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Referral and warning signs
When to refer
Refer if: Contraindications identified. Suspected ectopic pregnancy (severe abdominal pain, amenorrhoea +/- bleeding). Persistent, unacceptable bleeding changes. Need for alternative method due to drug interactions or side effects.
Red flags
- Symptoms suggestive of ectopic pregnancy (severe unilateral lower abdominal pain, dizziness, collapse, amenorrhoea)
- Development of known contraindications (e.g., breast cancer diagnosis)
- Severe persistent headaches (especially new onset/migraine with aura)
Signs and symptoms
- Common Side Effects: Changes in bleeding pattern (irregular bleeding, spotting, frequent bleeding, or amenorrhoea - most common reason for discontinuation), Headaches, Dizziness, Nausea, Breast tenderness, Acne.
- Warning Signs (less common than COC): Need evaluation if severe persistent headache, signs of ectopic pregnancy (if amenorrhoea followed by pain/bleeding).
Risk factors
- Contraindications (MEC Category 4): Current Breast Cancer.
- Relative Contraindications (MEC Category 3): Past breast cancer >5yrs ago, Severe liver disease (active/tumour), Malabsorptive bariatric surgery, Current/history of IHD/Stroke (initiation concern, continuation okay), SLE with positive antiphospholipid antibodies, Certain drug interactions (Rifampicin, some anticonvulsants reduce efficacy).
Diagnosis
Clinical assessment
Eligibility assessment based on medical history and MEC guidelines. Suitable option for breastfeeding women, women >35 who smoke, or those with contraindications to estrogen (e.g., VTE history, migraine with aura, certain cardiovascular risks).
Investigations
- Rule out pregnancy before starting.
- Assess for contraindications via history.
Diagnostic criteria
Client meets medical eligibility criteria for POP use.
Management
Non-pharmacological management
- Counseling: Explain mechanism (mainly mucus thickening), effectiveness (slightly less than COC, very dependent on taking it at the same time each day), how to take it strictly every day with no break, what to do if pills missed (critical window is often only 3 hours for traditional POPs, up to 12 hours for newer desogestrel POPs), common side effect of bleeding changes, lack of STI protection.
- Supply 3 cycles initially.
Pharmacological treatment
- Take one pill at the same time every day, continuously, with no pill-free interval.
- Starting: Can start any time if reasonably sure not pregnant. If starting >5 days after LMP start, use backup contraception for 2 days.
- Management of Missed Pills: If pill taken >3 hours late (or >12 hours for desogestrel POPs), take missed pill ASAP, continue subsequent pills at usual time, AND use backup contraception (e.g., condoms) for the next 2 days.
- Consider Emergency Contraception if unprotected sex occurred after the missed pill timeframe.
- Management of Side Effects:
- - Irregular Bleeding/Spotting/Amenorrhoea: Reassure this is common and usually not harmful. Rule out pregnancy/other pathology if change in pattern or heavy/prolonged bleeding occurs. NSAIDs (Ibuprofen 400-800mg TID for 5 days) may help manage troublesome irregular bleeding, but often reassurance is sufficient. Consider switching method if unacceptable.
- - Headache/Nausea/Dizziness: Often transient. Manage symptomatically. Rule out other causes.
- Drug Interactions: Reduced effectiveness with enzyme inducers (Rifampicin, some anticonvulsants - Phenytoin, Carbamazepine, Barbiturates, Topiramate; St John's Wort; some ARVs - Efavirenz, Nevirapine). Requires backup method or alternative contraceptive.
Monitoring
Follow-up visits for resupply, assess side effects/bleeding pattern, reinforce correct timing of pill taking.
Complications
- Method failure leading to unintended pregnancy (higher risk than COC if timing inconsistent).
- Ectopic pregnancy (slightly increased relative risk if pregnancy occurs, but overall absolute risk is low due to high contraceptive efficacy).
- Functional ovarian cysts (common, usually asymptomatic, resolve spontaneously).
- Problematic bleeding changes leading to discontinuation.
Prevention
- Strict adherence to taking the pill at the same time each day.
- Using backup contraception when needed (missed pills, interacting drugs).
Patient education
- Critical importance of taking pill at the exact same time every day.
- What to do if a pill is missed (backup contraception needed).
- Common side effect is change in bleeding pattern - reassure.
- Does not protect against STIs/HIV.
- Start next pack immediately after finishing one (no break).
- When to seek medical advice (warning signs, suspected pregnancy).
Uganda-specific notes
Good option for breastfeeding women and those with estrogen contraindications. Emphasis on correct timing is essential for effectiveness. Levonorgestrel and Norethisterone POPs are common.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 15, Section 15.2.4
- MOH (2016) / WHO (2020) Medical Eligibility Criteria for Contraceptive Use
(Referenced for contraindications)