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WHO Simplifies the Missed-Pill Recommendation
Research has found that the WHO missed-pill recommendation for combined oral contraceptives (OCs) published in 2002 is too complex for many OC users to understand (11). The recommendation included detailed and differing instructions depending on the number of pills missed and when they were missed. Similar instructions from the US Food and Drug Administration (US FDA) have proved difficult to understand, as well (47). The 2004 WHO Expert Working Group simplified the missed-pill recommendation by giving one over-arching instruction to women who miss any number of combined pills1 and one additional overarching instruction to women who miss three or more hormonal pills in a row:
- A woman who misses any number of hormonal pills should take a hormonal pill as soon as possible and then continue taking one pill each day.2
- A woman who misses three or more hormonal pills in a row needs to take an additional step. She should use condoms or abstain from sex until she has taken hormonal pills for seven days in a row (see Figure 1). A woman must take hormonal OCs for seven days continuously in order to prevent ovulation reliably (40).
It is particularly important to avoid extending the gap between taking hormonal pills. Therefore, if a woman misses three or more hormonal pills during the third week of the pill pack, she should finish only the hormonal pills in that pack and then start a new pack on the next day. She should throw away all the reminder pills (see Figure 1). Also, if a woman misses three or more hormonal pills in the first week of the pill pack and has had unprotected sex, the Expert Working Group advises that she may wish to consider using emergency contraception, because the risk of pregnancy in such a case could be substantial.
In addition, since the reminder pills do not contain hormones, a woman who misses any number of reminder pills simply should throw away the missed reminder pills and continue taking one pill each day.
The 2004 Expert Working Group considered three to be the critical number of missed pills that should prompt women to take extra precautions. They based their judgment on evidence that up to nine days without hormones is not likely to lead to ovulation (12, 16, 17, 24, 25, 28, 29, 33, 34, 36, 37, 55, 57). Therefore, if a woman misses hormonal pills immediately before or after the seven-day hormone-free interval (that is, in either the third or first week of the pill pack), she could miss up to two hormonal pills—but not three—without risking pregnancy (two missed hormonal pills plus seven nonhormonal reminder pills equals nine days without hormones).
The more complex 2002 missed-pill recommendation instructed women to take extra precautions after missing two hormonal pills in a row, not three. Also, the 2002 recommendation for when to take extra precautions depended on when she missed the pills. For example, women who miss pills in the second or third week of the pill pack would have been taking hormonal pills for at least seven days previously, so they actually do not need to use additional contraception.
The 2004 guidance does not make such a distinction, however. The 2004 Expert Working Group’s advice to use condoms or abstain from sex applies to all weeks of the pill pack. The Expert Working Group decided to sacrifice some scientific precision in the interest of simpler, easier to follow guidelines.
Guidance more cautious for very low dose hormonal pills. Some combined OCs contain 20 µg or less of the estrogen ethinyl estradiol—a very low dose. If a woman misses any of these pills, WHO advises following the same rules as for other combined OCs—but with one key difference: A woman should take extra precautions after missing two hormonal pills, instead of after missing three.
1This guidance refers to combined OCs containing more than 20 µg of the estrogen ethinyl estradiol.
2 If a woman follows a pill-taking schedule that involves starting on a certain day of the week, she must throw away the missed hormonal pills if she wants to maintain her schedule.
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