, whether breastfeeding or not:  Vomiting or diarrhoea might cause irregular bleeding.

 Taking anticonvulsants or rifampicin might cause irregular bleeding.
To reduce irregular bleeding: • Tell her to make up for missed pills properly, including after vomiting or diarrhoea.

• For temporary relief:  Tab.

ibuprofen 800 mg TDS after meals for 5 days, or  Tab.

Ponstan 2TDS, beginning when irregular bleeding starts.

• If even after taking medication condition does not improve, counsel her for another method.

• Consider underlying conditions unrelated to • Counsel for another suitable method if needed.

method use.

Refer.
method use.

Refer.

page 133 Oral Contraceptive Pills 8 Side Effect Heavy or prolonged bleeding (twice as much as usual or longer than 8 days) • If heavy or prolonged bleeding continues or starts after several months of normal or no monthly bleeding Headache • Headaches that get worse or occur more often Depression or irritability Loss of sexual desire Severe pain in lower abdomen Management • Reassure her that it is not harmful and usually • For temporary relief: lessens or stops after a few months.
 Tab.

ibuprofen 800 mg (max) TDS after meals for 5 days, or  Tab.

Ponstan 2TDS, beginning when irregular bleeding starts.

Iron Tab.

1 TDS and eat foods containing iron.

 • Consider underlying conditions unrelated to method use.

Refer if necessary.

• Counsel for another suitable method if needed.

Consider underlying conditions unrelated to method use.

Give her: • Tab.

aspirin (325-650 mg), 1TDS • Tab.

ibuprofen (200-400 mg), 1BD • Tab.


paracetamol (325-1,000 mg), 1TDS The number of tabs will depend on the formulation.

Dosage will vary according to the severity of the headache.

Counsel her for another suitable contraceptive method.

If confirmed to have happened after starting the pills, stop pills; give another suitable contraceptive method.

If confirmed to have happened after starting pills: • Rule out local infections as a cause.

• Stop pills, and give another suitable contraceptive method.
Many conditions can cause severe abdominal pain.

Check for signs and symptoms of ectopic pregnancy, which are: • Unusual abdominal pain or tenderness • Abnormal vaginal bleeding or no monthly bleeding, especially if this is a change from her usual bleeding pattern • Light-headedness or dizziness • Fainting If ectopic pregnancy or other serious health condition is suspected, refer at once for immediate diagnosis and care.
page 134 Oral Contraceptive Pills 8 Counselling A client who chooses POPs can benefit from good counselling.

A friendly provider who listens to a client's concerns, answers her questions, and gives clear, practical information helps the woman use POPs with success and satisfaction.

Thorough counselling about bleeding changes and other side effects is an important part of providing the method.

Counselling about menstrual changes may be the most important help a client needs to keep using the method.
The health care provider should follow these steps to provide POPs: „ Show the client the POP packet that she will use, even if she will be getting her pills elsewhere later.

„ Explain that all pills in POP packets are the same white colour and all are active hormonal pills.

„ Tell her about the advantages and limitations.

„ Inform her about the common side effects and what to do.

„ Give her a sufficient number of pills packets, depending on her need.
Running out of pills is a major reason for unintended pregnancies.

„ Explain how to use POPs and what to do if she misses pills.

„ If possible, give her condoms or spermicide to use: „ Until she can start taking her pills (if needed).

„ „ If she starts a packet of pills late, if she forgets several pills in a row, or if she stops taking oral contraceptives for any reason.

If she or her spouse are at risk of HIV/AIDS or any other STI, show her how to use condoms.
„ Plan a return visit in time to give her more pills before her supply runs out.

„ Invite the client to come back to the clinic at any time if she has questions, problems, or wants another method.

„ Ask her to repeat the most important instructions and, using the pill packet, show her how she will take her pills.

„ Ask her if she has any questions, fears, or concerns, and answer her concerns respectfully and caringly.

„ For any unscheduled visit, ask her to bring the packet in use with her.
Follow-Up The follow-up care and support of the client is very important for continued use of OCPs.

The health care provider has a responsibility to keep the client satisfied, in case she has side effects, by providing correct information and reassurance.

page 135 Oral Contraceptive Pills 8 Explain Specific Reasons to See a Trained Health Care Provider Assure the client that she is welcome to come back at any time, especially if: „ She has problems, questions, or wants another method.
„ She has a major change in health status.

„ She thinks she might be pregnant.

„ She has stopped breastfeeding and wants to switch to another method.

„ She took a pill more than 3 hours late or missed one completely, and also had sex during this time; she may wish to consider ECPs.

She should immediately see a health care provider if she has any of the following warning signs.
Warning signs A= S= H= Y= Abnormal heavy bleeding Stroke and heart disease (chest pain with dyspnoea) Headache (severe) Yellow colour of eyes (jaundice) Helping Clients at Any Return Visit „ Ask if the client has any questions or anything to discuss.

„ Ask the client about her experience with the method, whether she is satisfied, and whether she has any problems.

Give her any information or help that she needs and invite her to return again at any time she has questions or concerns.
If she has problems that cannot be resolved, help her choose another suitable contraceptive method.

Plan for Next Visit „ Encourage her to come back for more pills before she uses up her supply of pills.
Minimum Record Maintain the following record for follow-up of the client: „ Daily register „ Client record card „ Client card, to be given to the client with information such as: „ Name, age and registration number „ Type of POP given „ Date for follow-up visit Update records at each visit including details of complaints, side effects, and treatment given.

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