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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

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When a pill has been missed for more than the 3h window (12h with Cerazette
^®) advise the woman to take the missed pill as soon as she remembers it and to continue with her normal pill-taking routine.
Only the
last
missed pill should be taken, if she has missed more than one.
Additional barrier protection should be used if any sexual contact occurs in the next 48h, e.g. male condom.
Additional emergency contraception may be used, particularly if more than one pill has been missed (b see Emergency contraception,
p. 572).
Follow-up
Normally, the first prescription is for 3 months, with an appointment to return to clinic in 8–10 weeks for review.
Unless there any menstrual irregularities or other side-effects are evident, follow-up and repeat prescription is then 6–12 months, dependent on local policy.
Check blood pressure and personal and family medical history annually, to check for any significant changes that may signal caution or discontinuation of this method of contraception, which is rare.
Points to remember
2 There is only a 3h ‘window’ during which a pill may be taken late, but still be ‘safe’. If more than 3h late, this must be classed as a missed pill. The exception to this rule is Cerazette
^®, which has a 12h window.
If a breastfeeding mother requires hormonal contraception, the POP is ideal.
The POP is highly effective if taken regularly each day, without any missed pills or breaks.
In women >30 it is almost as effective as the combined pill.
A useful tip for an effective pill-taking regimen is to ask the woman to make a note of the day she started the pill for the first time: that is the day she will always start a new pack.
2 There are no pill-free days. The next pack must be started immediately.
She should make a note of the new pack start date. Again, a paper diary, electronic diary, or mobile phone calendar and alarm can be used.
Following birth
Ideally the POP should not be started until at least 21 days after birth, to allow the body to recover physiologically from birth. However, there are some women for whom the risk of further pregnancy is high and who need highly effective contraception. In this case, refer the woman to the Contraception and Sexual Health Clinic for appropriate management.
If the POP is started while the mother still has a vaginal blood loss, it will cause bleeding to become heavier and more prolonged. Be aware of this and also warn the mother.
CHAPTER 22
Contraception
540
- The POP is a better choice than a combined oral contraceptive in a mother who has reduced mobility following birth, e.g. after caesarean section, because of the increased thrombo-embolic risk.
  Antibiotic therapy
  Any period of antibiotic therapy will not affect the uptake of this pill and the woman should continue to take it as normal. No additional barrier protection is required.
  Antiretroviral therapy
  HIV positive women on antiretroviral therapy should be advised to use consistent additional barrier contraception.
  Nausea and vomiting
  If the woman vomits within 3h of taking the pill, she may not have absorbed a sufficient amount of the pill for it to be effective. In this case, a condom should also be used for every act of sexual intercourse for the duration of the episode of illness involving vomiting and for the next 7 days, to allow the contraceptive effect to return. If she does not follow this advice, additional emergency contraception may be required (b see Emergency contraception, p. 572).
  Drug interactions and the pill
  Certain drugs
  may
  inhibit absorption or reduce the effectiveness of the
  POP, so it is imperative to check whether or not the woman is taking any other medication when discussing possible use of the pill. However, it is very unusual to find a drug that will inhibit the POP uptake and effectiveness.
  1
  Guillebaud J (2008).
  Contraception Today
  , 6th edn. London: Taylor and Francis.
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  CHAPTER 22
  Contraception
  542‌‌
  Implant
  Known as Nexplanon
  ^®in the UK (Implanon
  ^®previously available). The contraceptive implant offers 3 years’ contraception, being most effective in the first 2 years.
  Content
  The implant is a single rate-limiting polymer capsule, 4cm long and 2mm in diameter, containing 68mg etonogestrel, which is released at over 30micrograms/day to inhibit ovulation.
  Benefits
- Long-term effective contraception. Zero failure rate in initial clinical trials.
- One insertion.
- No daily pill-taking regime.
- Non-intercourse related.
  Mode of action
- The subdermal implant is inserted into the under side of the upper arm by a doctor, midwife, or nurse trained and competent in the technique (Fig. 22.4).
  •
  The hormone is released directly into the surrounding interstitial tissue and absorbed by capillaries into the bloodstream.
- Ovulation is suppressed at the level of the hypothalamus, therefore the luteal phase of the menstrual cycle is deficient, preventing implantation, should ovulation and fertilization occur.
  Insertion
- Insertion is a minor surgical procedure under local anaesthesia.
- The preloaded single-capsule system is contained within a sterile, disposable applicator and is an easy and rapid subdermal injection technique.
- The implant should be inserted at the beginning of the menstrual cycle, ideally on day 1. If inserted on day 1, the serum etonogestrel levels will be sufficient for ovulation inhibition within the first day and no further contraception will be required in that cycle.
- If inserted on the 2nd day or later, then it is important to recommend 7 days extra barrier contraception, if sexual intercourse occurs within this period.
  Points to remember
- Following first trimester abortion, the implant can be inserted immediately.
- Following second trimester abortion, it is wise to wait 21 days before insertion, because of the side-effect of prolonged or heavy bleeding.
- After giving birth, again it is wise to wait 21 days, for the above reason.
- At any time, it is important to remember that for some women the risk of repeated pregnancy is greater than the risk of early insertion.
  IMPLANT
  Fig. 22.4
  Implanon
  ^®capsule showing position in arm. © Family Planning Association 2009, reprinted by permission of the publisher.
  543