Progestin-Only Pills

Progestin Only Pills

This chapter focuses on progestin-only pills for breastfeeding women. Women who are not breastfeeding also can use progestin-only pills. Guidance that differs for women who are not breastfeeding is noted.

Key Points for Providers and Clients

• Take one pill every day. No breaks between packs.
• Safe for breastfeeding women and their babies. Progestin- only pills do not affect milk production.
• Add to the contraceptive effect of breastfeeding. Together, they provide effective pregnancy protection.
• Bleeding changes are common but not harmful. Typically, pills lengthen how long breastfeeding women have no monthly bleeding. For women having monthly bleeding, frequent or irregular bleeding is common.
• Can be given to a woman at any time to start later. If pregnancy cannot be ruled out, a provider can give her pills to take later, when her monthly bleeding begins.

Progestin Only Pills

What Are Progestin-Only Pills?
• Pills that contain very low doses of a progestin like the natural hormone progesterone in a woman’s body.
• Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen.
• Progestin-only pills (POPs) are also called “minipills” and progestin-only oral contraceptives.
• Work primarily by:
— Thickening cervical mucus (this blocks sperm from meeting an egg)
— Disrupting the menstrual cycle, including preventing the release of eggs from the ovaries (ovulation)

How Effective?

Effectiveness depends on the user: For women who have monthly bleeding, risk of pregnancy is greatest if pills are taken late or missed completely.

Breastfeeding women:
• As commonly used, about I pregnancy per 100 women using POPs over the first year. This means that 99 of every 100 women will not become pregnant.
• When pills are taken every day, less than I pregnancy per 100 women using POPs over the first year (3 per 1,000 women).

Less effective for women not breastfeeding:
• As commonly used, about 3 to 10 pregnancies per 100 women using POPs over the first year. This means that 90 to 97 of every 100 women will not become pregnant.
• When pills are taken every day at the same time, less than I pregnancy per 100 women using POPs over the first year (9 per 1,000 women).

Return of fertility after POPs are stopped: No delay
Protection against sexually transmitted infections (STIs): None

Why Some Women Say They Like Progestin-Only Pills

• Can be used while breastfeeding
• Can be stopped at any time without a provider’s help
• Do not interfere with sex
• Are controlled by the woman

Side Effects, Health Benefits, and Health Risks

Some users report the following:
• Changes in bleeding patterns including:
– For breastfeeding women, longer delay in return of monthly bleeding after childbirth (lengthened postpartum amenorrhea)
– Frequent bleeding
– Irregular bleeding
– Infrequent bleeding
– Prolonged bleeding
– No monthly bleeding

Breastfeeding also affects a woman’s bleeding patterns.
• Headaches
• Dizziness
• Mood changes
• Breast tenderness
• Abdominal pain
• Nausea

Other possible physical changes:
• For women not breastfeeding, enlarged ovarian follicles

Known Health Benefits
Help protect against:
• Risks of pregnancy

Known Health Risks
None

Correcting Misunderstandings

Progestin-only pills:
• Do not cause a breastfeeding women’s milk to dry up.
• Must be taken every day, whether or not a women has sex that day.
• Do not make women infertile.
• Do not cause dirrhea in breastfeeding babies.
• Reduce the risk of ectopic pregnancy.

Who Can and Cannot Use Progestin-Only Pills

Safe and Suitable for Nearly All Women

Nearly all women can use POPs safely and effectively, including women who:
• Are breastfeeding (starting as soon as 6 weeks after childbirth)
• Have or have not had children
• Are not married
• Are of any age, including adolescents and women over 40 years old
• Have just had an abortion, miscarriage, or ectopic pregnancy
• Smoke cigarettes, regardless of woman’s age or number of cigarettes smoked
• Have anemia now or had in the past
• Have varicose veins
• Are infected with HIV, whether or not on antiretroviral therapy.

Women can begin using POPs:
• Without a pelvic examination
• Without any blood tests or other routine laboratory tests
• Without cervical cancer screening
• Without a breast examination
• Even when a woman is not having monthly bleeding at the time, if it is reasonably certain she is not pregnant.

Medical Eligibility Criteria for
Progestin-Only Pills

Ask the client the questions below about known medical conditions. Examinations and tests are not necessary. If she answers “no” to all of the questions, then she can start POPs if she wants. If she answers “yes” to a question, follow the instructions. In some cases she can still start POPs.

1. Are you breastfeeding a baby less than 6 weeks old?

□ NO □ YES She can start taking POPs as soon as 6 weeks after childbirth. Give her POPs now and tell her when to start taking them .

2. Do you have severe cirrhosis of the liver, a liver infection, or liver tumor? (Are her eyes or skin unusually yellow? [signs of jaundice])

□ NO □ YES If she reports serious active liver disease (jaundice, active hepatitis, severe cirrhosis, liver tumor), do not provide POPs. Help her choose a method without hormones.

3. Do you have a serious problem now with a blood clot in your legs or lungs?

□ NO □ YES If she reports a current blood clot (not superficial clots), do not provide POPs. Help her choose a method without hormones.

4. Are you taking medication for seizures? Are you taking rifampicin for tuberculosis or other illness?

□ NO □ YES If she is taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, or rifampicin, do not provide POPs. They can make POPs less effective. Help her choose another method but not combined oral contraceptives or implants.

5. Do you have or have you ever had breast cancer?

□ NO □ YES Do not provide POPs. Help her choose a method without hormones.

Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable, when relevant to the client.

Using Clinical Judgment in Special Cases

Usually, a woman with any of the conditions listed below should not use POPs. In special circumstances, however, when other, more appropriate methods are not available or acceptable to her, a qualified provider who can carefully assess a specific woman’s condition and situation may decide that she can use POPs. The provider needs to consider the severity of her condition and, for most conditions, whether she will have access to follow-up.

• Breastfeeding and less than 6 weeks since giving birth
• Current blood clot in deep veins of legs or lungs
• Had breast cancer more than 5 years ago, and it has not returned
• Severe liver disease, infection, or tumor
• Taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramace, or rifampicin. A backup contraceptive method should also be used because these medications reduce the effectiveness of POPs.

Progestin-Only Pills for Women With HIV

• Women who are infected with HIV, have AIDS, or are on antiretroviral (ARV) therapy can safely use POPs.
• Urge these women to use condoms along with POPs. Used consistently and correctly, condoms help prevent transmission of HIV and other STIs. Condoms also provide extra contraceptive protection for women on ARV therapy. It is not certain whether ARV medications reduce the effectiveness of POPs.
• For appropriate breastfeeding practices for women with HIV.

Providing Progestin-Only Pills

When to Start

IMPORTANT: A woman can start using POPs any time she wants if it is reasonably certain she is not pregnant. To be reasonably certain she is not pregnant. Also, a woman can be given POPs at any time and told when to start taking them.

 
Woman’s situation When to start
Fully or nearly fully breastfeeding
Less than 6 months after giving birth
• If she gave birth less than 6 weeks ago, give her POPs and tell her to start taking them 6 weeks after giving birth.• If her monthly bleeding has not returned, she can start POPs any time between 6 weeks and 6 months. No need for a backup method.

• If her monthly bleeding has returned, she can start POPs as advised for women having menstrual cycles.

More than 6 months after giving birth • If her monthly bleeding has not returned, she can start POPs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 2 days of taking pills. (If you cannot be reasonably certain, give her POPs now and tell her to start taking them during her next monthly bleeding.)• If her monthly bleeding has returned, she can start POPs as advised for women having menstrual cycles.
Partially breastfeeding
Less than 6 weeks after giving birth
• Give her POPs and tell her to start taking them 6 weeks after giving birth.• Also give her a backup method to use until 6 weeks since giving birth if her monthly bleeding returns before this time.
Partially breastfeeding
More than 6 weeks after giving birth
• If her monthly bleeding has not returned, she can start POPs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 2 days of taking pills. (If you cannot be reasonably certain, give her POPs now and tell her to start taking them during her next monthly bleeding.)• If her monthly bleeding has returned, she can start POPs as advised for women having menstrual cycles.
Not breastfeeding
Less than 4 weeks after giving birth
• She can start POPs at any time. No need for a backup method.
Not breastfeeding
More than 4 weeks after giving birth
• If her monthly bleeding has not returned, she can start POPs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 2 days of taking pills. (If you cannot be reasonably certain, give her POPs now and tell her to start taking them during her next monthly bleeding.)• If her monthly bleeding has returned, she can start POPs as advised for women having menstrual cycles.
Switching from a hormonal method • Immediately, if she has been using the hormonalmethod consistently and correctly or if it is otherwise reasonably certain she is not pregnant. No need to wait for her next monthly bleeding. No need for a backup method.• If she is switching from injectables, she can begin taking POPs when the repeat injection would have been given. No need for a backup method.
Having menstrual cycles or switching from a nonhormonal method Any time of the month• If she is starting within 5 days after the start of her monthly bleeding, no need for a backup method.

• If it is more than 5 days after the start of her monthly bleeding, she can start POPs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 2 days of taking pills. (If you cannot be reasonably certain, give her POPs now and tell her to start taking them during her next monthly bleeding.)

• If she is switching from an IUD, she can start POPs immediately.

No monthly bleeding (not related to childbirth or breastfeeding) • She can start POPs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 2 days of taking pills.
After miscarriage or abortion • Immediately. If she is starting within 7 days after first- or second-trimester miscarriage or abortion, no need for a backup method.• If it is more than 7 days after first- or second- trimester miscarriage or abortion, she can start POPs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 2 days of taking pills. (If you cannot be reasonably certain, give her POPs now and tell her to start taking them during her next monthly bleeding.)
After taking emergency contraceptive pills (ECPs) • She can start POPs the day after she finishes taking the ECPs. There is no need to wait for her next monthly bleeding to start her pills.
– A new POP user should begin a new pill pack.
– A continuing user who needed ECPs due to pill-taking errors can continue where she left off with her current pack.
– All women will need to use a backup method for the first 2 days of taking pills.

Giving Advice on Side Effects

IMPORTANT: Thorough counseling about bleeding changes and other side effects is an important part of providing the method. Counseling about bleeding changes may be the most important help a woman needs to keep using the method.

Describe the most common side effects
• Breastfeeding women normally do not have monthly bleeding for several months after giving birth. POPs lengthen this period of time.
• Women who are not breastfeeding may have frequent or irregular bleeding for the first several months, followed by regular bleeding or continued irregular bleeding.
• Headaches, dizziness, breast tenderness, and possibly other side effects.

Explain about these side effects
• Side effects are not signs of illness.
• Usually become less or stop within the first few months of using POPs. Bleeding changes, however, usually persist.
• Common, but some women do not have them.

Explain what to do in case of side effects
• Keep taking POPs. Skipping pills risks pregnancy.
• Try taking pills with food or at bedtime to help avoid nausea.
• The client can come back for help if side effects bother her.

Explaining How to Use

1. Give pills
• Give as many packs as possible—even as much as a year’s supply (11 or 13 packs).

2. Explain pill pack
• Show which kind of pack—28 pills or 35 pills.
• Explain that all pills in POP packs are the same color and all are active pills, containing a hormone that prevents pregnancy.
• Show how to take the first pill from the pack and then how to follow the directions or arrows on the pack to take the rest of the pills.

3. Give key instruction
• Take one pill each day— until the pack is empty.
• Discuss cues for taking a pill every day. Linking pill-taking to a daily activity—such as cleaning her teeth— may help her remember.
• Taking pills at the same time each day helps to remember them.

4. Explain starting next pack
• When she finishes one pack, she should take the first pill from the next pack on the very next day.
• It is very important to start the next pack on time. Starting a pack late risks pregnancy.

5. Provide backup method and explain use
• Sometimes she may need to use a backup method, such as when she misses pills.
• Backup methods include abstinence, male or female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptive methods. Give her condoms, if possible.

6. Explain that effectiveness decreases when breastfeeding stops
• Without the additional protection of breastfeeding itself, POPs are not as effective as most other hormonal methods.
• When she stops breastfeeding, she can continue taking POPs if she is satisfied with the method, or she is welcome to come back for another method.

Supporting the User

Managing Missed Pills

it is easy to forget a pill or to be late in taking it. POP users should know what to do if they forget to take pills. If a woman is 3 or more hours late taking a pill or misses one completely, she should follow the instructions below. For , breastfeeding women, whether missing a pill places  her at risk of pregnancy depends on whether or not her monthly bleeding has returned.

Making Up Missed Progestin-Only Pills

Key message
• Take a missed pill as soon as possible.
• Keep taking pills as usual, one each day. (She may take 2 pills at the same time or on the same day.)

Do you have monthly bleeding regularly?
• If yes, she also should use a backup method for the next 2 days.
• Also, if she had sex in the past 5 days, can consider taking ECPs .

Severe vomiting or diarrhea
• If she vomits within 2 hours after taking a pill, she should take another pill from her pack as soon as possible, and keep taking pills as usual.
• If her vomiting or diarrhea continues, follow the instructions for making up missed pills above.

“Come Back Any Time”: Reasons to Return

Assure every client that she is welcome to come back any time—for example, if she has problems, questions, or wants another method; she has a major change in health status; or she thinks she might be pregnant. Also if:

• She has stopped breastfeeding and wants to switch to another method.
• For a woman who has monthly bleeding: If she took a pill more than 3 hours late or missed one completely, and also had sex during this time, she may wish to consider ECPs .

General health advice: Anyone who suddenly feels that something is seriously wrong with her health should immediately seek medical care from a nurse or doctor. Her contraceptive method is most likely not the cause of the condition, but she should tell the nurse or doctor what method she is using.

Planning the Next Visit

1. Encourage her to come back for more pills before she uses up her supply of pills.
2. Contacting women after the first 3 months of POP use is recommended. This offers an opportunity to answer any questions, help with any problems, and check on correct use.

Helping Continuing Users

1. Ask how the client is doing with the method and whether she is satisfied. Ask if she has any questions or anything to discuss.
2. Ask especially if she is concerned about bleeding changes. Give her any information or help that she needs.
3. Ask if she often has problems remembering to take a pill every day. If so, discuss ways to remember, making up for missed pills, and ECPs, or choosing another method.
4. Give her more pill packs—as much as a full year’s supply (11 or 13 packs), if possible. Plan her next resupply visit before she will need more pills.
5. Ask a long-term client if she has had any new health problems since her last visit. Address problems as appropriate. For new health problems that may require switching methods.
6. Ask a long-term client about major life changes that may affect her needs—particularly plans for having children and STI/HIV risk. Follow up as needed.

Managing Any Problems

Problems Reported as Side Effects or Problems With Use

May or may not be due to the method.

• Problems with side effects affect women’s satisfaction and use of POPs. They deserve the provider’s attention. If the client reports side effects or problems, listen to her concerns, give her advice, and, if appropriate, treat.

• Encourage her to keep taking a pill every day even if she has side effects. Missing pills can risk pregnancy.

• Many side effects will subside after a few months of use. For a woman whose side effects persist, give her a different POP formulation, if available, for at least 3 months.

• Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

No monthly bleeding
• Breastfeeding women:
– Reassure her that this is normal during breastfeeding. It is not harmful.

• Women not breastfeeding:
– Reassure her that some women using POPs stop having monthly bleeding, and this is not harmful. There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding.)

Irregular bleeding (bleeding at unexpected times that bothers the client)
• Reassure her that many women using POPs experience irregular bleeding—whether breastfeeding or not. Breastfeeding itself also can cause irregular bleeding. It is not harmful and sometimes becomes less or stops after the first several months of use. Some women have irregular bleeding the entire time they are taking POPs, however.

• Other possible causes of irregular bleeding include:
– Vomiting or diarrhea
– Taking anticonvulsants or rifampicin.

• To reduce irregular bleeding:
– Teach her to make up for missed pills properly, including after vomiting or diarrhea.
– For modest short-term relief she can try 800 mg ibuprofen 3 times daily after meals for 5 days or other nonsteroidal anti-inflammatory drug (NSAID), beginning when irregular bleeding starts. NSAIDs provide some relief of irregular bleeding for implants, progestin-only injectables, and IUDs, and they may also help POP users.
– If she has been taking the pills for more than a few months and NSAIDs do not help, give her a different POP formulation, if available. Ask her to try the new pills for at least 3 months.

• If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use.

Heavy or prolonged bleeding (twice as much as usual or longer than 8 days)
• Reassure her that some women using POPs experience heavy or prolonged bleeding. It is generally not harmful and usually becomes less or stops after a few months.

• For modest short-term relief she can try NSAIDs, beginning when heavy bleeding starts. Try the same treatments as for irregular bleeding.

• To help prevent anemia, suggest she take iron tablets and tell her it is important to eat foods containing iron, such as meat and poultry (especially beef and chicken liver), fish, green leafy vegetables, and legumes (beans, bean curd, lentils, and peas).

• If heavy or prolonged bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use .

Ordinary headaches (nonmigrainous)
• Suggest aspirin (325-650 mg), ibuprofen (200-400 mg), paracetamol (325-1000 mg), or other pain reliever.
• Any headaches that get worse or occur more often during POP use should be evaluated.

Mood changes or changes in sex drive
• Ask about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give her support as appropriate.

• Some women experience depression in the year after giving birth. This is not related to POPs. Clients who have serious mood changes such as major depression should be referred for care.

• Consider locally available remedies.

Breast tenderness
• Breastfeeding women:
– See Maternal and Newborn Health, Sore Breasts.
• Women not breastfeeding:
– Recommend that she wear a supportive bra (including during strenuous activity and sleep).
– Try hot or cold compresses.
– Suggest aspirin (325-650 mg), ibuprofen (200-400 mg), paracetamol (325-1000 mg), or other pain reliever.
– Consider locally available remedies.

Severe pain in lower abdomen (suspected ectopic pregnancy or enlarged ovarian follicles or cysts)
• Many conditions can cause severe abdominal pain. Be particularly alert for additional signs or symptoms of ectopic pregnancy, which is rare but can be life-threatening .

• In the early stages of ectopic pregnancy, symptoms may be absent or mild, but eventually they will become severe. A combination of these signs or symptoms should increase suspicion of ectopic pregnancy:
– Unusual abdominal pain or tenderness
– Abnormal vaginal bleeding or no monthly bleeding—especially if this is a change from her usual bleeding pattern
– Light-headedness or dizziness
– Fainting

• If ectopic pregnancy or other serious health condition is suspected, refer at once for immediate diagnosis and care.

• Abdominal pain may be due to other problems such as enlarged ovarian follicles or cysts.
– A woman can continue to use POPs during evaluation and treatment.
– There is no need to treat enlarged ovarian follicles or cysts unless they grow abnormally large, twist, or burst. Reassure the client that they usually disappear on their own. To be sure the problem is resolving, see the client again in 6 weeks, if possible.

Nausea or dizziness
• For nausea, suggest taking POPs at bedtime or with food.
• If symptoms continue, consider locally available remedies.

New Problems That May Require Switching Methods

May or may not be due to the method.
Unexplained vaginal bleeding (that suggests a medical condition not related to the method)

• Refer or evaluate by history and pelvic examination. Diagnose and treat as appropriate.
• She can continue using POPs while her condition is being evaluated.
• If bleeding is caused by a sexually transmitted infection or pelvic inflammatory disease, she can continue using POPs during treatment.

Starting treatment with anticonvulsants or rifampicin
• Barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate.and rifampicin may make POPs less effective. If using these medications long-term, she may want a different method, such as monthly injectables, progestin-only injectables, or a copper-bearing or hormonal IUD.

• If using these medications short-term, she can use a backup method along with POPs.

Migraine headaches
• If she has migraine headaches without aura, she can continue to use POPs if she wishes.
• If she has migraine aura, stop POPs. Help her choose a method without hormones.

Certain serious health conditions (suspected blood clots in deep veins of legs or lungs, liver disease, or breast cancer).
• Tell her to stop taking POPs.
• Give her a backup method to use until the condition is evaluated.
• Refer for diagnosis and care if not already under care.

Heart disease due to blocked or narrowed arteries (ischemic heart disease) or stroke
• A woman who has one of these conditions can safely start POPs. If, however, the condition develops after she starts using POPs, she should stop. Help her choose a method without hormones.

• Refer for diagnosis and care if not already under care.

Suspected pregnancy
• Assess for pregnancy, including ectopic pregnancy.
• Tell her to stop taking POPs if pregnancy is confirmed.
• There are no known risks to a fetus conceived while a woman is taking POPs.

Questions and Answers About Progestin-Oniy Pills

1. Can a woman who is breastfeeding safely use POPs?

Yes. This is a good choice for a breastfeeding mother who wants to use pills. POPs are safe for both the mother and the baby, starting as early as 6 weeks after giving birth. They do not affect milk production.

2. What should a woman do when she stops breastfeeding her baby? Can she continue taking POPs?

A woman who is satisfied with using POPs can continue using them when she has stopped breastfeeding. She is less protected from pregnancy than when breastfeeding, however. She can switch to another method if she wishes.

3. Do POPs cause birth defects? Will the fetus be harmed if a woman accidentally takes POPs while she is pregnant?

No. Good evidence shows that POPs will not cause birth defects and will not otherwise harm the fetus if a woman becomes pregnant while taking POPs or accidentally takes POPs when she is already pregnant.

4. How long does it take to become pregnant after stopping POPs?

Women who stop using POPs can become pregnant as quickly as women who stop nonhormonal methods. POPs do not delay the return of a woman’s fertility after she stops taking them. The bleeding pattern a woman had before she used POPs generally returns after she stops taking them. Some women may have to wait a few months before their usual bleeding pattern returns.

5. If a woman does not have monthly bleeding while taking POPs, does this mean that she is pregnant?

Probably not, especially if she is breastfeeding. If she has been taking her pills every day, she is probably not pregnant and can keep taking her pills, if she is still worried after being reassured, she can be offered a pregnancy test, if available, or referred for one. If not having monthly bleeding bothers her, switching to another method may help—but not to a progestin-only injectable.

6. Must the POP be taken every day?

Yes. All of the pills in the POP package contain the hormone that prevents pregnancy. If a woman does not take a pill every day— especially a woman who is not breastfeeding—she could become pregnant. (In contrast, the last 7 pills in a 28-pill pack of combined oral contraceptives are not active. They contain no hormones.)

7. Is it important for a woman to take her POPs at the same time each day?

Yes, for 2 reasons. POPs contain very little hormone, and taking a pill more than 3 hours late could reduce their effectiveness for women who are not breastfeeding. (Breastfeeding women have the additional protection from pregnancy that breastfeeding provides, so taking pills late is not as risky.) Also, taking a pill at the same time each day can help women remember to take their pills more consistently. Linking pill taking with a daily activity also helps women remember to take their pills.

8. Do POPs cause cancer?

No. Few large studies exist on POPs and cancer, but smaller studies of POPs are reassuring. Larger studies of implants have not shown any increased risk of cancer. Implants contain hormones similar to those used in POPs, and, during the first few years of implant use, at about twice the dosage.

9. Can POPs be used as emergency contraceptive pills (ECPs) after unprotected sex?

Yes. As soon as possible, but no more than 5 days after unprotected sex, a woman can take POPs as ECPs . Depending on the type of POP, she will have to take 40 to 50 pills. This is many pills, but it is safe because there is very little hormone in each pill.

10. Do POPs change women’s mood or sex drive?

Generally, no. Some women using POPs report these complaints. The great majority of POP users do not report any such changes, however, and some report that both mood and sex drive improve. It is difficult to tell whether such changes are due to the POPs or to other reasons. Providers can help a client with these problems . There is no evidence that POPs affect women’s sexual behavior.

11. What should be done if a POP user has an ovarian cyst?

The great majority of cysts are not true cysts but actually fluid-filled structures in the ovary (follicles) that continue to grow beyond the usual size in a normal menstrual cycle. They may cause some mild abdominal pain, but they only require treatment if they grow abnormally large, twist, or burst. These follicles usually go away without treatment .

12. Do POPs increase the risk of ectopic pregnancy?

No. On the contrary, POPs reduce the risk of ectopic pregnancy. Ectopic pregnancies are rare among POP users. The rate of ectopic pregnancy among women using POPs is 48 per 10,000 women per year. The rate of ectopic pregnancy among women in the United States using no contraceptive method is 65 per 10,000 women per year.

On the uncommon occasions that POPs fail and pregnancy occurs, 5 to 10 of every 100 of these pregnancies are ectopic. Thus, the great majority of pregnancies after POPs fail are not ectopic. Still, ectopic pregnancy can be life-threatening, so a provider should be aware that ectopic pregnancy is possible if POPs fail.