Missed contraceptive pills

Advice regarding missed pills depends on the preparation the woman is taking. It varies depending on whether she is taking the combined or progestogen-only pill. She will need to know what to do with the rest of her packet, whether she needs to use additional contraceptive precautions and for how long, and whether she needs emergency contraception. Patient information leaflets within the packet should give this information.

Combined oral contraceptive pills (except Qlaira® and Zoely®)¹

• If it has been 9 completed days or more since the last active pill was taken when restarting the pill after the hormone-free interval (HFI), consider emergency contraception if unprotected sexual intercourse (UPSI) has taken place during or after the HFI, and advise the woman to:
  

  • Take the missed pill as soon as possible.

  • Continue taking the remaining pills at the usual time.

  • Avoid sexual intercourse or use a barrier method of contraception (such as condoms) until 7 consecutive pills have been taken.

  • Consider a follow-up pregnancy test.

• If one pill has been missed (48 to <72 hours since the last pill in the current pack was taken) on week 1 after HFI, advise the woman:
  

  • That emergency contraception is not required if there was consistent, correct use earlier in week 1 and the 7 days prior to HFI.

  • To take the missed pill as soon as possible.

  • To continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).

  • That no additional contraceptive precautions are required if there was consistent, correct use earlier in week 1 and the 7 days prior to HFI.

• If one pill has been missed (48 to <72 hours since the last pill in the current pack was taken) on week 2 or 3 after HFI (or subsequent consecutive weeks of continuous pill-taking), advise the woman:
  

  • That emergency contraception is not required if there was consistent, correct use in the previous 7 days.

  • To take the missed pill as soon as possible.

  • To continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).

  • That no additional contraceptive precautions are required if there was consistent, correct use in the previous 7 days.

• If 2-7 pills have been missed (72 hours or more since the last pill in the current pack was taken) in week 1 after HFI, consider emergency contraception if UPSI has taken place during the HFI or week 1; advise the woman to:
  

  • Take the most recent missed pill as soon as possible.

  • Continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the most recent missed pill and the next one at the usual time).

  • Avoid sexual intercourse or use a barrier method of contraception (such as condoms) until 7 consecutive pills have been taken.

  • Consider a follow-up pregnancy test.

• If 2-7 pills have been missed (72 hours or more since the last pill in the current pack was taken) in week 2 or 3 after HFI (or subsequent consecutive weeks of continuous pill-taking), advise the woman:
  

  • That emergency contraception is not required if there was consistent, correct use in the previous 7 days.

  • To take the most recent missed pill as soon as possible. Any earlier missed pills should be ignored.

  • To continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the most recent missed pill and the next one at the usual time).

  • That if there were two or more missed pills in the 7 days prior to scheduled HFI, to omit the HFI.

  • To avoid sexual intercourse or use a barrier method of contraception (such as condoms) until 7 consecutive pills have been taken. (NB: this is overcautious, but is a back-up in case of subsequent incorrect use.)

• If more than 7 consecutive combined oral contraceptive (COC) pills have been missed in any week of pill-taking, consider emergency contraception. Advise the woman to:
  

  • Restart the COC pill as a new user.

  • Consider an immediate pregnancy test.

  • Quick start a new COC pill pack (or consider other effective contraception).

  • Avoid sexual intercourse or use a barrier method of contraception (such as condoms) until 7 consecutive pills have been taken.

  • Consider a follow-up pregnancy test.

Qlaira® and Zoely®

Missed pill advice differs from the above for Qlaira® and Zoely®.

Qlaira®²

Qlaira® is currently the only quadriphasic COC pill in the UK. It contains estradiol valerate and dienogest in 26 active tablets with sequential dose changes, followed by just two inactive tablets. The manufacturer's missed pill advice is as follows:

• If the missed pill is less than 12 hours late, the pill should be taken immediately. Further pills should be taken as usual. Emergency contraception is not needed.

• If the missed pill is more than 12 hours late, advice depends on where in the cycle it was missed:

  • Day 1-17: take the missed pill immediately and the next pill as usual. (Even if this means taking two pills on the same day. Do not take MORE than two pills on the same day.) Continue the packet. Use additional contraceptive measures (eg, condoms) or abstain from sexual intercourse for nine days.

  • Day 18-24: discard the rest of the current packet. Start the next packet immediately. Use additional contraceptive measures (eg, condoms) or abstinence for nine days.

  • Day 25-26: take the missed pill immediately and the next pill at the usual time. (Even if this means taking two pills on the same day. Do not take MORE than two pills on the same day.) Additional contraceptive precautions are not necessary.

  • Day 27-28: discard the forgotten pill, and continue taking pills in the usual way. Additional contraceptive precautions are not necessary.

• If pills have been missed and no withdrawal bleed occurs at the end of the packet, pregnancy should be excluded.

• Pregnancy and emergency contraception should be considered if more than one pill is missed.

Zoely®³

Zoely® is a monophasic COC pill containing 17-beta-estradiol and nomegestrol with 24 active tablets, and 4 inactive tablets. The manufacturer's missed pill advice is as follows:

• If the missed pill is less than 12 hours late, the pill should be taken immediately. Further pills should be taken as usual. Emergency contraception is not needed.

• If the missed pill is more than 12 hours late, the advice depends on where in the cycle it was missed:

  • Days 1-7: take the missed pill immediately and the next pill as usual (even if this means taking two pills on the same day). Continue with the rest of the packet in the normal way. Use additional contraceptive measures (eg, condoms) or abstain from sexual intercourse for seven days.

  • Days 8-17: take the missed pill immediately and the next pill as usual (even if this means taking two pills on the same day). Continue with the rest of the packet in the normal way. No extra contraceptive precautions are required as long as the seven preceding pills have been taken correctly.

  • Days 18-24: take the missed pill immediately and the next pill at the usual time (even if it means taking two tablets on the same day). Continue with the active pills in the normal way (pills are active from day 1-24 and inactive from day 25-28). Omit the inactive pills and start the next packet of pills. A withdrawal bleed is likely to be absent. OR, an alternative option is to discard the remainder of the active pills in the current pack and take the remaining four inactive pills in the normal way, then start the next packet of pills. If no withdrawal bleed occurs, the possibility of pregnancy should be considered.

  • Days 25-28: discard the missed pill and continue to the end of the packet in the normal way. Additional contraception is not necessary.

• Advise the woman that if pills have been missed and no withdrawal bleed occurs at the end of the packet, she should consider a pregnancy test.

Progestogen-only contraceptives⁴

When a woman realises she has missed a pill:

• She should take the missed pill as soon as she remembers and resume her usual pill-taking schedule - even if this means taking two pills on the same day, ie one when she remembers and the next pill on time.

• In addition, if the pill is more than three hours late (12 hours for desogestrel pills such as Cerazette®) other contraceptive precautions are required (eg, condoms) or abstinence for the next 48 hours.

• Consider emergency contraception if there was unprotected sexual intercourse 2-3 days prior to the missed pills, or there has been intercourse since the missed pill(s).