11/13/24, 8\:19 PM Guide | POP counselling

POP counselling

Table of contents

Introduction

Contraceptive counselling often features in OSCEs, and it’s important to be familiar with the various methods of
contraception available.
This article focuses on counselling patients about the progestogen only pill (POP, also referred to as the "mini-pill"), including
the common questions patients ask, the information you'll be expected to give and how best to structure the consultation.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain the reason for the consultation\:
t h a t c o r r e c t ?”
.
“ I u n d e r s t a n d y o u a r e i n t e r e s t e d i n u s i n g t h e p r o ge s t o ge n-o n l y p i l l f o r c o n t r a c e p t i o n . I s
It is important to establish a good rapport and an open line of communication with the patient early in the consultation\:
h a v e a n y q u e s t i o n s a t a n y p o i n t , o r i f s o m e t h i n g i s n o t c l e a r , p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e .
”
“ I f y o u
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to
ask questions (this is often referred to as ‘chunking and checking’).

Ideas, concerns & expectations

A key component of contraceptive counselling involves exploring a patient’s ideas, concerns and expectations (often referred
to as ICE).
In a contraceptive consultation, it is important to explore ICE, as many patients will have researched or have prior experience
with contraceptive methods. This will help you tailor the consultation and the advice you give regarding speci
important to identify any patient concerns and expectations early in the consultation, as this may a
method and subsequent contraceptive e
It can sometimes be challenging to use the ICE structure in a way that sounds natural in your contraceptive consultation, but
we have provided some examples for each of the three areas below.

Ideas

Explore what the patient currently understands about the POP\:
“ H a v e y o u h e a r d o f t h e p r o g e s t o g e n-o n l y p i l l ?”
“ W h a t d o y o u a l r e a d y k n o w a b o u t t h e p r o g e s t o g e n-o n l y p i l l ?”

Concerns

Ask if the patient has any concerns about the POP\:
“ I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t t a k i n g t h e p r o ge s t o ge n-o n l y p i l l ?”

Expectations

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Explore the patient’s expectations of the POP\:
" W h a t f a c t o r s i n
" W h a t a r e y o u h o p i n g t h e p r o g e s t o ge n-o n l y p i l l c a n d o f o r y o u ?"

Eligibility

Before starting any method of contraception, it is vital to check the patient's eligibility and for any contraindications.
The Faculty of Sexual and Reproductive Health (FSRH) produce the UK Medical Eligibility Criteria for Contraceptive Use
(UKMEC) which guides clinicians on the safety of di
characteristics and medical co-morbidities\:
UKMEC 1\: no restriction
UKMEC 2\: bene
UKMEC 3\: theoretical or proven risk generally outweighs the bene
UKMEC 4\: contra-indicated
Note\: Drospirenone is not currently included in the UKMEC.

UKMEC 4 criteria

UKMEC 4 criteria for the POP include\:
Current breast cancer

UKMEC 3 criteria

UKMEC 3 criteria for the POP include\:
Severe decompensated cirrhosis
Benign hepatocellular adenoma
Malignant hepatocellular carcinoma
Past history of breast cancer
If a patient is pregnant, this is also a contraindication to starting contraception. This means that you should be ‘reasonably
certain’ that individuals are not pregnant before starting any contraception.
This is particularly important for the POP as it may cause amenorrhoea, which could mask a developing pregnancy (patients
may think their amenorrhea is due to the POP, rather than considering pregnancy).

What is the POP?

Using patient-friendly language, explain that the progestogen-only pill contains progestogen, a synthetic version of the
hormone progesterone. The progestogen-only pill must be taken every day.
Example
“ T h e p r o g e s t o g e n-o n l y p i l l , i s a t y p e o f c o n t r a c e p t i v e p i l l t h a t c o n t a i n s a h o r m o n e c a l l e d p r o ge s t o g e n w h i c h i s s i m i l a r t o
y o u r b o d y' s n a t u r a l h o r m o n e p r o g e s t e r o n e . T h e p i l l n e e d s t o b e t a k e n e v e r y d a y .
”

How e

When counselling patients regarding contraception, it is very important to explain how e
any factors which may impact e
Explain to the patient that the e
With perfect use, the pill is around 99% e
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Factors that reduce the e
Drug interactions (notably cytochrome P-450 inducers reduce POP e
Missed/late pills
Vomiting and/or diarrhoea
Bariatric surgery\: there are theoretical concerns that both malabsorptive and restrictive bariatric procedures could decrease
the absorption of oral contraceptives
Other conditions causing malabsorption (e.g. small bowel resection)
With typical use, the pill is less e
contraceptive implant.
Example
“ W h i l s t t h e p r o g e s t o g e n-o n l y p i l l c a n b e v e r y e
w o m e n u s i n g i t b e c o m e p r e g n a n t w i t h i n t h e
n i n e w o u l d b e c o m e p r e g n a n t a f t e r o n e y e a r .
”

What are the di

Explain to the patient that there are di
Desogestrel (one of the most popular types of POP, brands include Cerazette and Cerelle)
Norethisterone
Levonorgestrel
Drospirenone\: a new type of POP
Pills containing norethisterone and levonorgestrel are sometimes referred to as traditional pills.
In many cases, desogestrel is usually given as the
“pill-taking window” refers to the speci
Desogestrel\: 12-hour window
Norethisterone\: 3-hour window
Levonorgestrel\: 3-hour window
Drospirenone\: 24-hour window (but has additional restrictions)
Example
“ A l l t h e p r o g e s t o g e n-o n l y p i l l s s h o u l d b e t a k e n a t t h e s a m e t i m e e a c h d a y . T h e d e s o ge s t r e l p i l l ( e .g C e r a z e t t e / C e r e l l e )
h a s a 1 2-h o u r w i n d o w p e r i o d . T h i s m e a n s , i f y o u n o r m a l l y t a k e t h e p i l l a t 8 a m , y o u h a v e u n t i l 8 p m t o r e m e m b e r t o t a k e i t .
A f t e r t h i s , i t i s c l a s s e d a s a m i s s e d p i l l a n d y o u m a y n e e d e m e r g e n c y c o n t r a c e p t i o n”

How does the POP work?

The progestogen-only pill has two main modes of action\:
Thickening the cervical mucus (to prevent sperm from entering the uterus)
Suppression of ovulation.
There are additional minor modes of action, including endometrial changes and reduced fallopian tube cilial activity.
The di
to be (see above)\:
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The main mode of action of norethisterone and levonorgestrel is the cervical mucus e
taken within 3 hours of the same time each day
The main mode of action of desogestrel is suppression of ovulation, which means it must be taken within 12 hours of the
same time each day
Example
“ A s w e’ v e d i s c u s s e d , t h e P O P i s a v e r y e
w i l l w o r k s l i g h t l y d i
( c e r v i x ) t o p r e v e n t s p e r m f r o m e n t e r i n g t h e w o m b a n d r e a c h i n g a n e g g. S e c o n d l y \: I t p r e v e n t s y o u f r o m o v u l a t i n g a n d
r e l e a s i n g a n e g g f r o m y o u r o v a r i e s .
”

Pros and cons of the POP

When discussing contraceptive options, it is important to give the patient enough information to make an informed
decision and direct them to reputable sources of further information.
When explaining potential advantages and disadvantages, you should consider the patient’s ideas, concerns and
expectations (identi
Signposting is important to help you structure the consultation\:
“ N e x t , I’ d l i k e t o t a l k a b o u t s o m e o f t h e a d d i t i o n a l b e n e
h a v i n g t h e p r o g e s t o g e n-o n l y p i l l a n d s o m e o f t h e p o t e n t i a l d i s a d v a n t a ge s . I s t h a t o k ? .
”

Advantages of the POP

Advantages of the POP include\:
Non-invasive method
E
Problems associated with periods (heavy or painful periods) can improve
Useful when oestrogens are contraindicated
Safe during breastfeeding
Easily reversible
Example
“ T h e P O P i s a n e
T h e P O P i s a l s o a u s e f u l o p t i o n f o r w o m e n w h o c a n n o t t a k e o e s t r o g e n . – w h e n y o u s t o p t a k i n g i t , y o u r f e r t i l i t y w i l l r e t u r n .
”
I t i s n o n-i n v a s i v e . S o m e w o m e n a l s o
I t i s s a f e w h e n b r e a s t f e e d i n g, a n d e a s i l y r e v e r s i b l e

Disadvantages of the POP

Potential disadvantages of the POP include\:
User dependent\: e
Irregular bleeding (this is the most common reason given for stopping the POP)
Does not protect against sexually transmitted infections
Possible association with a small increased risk of breast cancer
Side e
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Example
“ A s w e’ v e d i s c u s s e d t h e P O P c a n b e a v e r y e
y o u t a k e i t . T o b e 9 9 % e
”
“ W h e n t a k i n g t h e P O P , y o u r p e r i o d s m a y c h a n ge , y o u m a y e x p e r i e n c e i r r e gu l a r , p e r i o d s c o u l d a l s o s t o p c o m p l e t e l y .
”
l i g h t o r m o r e f r e q u e n t p e r i o d s . Y o u r
“ O n l y c o n d o m s w i l l p r o t e c t a g a i n s t s e x u a l l y t r a n s m i t t e d i n f e c t i o n s . T h e r e f o r e , w e w o u l d a d v i s e u s i n g c o n d o m s a l o n gs i d e
t h e P O P .
”
“ S o m e w o m e n m a y e x p e r i e n c e s i d e e
”
h e a d a c h e s a n d b r e a s t t e n d e r n e s s w i t h t h e P O P . H o w e v e r ,

Starting the pill and missed pills

This section of the consultation can be confusing for the patient. It is important to explain this in a patient-friendly manner,
check understanding at regular intervals and invite questions at the end.

Starting the POP

The POP can be started without the need for additional contraceptive cover (e.g. condoms) at any of the following times\:
Up to day 5 of a natural cycle
Up to 5 days after
Up to 21 days postpartum
Starting a POP at any other time will require forty-eight hours of extra contraceptive precautions.
Example
“ Y o u c a n s t a r t t h e p r o g e s t o g e n-o n l y p i l l a t a n y t i m e i n y o u r m e n s t r u a l c y c l e .
”
“ I f y o u s t a r t i t o n d a y 1 t o 5 o f y o u r m e n s t r u a l c y c l e ( t h e
”
i t’ l l w o r k s t r a i gh t a w a y a n d y o u’ l l b e
“ I f y o u s t a r t t h e p r o g e s t o g e n-o n l y p i l l o n a n y o t h e r d a y o f y o u r c y c l e , y o u w i l l n o t b e p r o t e c t e d f r o m p r e gn a n c y s t r a i gh t
a w a y a n d w i l l n e e d a d d i t i o n a l c o n t r a c e p t i o n , s u c h a s c o n d o m s , u n t i l y o u’ v e t a k e n t h e p i l l f o r 2 d a y s .
”
"Quick starting" the POP
In some cases, it may not be possible to completely rule out a very early pregnancy, but you may still consider initiating
contraception. It is important to remember that a pregnancy test will not be reliable until at least 21 days after the last episode
of unprotected sexual intercourse (UPSI).
If a pregnancy test is negative but there has been UPSI within the last 21 days, and there is an ongoing risk of pregnancy, you
can ‘quick start’ the POP. However, the POP will require 2 days to become e
pregnancy test 21 days after the POP has become e
If the pregnancy test is positive, the patient must stop taking the POP. Current evidence does not suggest that the POP poses
any harm to a developing fetus, but obviously, it needs to be stopped!

Missed pills

The missed pill guidance depends on the type of POP being taken\:
Desogestrel\: a missed pill is de
Levonorgestrel and norethisterone\: a missed pill is de
the last pill)
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If a patient misses a pill, they should take it as soon as they remember. This may mean they take two pills in one day. They
should use additional contraceptive cover for two days.
If a patient vomits or has severe diarrhoea within 2 hours (3-4 hours if desogestrel) of taking their POP, another pill should be
taken as soon as possible. If the subsequent pill is more than 3 hours (12 if desogestrel), or if vomiting continues, then missed
pill rules apply.
Example
“ W h e n y o u r e a l i s e y o u h a v e m i s s e d a p i l l , t a k e t h e m i s s e d p i l l s t r a i gh t a w a y . T h e n e x t p i l l s h o u l d b e t a k e n a t t h e u s u a l
t i m e . T h i s m a y m e a n t w o p i l l s a r e t a k e n i n o n e d a y .
”
“ A d d i t i o n a l c o n t r a c e p t i v e p r e c a u t i o n s , s u c h a s c o n d o m s , s h o u l d b e u s e d f o r t h e n e x t t w o d a y s”
“ Y o u w i l l n e e d t o s e e k a d v i c e o n e m e r ge n c y c o n t r a c e p t i o n i f u n p r o t e c t e d s e x u a l i n t e r c o u r s e h a s o c c u r r e d a f t e r t h e
m i s s e d p i l l a n d w i t h i n 4 8 h o u r s o f r e s t a r t i n g t h e P O P .
”

Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the
consultation.
Ask the patient if they have any further questions or concerns that haven’t been addressed.
Finally, thank the patient for their time and o
only pill.
Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Ashley Je
Community Sexual and Reproductive Health Registrar

References

1. FSRH. Progestogen-only Pills. 2022. Available from\: [LINK]
2. FSRH. UKMEC April 2016 Summary Sheet. 2019. Available from\: [LINK]
Source\: geekymedics.com
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