Starting Progestin Only Pills
Starting a progestin-only pill correctly decides whether the first cycles are protected. Traditional pills (levonorgestrel 30 microgram) need about 48 hours to establish cervical mucus change. Desogestrel 75 microgram and drospirenone 4 mg pills also suppress ovulation consistently, with product-specific start and backup rules.
Onset of protection. Starting on days 1 to 5 of menses gives protection without backup for traditional and desogestrel pills. Starting later needs backup for 2 days. Drospirenone starts on day 1; later starts need backup for 7 days.
Effectiveness. Typical use 9 and perfect use 0.3 pregnancies in 100 women in the first year.
Before starting. Take menstrual, obstetric, breastfeeding and medicine history and measure blood pressure. No pelvic or breast examination or laboratory test is needed. Offer an HIV test.
Pregnancy exclusion. Reasonably certain if any of: baby under 6 months, fully breastfeeding and amenorrhoeic; delivery within 21 days; no sex since the last normal period; within 5 days of menses; within 5 days of abortion; negative test with no unprotected sex for 3 weeks; consistent correct use of a reliable method. Otherwise do a sensitive urine test. Quick start with backup is acceptable after a negative test, with a repeat test when 3 weeks have passed since the last unprotected sex. Without testing, use condoms or abstain until menses.
Do not start (category 3 or 4). Current breast cancer (category 4); past breast cancer, acute deep vein thrombosis or pulmonary embolism, severe decompensated cirrhosis or liver tumour, lupus with positive or unknown antiphospholipid antibodies (category 3). Non-clinical providers do not start category 3 or 4 patients.
Interacting medicines. Rifampicin, rifabutin, phenytoin, carbamazepine, barbiturates, primidone, topiramate and oxcarbazepine make the pill category 3: choose DMPA or an intrauterine device. Efavirenz, nevirapine and ritonavir-boosted regimens are category 2: start with added condoms.
Counselling. Consent, confidentiality, absence of coercion; assent for adolescents under 18 years. Explain bleeding change, strict timing, missed-tablet rules and condoms for infection protection.
Start timing.
| Situation | Start | Backup |
|---|---|---|
| Regular menses | Days 1 to 5, preferably day 1 | None; 2 days if later (7 days for drospirenone) |
| Amenorrhoea or irregular menses | Any time if reasonably certain not pregnant | 2 days (7 days for drospirenone) |
| Fully breastfeeding and amenorrhoeic, under 6 months | From 4 weeks (earlier is category 2) | Not needed if criteria still met |
| Breastfeeding with return of menses | From 4 weeks, by the regular-menses rule | By the regular-menses rule |
| Not breastfeeding | At once or within 3 weeks | After 3 weeks without menses: exclude pregnancy, backup 2 days |
| After abortion or miscarriage | At once | None |
| From a combined or other hormonal method | At once if used correctly | None |
| From an injectable | When the repeat injection is due | None |
| From a non-hormonal method | Days 1 to 5, or later if not pregnant | 2 days if after day 5 |
| From an intrauterine device | Days 1 to 5, remove then | After day 5: keep device until next menses |
Regimens.
- Levonorgestrel 30 microgram, one tablet orally daily, same time, no break; late at 3 hours; backup 2 days.
- Desogestrel 75 microgram, one tablet orally daily, same time, no break; late at over 12 hours; backup 2 days.
- Drospirenone 4 mg, one active tablet orally daily for 24 days then 4 inactive tablets; late at over 24 hours; backup 7 days.
Instructions given at start. Take one tablet daily at the same time. Begin the next pack the day after the last tablet, with no break (for drospirenone, after the 4 inactive tablets). Missed tablet: take it at once, continue daily, use the backup stated for the product, and consider emergency contraception if unprotected sex occurred in the last 5 days. Vomiting within 2 hours: take another tablet.
Supply and follow up. Community providers start and resupply category 1 users and give up to 3 cycles at a time to category 2 users. The patient may return at any time; review for problems and at least yearly.
Expected effects. Irregular, frequent, prolonged or absent bleeding; headache; dizziness; mood change; breast tenderness; acne. These are not harmful.
Problems in early use.
- Spotting: reassure; check for vomiting, diarrhoea and interacting medicines.
- Heavy or prolonged bleeding: exclude gynaecological disease and pregnancy. Ibuprofen 400 to 800 mg orally three times daily with food for 7 to 14 days, maximum 2400 mg in 24 hours (avoid in peptic ulcer, renal impairment, severe liver disease, NSAID-sensitive asthma), or a combined oral contraceptive, one active tablet daily for 1 to 3 cycles, if oestrogen is not contraindicated and not breastfeeding under 6 months.
- Amenorrhoea: reassure; test for pregnancy if tablets were missed.
- Unacceptable symptoms: stop and offer another method.
Red flags. Severe lower abdominal pain (exclude ectopic pregnancy), calf swelling, chest pain, jaundice, breast lump, new migraine with aura.
Referral and escalation. Refer unexplained bleeding for examination and cervical screening where available. Refer pregnancy for antenatal care after stopping the pill.
