Mastering UKMLA & PLAB 1: Managing a Missed Progestogen-Only Pill (POP)
This article covers a high-yield contraception question from the UKMLA and PLAB 1 exams, helping you understand the clinical guidelines for missed progestogen-only pills (POP). Timing is critical when advising patients about missed pills, and this scenario tests your ability to provide evidence-based contraceptive advice.
PLAB 1/UKMLA Exam Question: Missed Progestogen-Only Pill
Scenario:
A 25-year-old woman on the progestogen-only pill (POP) reports missing her pill yesterday. She usually takes it at 8 AM but forgot until 8 PM today (a 36-hour delay). She had unprotected intercourse yesterday evening and is unsure about what to do. She has no significant medical history and takes no medications that interact with her contraceptive.
Question:
What is the most appropriate advice?
A) Take the missed pill immediately and continue as normal
B) Take the missed pill and use additional contraception for 48 hours
C) Take emergency contraception and continue the POP
D) Discontinue the POP and start the combined oral contraceptive pill
E) No action is required as the risk of pregnancy is low
Answer with an explanation is provided below.
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Our content is updated to align with the MLA content map 〰️
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Correct Answer: B) Take the missed pill and use additional contraception for 48 hours
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Understanding the Clinical Guidelines for Missed POPs
Progestogen-only pills (POPs) require strict adherence to daily timing. A delay of more than 3 hours (or 12 hours for desogestrel-containing POPs) can reduce contraceptive effectiveness, increasing the risk of pregnancy.
Key Actions for a Missed POP:
Take the missed pill immediately (even if it means taking two pills in one day).
Use additional contraception (e.g., condoms) for the next 48 hours to allow time for contraceptive cover to be re-established.
Assess the need for emergency contraception (EC):
EC may be needed if unprotected intercourse occurred within the past 5 days.
Since this patient had unprotected intercourse within 24 hours of missing the pill, EC may be considered, but it is not always necessary.
Why "B) Take the missed pill and use additional contraception for 48 hours" is the Best Answer
Taking the missed pill maintains some contraceptive cover but does not immediately restore full efficacy.
Using additional contraception for 48 hours ensures that ovulation suppression is re-established.
Emergency contraception is not automatically required unless unprotected sex occurred in the 5 days before the missed pill (not just after).
Why the Other Options Are Incorrect
A) Take the missed pill immediately and continue as normal
❌ Incomplete advice – While taking the missed pill is correct, additional contraception for 48 hours is essential to restore protection.C) Take emergency contraception and continue the POP
❌ Not routinely required – Emergency contraception is only indicated if ovulation is likely due to multiple missed pills or intercourse in the 5 days prior to the missed dose.D) Discontinue the POP and start the combined oral contraceptive pill (COCP)
❌ Unnecessary and impractical – Switching methods would introduce a gap in contraception, requiring 7 days of extra protection before COCP becomes effective.E) No action is required as the risk of pregnancy is low
❌ Incorrect – A missed POP by more than 12 hours significantly reduces contraceptive efficacy, making additional contraception essential.
Management and Follow-Up for Missed POP
Immediate Actions:
✔ Take the missed pill as soon as possible.
✔ Use condoms or avoid intercourse for the next 48 hours.
✔ Assess the need for emergency contraception (EC) depending on the timing of unprotected intercourse and the type of POP used.
Assessing the Need for Emergency Contraception (EC):
EC is indicated if there was unprotected intercourse in the 5 days before the missed pill.
EC is not necessary if unprotected intercourse occurred after missing the pill (because the sperm would have already reached the reproductive tract before contraceptive efficacy was lost).
If EC is required, levonorgestrel (LNG) or ulipristal acetate (UPA) can be used, but UPA may delay POP restart.
Future Planning:
🔹 Educate patients on the importance of strict pill timing.
🔹 Consider long-acting reversible contraception (LARC) (e.g., implant, injection, IUD) for those with frequent missed pills.
🔹 Discuss backup contraception options, such as condoms or a reminder system to prevent future missed doses.
PLAB 1 / UKMLA Exam Tips: Key Learning Points
✔ Missed progestogen-only pills require additional contraception for 48 hours.
✔ Emergency contraception is not always needed but should be considered based on unprotected intercourse history.
✔ Timing matters: A delay of more than 3 hours (traditional POPs) or 12 hours (desogestrel POPs) reduces efficacy.
✔ Long-term solutions include discussing more reliable contraceptive options for patients prone to missing doses.
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