04 Oct 2018

What To Do If You Miss An Oral Contraceptive Pill

What do I do if I miss my oral contraceptive pill?

This is a very common problem faced by those taking oral contraception. Even if very diligent, there will be times when a pill is missed for a variety of reasons. When a pill is missed the contraceptive efficacy is reduced. This may increase the likelihood of pregnancy if unprotected sexual intercourse takes place.  

Advice on what to do when a pill is missed is included on the medication information leaflet in your pill packet. 

If you miss pills on a regular basis, it might be worth considering alternative contraception, such as subdermal implant, patch or intrauterine system, to improve overall compliance and therefore improve efficacy. 

Missed combined oral contraceptive pills

A missed pill is a pill that is completely omitted [i.e. more than 24 hours have passed since the pill was due (48 hours since last pill taken)]. When pills are missed, the inhibitory effects on the ovaries may be reduced sufficiently for ovulation to occur and women may therefore be at risk of pregnancy.

Combined oral contraceptive pills (other than Qlaira® and Zoely®) 

If one pill is missed, anywhere in the pack (ie more than 24 and up to 48 hours late)

  • The last pill that was missed should be taken now, even if it means taking two pills in one day.
  • The rest of the pack should be taken as usual.
  • No additional contraception is needed.
  • The seven-day break is taken as normal.

Minimising the risk of pregnancy

Emergency contraception is not needed if just one pill has been missed. However, Emergency Contraception (http://myclinic.ie/conditions/contraception-emergency) should be considered if other pills have been missed recently, either earlier in the current packet, or at the end of the previous packet.

If two or more pills are missed (ie more than 48 hours late)

  • The last pill that was missed should be taken now, even if it means taking two pills in one day.
  • Any earlier missed pills should be left.
  • The rest of the pack should be taken as usual and additional precautions (eg, condoms or abstinence) should be taken for the next seven days.

The next step then depends on where in the packet the pills are missed:

In the pills are missed in the first week of a pack (pills 1-7): emergency contraception (http://myclinic.ie/conditions/contraception-emergency) should be considered if the patient had unprotected sexual intercourse in the pill-free interval or the first week of the pill packet. She should finish the packet and have the usual pill-free interval.

If the pills are missed in the second week of a pack (pills 8-14): there is no need for emergency contraception as long as the pills in the preceding week have been taken correctly. Finish the pack and the usual pill-free interval should be taken.

If the pills are missed in the third week of a pack (pills 15-21): Omit the pill free interval by finishing the pills in the current pack (or discarding any placebo tablets) and starting a new pack the next day.  

If more than seven pills are missed, the woman should start again as if starting for the first time. (Exclude pregnancy, and start a new pack on the first day of the next menstrual period.)

Missed Pills Qlaira® (2)

Quadraphsic pill

Qlaira Contraceptive Pill

If you forget to take Qlaira Contraceptive Pills 

The manufacturer’s missed pill advice is as follows:

Inactive tablets: If you miss a white tablet (2 tablets at the end of the wallet), you do not need to take it later because they do not contain any active substances. However, it is important that you discard the missed white tablet(s) to make sure that the number of days when you take inactive tablets is not increased as this would increase the risk of pregnancy. Continue with the next tablet at the usual time.

Active tablets: Depending on the day of the cycle on which one active tablet has been missed, you may need to take additional contraceptive precautions, for example a barrier method such as a condom. Take the tablets according to the following principles.

If you are less than 12 hours late when taking a tablet, the protection against pregnancy is not reduced. Take the tablet as soon as you remember and then continue taking the tablets again at the usual time.

If you are more than 12 hours late taking a tablet, the protection against pregnancy may be reduced. Depending on the day of the cycle on which one tablet has been missed, use additional contraceptive precautions e.g. a barrier method such as a condom. 

More than one tablet forgotten in this wallet – contact your doctor. You may need emergency contraception (http://myclinic.ie/conditions/contraception-emergency).

Do not take more than 2 active tablets on a given day. 

If you have forgotten to start a new wallet, or if you have missed one or more tablets during days 3 – 9 of your wallet, there is a risk that you are already pregnant (if you had unprotected sexual intercourse in the seven days before forgetting the tablet). In that case, contact your doctor. The more tablets you have forgotten (especially those on days 3 – 24) and the closer they are to the inactive tablet phase, the greater the risk that the protection from pregnancy is reduced. 

If you have forgotten any of the active tablets in a wallet, and you have no bleeding at the end of a wallet, you may be pregnant. Contact your doctor before you start the next wallet.

Missed Pills Zoely® (3)

Monophasic COCP containing 17 beta-estradiol and nomegestrol with 24 active tablets, and 4 inactive tablets

Contraceptive Pill Zoely

The manufacturer’s missed pill advice is as follows: 

The following advice only refers to missed white active tablets: If the missed pill is less than 12 hours late in taking any active tablet, contraceptive protection is not reduced. The pill should taken as soon as she remembers and should take further tablets at the usual time. If she is more than 12 hours late in taking any active tablet, contraceptive protection may be reduced.

The management of missed tablets can be guided by the following two basic rules:

7 days of uninterrupted ‘white active tablet’-taking are required to attain adequate suppression of the hypothalamic-pituitary-ovarian-axis. (ie. Prevent ovulation)

The more ‘white active tablets’ are missed and the closer the missed tablets are to the 4 yellow placebo tablets, the higher the risk of a pregnancy.

Day 1-7

The user should take the last missed tablet as soon as she remembers, even if this means taking two tablets at the same time. She then continues to take tablets at her usual time. In addition, a barrier method such as a condom should be used for the next 7 days. If unprotected sexual intercourse took place in the preceding 7 days, the possibility of a pregnancy should be considered.

Day 8-17

The user should take the last missed tablet as soon as she remembers, even if this means taking two tablets at the same time. She then continues to take tablets at her usual time. Provided that the woman has taken her tablets correctly in the 7 days preceding the first missed tablet, there is no need to use extra contraceptive precautions. However, if she has missed more than 1 tablet, the woman should be advised to use extra precautions for 7 days.

Day 18-24

The risk of reduced reliability is imminent because of the forthcoming placebo tablet phase. However, by adjusting the tablet-intake schedule, reduced contraceptive protection can still be prevented. By adhering to either of the following two options, there is therefore no need to use extra contraceptive precautions, provided that in the 7 days preceding the first missed tablet the woman has taken all tablets correctly. If this is not the case, she should follow the first of these two options and use extra precautions for the next 7 days as well.

1.The user should take the last missed tablet as soon as she remembers, even if this means taking two tablets at the same time. She then continues to take tablets at her usual time until the active tablets are used up. The 4 placebo tablets from the last row must be discarded. The next blister pack must be started right away. The user is unlikely to have a withdrawal bleed until the end of the active tablets section of the second pack, but she may experience spotting or breakthrough bleeding on tablet-taking days.

2.The woman may also be advised to discontinue active tablet-taking from the current blister pack. She should then take placebo tablets from the last row for up to 4 days, including the days she missed tablets, and subsequently continue with the next blister pack. If the woman missed tablets and subsequently has no withdrawal bleed in the placebo tablet phase, the possibility of a pregnancy should be considered. Yellow placebo tablets missed Contraceptive protection is not reduced. Yellow tablets from the last (4th) row of the blister can be disregarded. However, the missed tablets should be discarded to avoid unintentionally prolonging the placebo tablet phase.

Missed Progesterone only pills (POP) (4)

Traditional POP: (Micronor®, Noriday®, Norgeston®, Femulen®)

Non traditional POP: DESOGESTREL-ONLY (Cerazette®)

POPs should be taken at the same time every day (every 24 hours). If more than 27 hours have elapsed since the last traditional POP was taken (or more than 36 hours after a desogestrel-only pill) then the missed pill rules should be followed.

Unprotected sexual intercourse occurring before a missed or late pill is protected because the effect on cervical mucus aims to prevent sperm penetration into the upper reproductive tract.

After a missed or late pill a woman should be advised to abstain or use additional contraception such as condoms for the next 2 days (48 hours after the pill has been taken) until the effect on cervical mucus has been restored. Emergency contraception may be indicated if unprotected sexual intercourse occurs during this 48-hour period.

The short time frame (3 hours) when taking a traditional POP may be too short for some women to allow good daily pill taking. Although the desogestrel-only pill and a levonorgestrel-only pill are comparable in clinical trials, the 12-hour window with desogestrel-only pills may facilitate timely pill taking which may improve efficacy.

Problems with other combined hormonal contraception

1)Contraceptive transdermal patch (1)

Unscheduled removal of the patch

If a patch has been partially or fully detached for less than 24 hours contraceptive efficacy is maintained and no additional precautions are required. The CEU would suggest that if the patch has been worn for 7 days a patch can remain off for up to 48 hours before contraceptive efficacy is reduced. After 48 hours of being detached additional contraception would be required.

Extended use of the patch

Pharmacokinetic data suggest that there is sufficient release of norelgestromin and EE to maintain serum levels within the reference range for up to 10 days. The Summary of product characteristics indicates that a patch can be worn for up to 9 days without contraceptive efficacy being affected.  After 9 days additional precautions are required and Emergency contraception (http://myclinic.ie/conditions/contraception-emergency) may need to be considered. 

Extended patch-free interval

Guidelines advise that the patch-free interval can be extended up to 48 hours (9-day patch-free interval) with no effect on contraceptive efficacy, providing the patch was worn consistently and correctly prior to the patch-free interval.

2)Contraceptive vaginal ring (1)

Extension of the ring-free interval

A small, open-label randomised trial looked at ovarian function in 45 women assigned either to the recommended regimen or an alternative regimen. Results from this would recommend that if the ring-free interval is extended by 48 hours or more additional contraception is required. Emergency contraception may be required if sexual intercourse has occurred in the ring-free interval or Week 1. 

Useful References

http://qlaira.org/

http://zoely.org.uk/

Online Contraception Services:

MyClinic.ie offers a comprehensive online oral contraception service making it easier and more affordable for Irish women to access the contraceptive pill. For more information please visit our oral contraceptive pill page. 

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