Oral contraceptives can be easy to forget, but the implications of a missed pill may not be so simple.
It’s not an uncommon scenario.
The urgent phone call from a female patient who has just realised she’s missed taking her daily oral contraceptive. What should she do?
For the treating clinician dealing with this issue, it’s useful, first of all, to make the distinction between taking a pill late and missing it altogether, said sexual health physician Dr Terri Foran in a recent Women’s and Children’s Health podcast.
For the common combined oral contraceptive pill, the cut-off is 24 hours. If it is more than 24 hours since the pill should have been taken then the pill has been missed, anything less than 24 hours the dose is considered ‘late’. In progesterone-only pills the time frame is generally a lot shorter. For the most common ‘minipill’ – the cut-off is usually only three hours – after three hours the dose is considered missed.
For women taking a combined oral contraceptive, if they are late with a pill they should simply take it as soon as they realise they are late and continue to take the future pills at the usual time going forward. However, if a pill dose is missed altogether there is a risk that the hormone levels may have dropped. They should continue with the pill as normal but add another form of contraception for the next seven days. Importantly, if the woman is scheduled to have the hormone-free week within the seven days following a missed pill, she should instead continue to take active pills effectively starting a new cycle.
As Dr Foran explained, it seems counterintuitive for many patients that the riskiest time to miss a pill is in fact close to a period. Most women think they are at highest risk of accidentally falling pregnant when missing a pill mid-cycle, but this is not the case.
For women on a progesterone-only pill who miss a dose, the principle is the same but the time frame is different. As stated earlier, a delay of three hours is considered a missed pill, and in addition to take future daily doses, extra protection is advised but only for the next three days.
If a woman is assessed as being at risk of an unwanted pregnancy because of a recent missed pill, not taking the seven days of active pills, not taking extra contraception and having unprotected sex, she can take emergency contraception.
In this situation, the old-fashioned levonorgestrol emergency contraception is the recommended option as the newer EllaOne treatment has reduced effectiveness when taken with the combined oral contraceptive pill and even the progesterone-only pill.
There are two exceptions to this general advice on managing delayed and missed pills, Dr Foran added. The first is the latest progesterone-only contraceptive, Slinda which has a 24-hour window rather than the three-hour window associated with other progesterone-only options.
The second exception is the combined oral contraceptive, Qlaira which has a missed dose management plan that is very complicated as it depends on where in the cycle the pill has been missed. Dr Foran suggests women taking this particular pill read the accompanying instructions which detail the appropriate missed dose management.
In the Healthed podcast, Dr Foran along with Professor Deborah Bateson, former Medical Director of Family Planning NSW, answered questions about oral contraceptives posed by GPs as part of a recent survey involving 1000 GPs.
This article was originally published on Healthed.
Dr Linda Calabresi is an Australian-based health professional. Linda is trained as a GP (General Practitioner) and has practices located in North Ryde, Artarmon.
