Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Select and use progestogen-only pills, the etonogestrel implant and injectable contraception safely, with exact timing, bleeding, interaction, bone-health and fertility-return counselling.
Progestogen-only pills thicken cervical mucus; desogestrel and drospirenone formulations also suppress ovulation more consistently than traditional POPs. They require daily use and formulation-specific timing. A traditional norethisterone or levonorgestrel pill is late after three hours, desogestrel after 12 hours and drospirenone after 24 hours. Drospirenone is supplied as 24 active tablets followed by four inactive tablets, so its missed-pill algorithm cannot be substituted for desogestrel rules. Name the product when counselling.
Quick-start rules depend on formulation. A POP started early in a natural cycle may be immediately effective; later starts generally require additional precautions for two days with traditional or desogestrel POPs and seven days with drospirenone, subject to current product guidance and switching context. Following a missed pill, establish lateness, subsequent tablets and intercourse before deciding about emergency contraception. Vomiting soon after a dose or severe diarrhoea may act like a missed tablet.
The etonogestrel implant is a single subdermal rod that suppresses ovulation and thickens mucus. The UK licence was extended in 2026 from three to five years, so use the current replacement interval and document insertion date. Effectiveness exceeds 99% and fertility returns promptly after removal. Confirm the rod is palpable immediately after insertion and teach the patient how to check its location. Deep, migrated, fractured or impalpable implants need trained assessment and imaging, not exploratory removal.
Three, 12 and 24-hour POP windows are not interchangeable; the active and inactive tablet pattern also determines what action is required.
Failure to feel both ends may reflect deep placement or migration and requires localisation before removal and assessment of contraceptive cover.
Amenorrhoea, spotting, prolonged or frequent bleeding can occur without disease, but a new concerning pattern still deserves focused assessment.
A repeat dose after its accepted interval can allow ovulation to resume, making exact administration and intercourse dates essential.
Ovulation may remain suppressed for months after the final DMPA dose, unlike the rapid fertility return after POP cessation or implant removal.
Check pregnancy, breast and liver eligibility and enzyme-inducing medicines; explain irregular bleeding, vomiting or diarrhoea advice and the need for condoms for STI prevention.
Avoid uncritical substitution of other POP rules; assess renal, hepatic and adrenal disease, medicines that raise potassium, enzyme induction, pregnancy risk and bleeding acceptability.
Confirm immediate palpability, check insertion timing and enzyme inducers, and refer deep or impalpable devices for imaging and specialist removal rather than exploring blindly.
Calling every formulation the mini-pill obscures three different late windows and can convert a correct instruction into contraceptive failure.
UK licensing changed in 2026; replacement counselling and records should use the current five-year duration rather than the historic three-year interval.
Irregular implant or POP bleeding does not itself show that ovulation has returned, although pregnancy and interactions must be assessed when relevant.
This practical difference matters when uncertain about adverse effects, fertility timing or coercion and should be explained before administration.
Its high systemic progestogen exposure remains reliable with enzyme inducers, unlike POPs and the etonogestrel implant.
Giving one missed-pill rule for traditional, desogestrel and drospirenone progestogen-only pills.
Telling patients in 2026 that the etonogestrel implant routinely expires after three years.
Attempting to remove an impalpable implant before imaging has established its location.
Treating all irregular bleeding as hormonal without checking pregnancy risk, infection features, cervical symptoms and interactions.
Omitting DMPA’s delayed fertility return or temporary bone-density effect from pre-injection counselling.
Assuming enzyme induction affects DMPA in the same way that it affects POPs and implants.
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A patient had a correctly placed etonogestrel contraceptive implant inserted two years ago and asks when it now needs routine replacement under the current UK licence. What should she be told?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Unscheduled bleeding is the commonest implant problem and does not indicate reduced effectiveness when the device is in date and no interaction exists. Explore the pattern, pregnancy risk, infection symptoms, cervical screening status and medicine changes. Explain that bleeding may be absent, infrequent, frequent or prolonged and remains unpredictable for an individual. If treatment is requested, use a guideline-supported short course selected for eligibility and preferences; removal remains available at any time.
DMPA provides high-dose ovulation suppression. Depo-Provera 150 mg IM and Sayana Press 104 mg SC are administered every 13 weeks; properly supported self-administration of the subcutaneous product may improve autonomy. Typical-use effectiveness is about 94% because late repeat doses occur. DMPA is unaffected by hepatic enzyme induction, but it cannot be removed after injection and adverse effects persist while drug levels decline.
Counselling for DMPA must include bleeding change, possible weight gain, temporary bone-mineral-density loss and delayed fertility return. Fertility may take up to one year to return to its prior level after stopping, which differs from implant and POP. Review ongoing use in adolescents and people with significant osteoporosis risk, and reassess beyond age 45 rather than imposing an arbitrary two-year maximum. Balance bone considerations against pregnancy risk and alternative acceptability.
Across all three methods, use UKMEC for breast cancer, liver disease and major comorbidity. Progestogen-only methods do not carry the same oestrogen-related VTE restrictions, but DMPA may differ from POP or implant in some cardiovascular settings. Reconcile enzyme-inducing antiseizure medicines, rifamycins and St John’s wort: these reduce POP and implant reliability, whereas DMPA and intrauterine methods remain effective. Include STI prevention and a seamless switch whenever a method is stopped.
Discuss bleeding, weight, temporary bone-density reduction, delayed fertility return and inability to reverse a dose; reassess cardiovascular and osteoporosis risks and pregnancy status when late.