Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only pills [CoSRH, 2023c].

How should I start a progestogen-only pill?

Any licensed progestogen-only pill (POP) may be used first line. Medically eligible women can be prescribed 12 12-month supply when initiating or continuing a POP. 

• In women with menstrual cycles:
  • On day 1 of the normal menstrual cycle for drospirenone, and days 1–5 for all other POPs:
    • Start the POP immediately.
    • No additional precaution is required.
    • It is advisable to check that the woman's menstrual period is typical of the woman's usual bleeding pattern in terms of duration, heaviness, and timing.
  • After day 1 of the cycle for drospirenone, and after day 5 for all other POPs, if it is reasonably certain that the woman is not pregnant:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
  • After day 1 of the cycle for drospirenone, and after day 5 for all other POPs, if there is a risk of pregnancy:
    • Consider performing a pregnancy test.
    • Assess the need for emergency contraception (EC), and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • Quick start the POP (off-label use) — delay for 5 days if ulipristal EC was given.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of unprotected sexual intercourse (UPSI).
• In women who are amenorrhoeic:
  • Perform a pregnancy test.
  • If the pregnancy test is negative and there was no UPSI in the last 21 days:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
  • If the pregnancy test is negative but there was UPSI in the last 21 days:
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • Quick start the POP (off-label use) — delay for 5 days if ulipristal EC was given.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
• In postpartum women (breastfeeding and non-breastfeeding):
  • Up to day 21 postpartum:
    • Start the POP immediately.
    • No additional precaution is required.
    • The POP can be started at any time after childbirth, including immediately after delivery.
  • After day 21 postpartum, if it is reasonably certain that the woman is not pregnant:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP unless the lactational amenorrhea method (LAM) criteria are met.
    • The LAM criteria are:
      • Fully or nearly fully breastfeeding day and night (no other liquids given or only water, juice or vitamins given infrequently in addition to breastfeeds; no long intervals between feeds day or night [for example, more than 4 hours during the day and more than 6 hours at night]).
      • Complete amenorrhoea. 
      • Less than 6 months postpartum.
  • After day 21 postpartum, if there is a risk of pregnancy: 
    • Consider performing a pregnancy test.
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • Quick start the POP (off-label use) — delay for 5 days if ulipristal EC was given.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
• In women after miscarriage, ectopic pregnancy or abortion:
  • On day 1 (after miscarriage, ectopic or abortion) for drospirenone, and days 1–5 for all other POPs:
    
    • Start the POP immediately.
    • No additional precaution is required.
    • A POP can be initiated after the first part of the medical abortion. Women should ideally start on the day or the day after a first- or second-trimester abortion.
  • After day 1 (following miscarriage, ectopic or abortion) for drospirenone, and after day 5 for all other POPs if it is reasonably certain that the woman is not pregnant:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
  • After day 1 (following miscarriage, ectopic or abortion) for drospirenone, and after day 5 for all other POPs if there is a risk of pregnancy and the woman wishes to start the POP without delay:
    • Consider performing a pregnancy test.
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • Quick start the POP (off-label use) — delay for 5 days if ulipristal EC was given.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
• If starting the POP after oral EC:
  • For levonorgestrel:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
  • For ulipristal acetate:
    • Start the POP 5 days after taking ulipristal acetate.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) until the POP is started and for 7 days after if taking drospirenone, or 2 days after for any other POP.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.

How should I switch to the progestogen-only pill from other methods of contraception?

• If switching from correctly taken combined hormonal contraception (CHC) to the progestogen-only pill (POP):
  • On days 1–2 of the hormone-free interval (HFI):
    • Start the POP immediately.
    • No additional precaution is required.
    • Day 1 is the optimal time to switch.
  • On days 3–7 of the HFI or week 1 following the HFI, if it is reasonably certain that the woman is not pregnant:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
  • On days 3–7 of the HFI or week 1 following the HFI, if unprotected sexual intercourse (UPSI) has occurred since the start of the HFI:
    • Restart or continue the CHC until 7 consecutive pills are taken after the HFI, then switch.
    • No additional precautions are required.
    • If CHC cannot be continued, start the POP immediately and consider the need for emergency contraception (EC) and a pregnancy test. See the CKS topic on Contraception - emergency for more information.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone, or 2 days if taking any other POP.
  • In weeks 2–3 (and later weeks of continuous CHC use):
    • Start the POP immediately.
    • No additional precaution is required, provided the method has been used consistently and correctly (that is, at least seven consecutive pills taken or 7 days of patch or ring use prior to switching).
    • There is evidence to suggest that taking hormonally active pills for 7 consecutive days prevents ovulation in the subsequent 7 days.
• If switching from a correctly taken POP to another POP:
  • Start the new POP at any time in the menstrual cycle.
    • If switching to drospirenone, advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days. 
    • For all other POPs, no additional precaution is required.
  • If switching from drospirenone: 
    • During HFI (placebo pills, days 25–28) or days 1–7 (active pills) after HFI and no UPSI since start of HFI — start immediately and advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • During HFI (placebo pills, days 25–28) or days 1–7 (active pills) after HFI and UPSI since start of HFI — restart/continue drospirenone until 7 consecutive pills taken then switch as for days 8–24.
    • Days 8-24 (active pills) — start immediately. No additional precautions required.
• If switching from a progestogen-only implant to a POP:
  • If the implant has been in situ for up to 3 years:
    • Remove the implant, and start the POP immediately.
    • No additional precaution is required.
  • If the implant has been in situ for more than 3 years but no longer than 4 years:
    • Perform a pregnancy test.
    • If the pregnancy test is negative and all episodes of UPSI occurred 21 days ago or longer, remove the implant and start the POP immediately. Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
    • If the pregnancy test is negative but UPSI occurred within the last 21 days, remove the implant and start the POP immediately. Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP and to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
  • If the implant has been in situ for over 4 years:
    • Perform a pregnancy test.
    • If the pregnancy test is negative and all UPSI occurred 21 days ago or longer, remove the implant and start the POP immediately. Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
    • If the pregnancy test is negative but UPSI occurred within the last 21 days, consider EC — see the CKS topic on Contraception - emergency for more information. Start the POP immediately (or after 5 days if ulipristal acetate EC was given). Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP and to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
• If switching from a progestogen-only injectable to a POP:
  • If it is 14 weeks or less since the last progestogen-only injection:
    • Start the POP immediately.
    • No additional precaution is needed.
  • If it is more than 14 weeks since the last progestogen-only injection and it is reasonably certain that the woman is not pregnant:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
  • If it is more than 14 weeks since the last progestogen-only injection and there is a risk of pregnancy: 
    • Consider the need for EC and a pregnancy test. See the CKS topic on Contraception - emergency for more information.
• If switching from a levonorgestrel intrauterine system (LNG-IUS) to a POP:
  • If there has been no UPSI in the last 7 days:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
  • If there has been UPSI in the last 7 days:
    • Start the POP immediately.
    • Retain the LNG-IUS for 7 days after last UPSI, plus advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone, or 2 days for any other POP. 
  • If a 52 mg LNG-IUS is out of date (been in situ for 6–7 years) and there has been UPSI.
    • Perform a pregnancy test.
    • If the test is negative, start the POP.
    • If the UPSI was 7 days or more ago, advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone, or 2 days for any other POP. 
    • If the UPSI was less than 7 days ago, also retain the IUS for 7 days after the last UPSI. 
    • Consider repeating the pregnancy test 21 days after UPSI.
  • If a 52 mg LNG-IUS is out of date (been in situ for over 7 years) and there has been UPSI:
    • Perform a pregnancy test.
    • If the test is negative, start POP.
    • If the UPSI was 21 days or more ago, advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone, or 2 days for any other POP.
    • If the UPSI was less than 21 days ago, also consider the need for EC, and consider retaining the IUS if UPSI was 7 days ago or less and repeat the pregnancy test 21 days after UPSI.
  • For other out of date LNG-IUS where there has been UPSI:
    • Perform a pregnancy test.
    • If the test is negative, start POP.
    • If the UPSI was 21 days or more ago, advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone, or 2 days for any other POP.
    • If the UPSI was less than 21 days ago, also consider the need for EC, and consider retaining the IUS if UPSI was 7 days ago or less and repeat the pregnancy test 21 days after UPSI.
• If switching from a copper intrauterine device (Cu-IUD) to a POP:
  • On day 1 of the cycle for drospirenone, or days 1–5 for all other POPs:
    • Remove the Cu-IUD, and start the POP immediately.
    • No additional precaution is required.
  • After day 1 of the cycle for drospirenone, or day 5 for all other POPs if there has been no UPSI in the last 7 days:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
  • After day 1 of the cycle for drospirenone, or day 5 for all other POPs if there has been UPSI in the last 7 days:
    • Start the POP immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
    • Also retain the Cu-IUD for 7 days after the last UPSI. 
• If switching from a barrier method to the POP:
  • On day 1 of the cycle for drospirenone, or days 1–5 for all other POPs:
    
    • Start the POP immediately.
    • No additional precaution is required.
  • After day 1 of the cycle for drospirenone, or day 5 for all other POPs:
    • Start the POP immediately if it is reasonably certain that the woman is not pregnant
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone or 2 days if taking any other POP.
    • If pregnancy cannot be excluded, consider the need for EC and a pregnancy test. See the CKS topic on Contraception - emergency for more information.

How can I exclude pregnancy in a woman considering using a progestogen-only pill?

• Health professionals can be ‘reasonably certain’ that a woman is not currently pregnant if any one or more of the following criteria are met and there are no symptoms or signs of pregnancy:
  • She has not had intercourse since the start of her last normal (natural) menstrual period, since childbirth, abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease.
  • She has been correctly and consistently using a reliable method of contraception.
    • For the purposes of being reasonably certain that a woman is not currently pregnant, barrier methods of contraception can be considered reliable provided they have been used consistently and correctly for every episode of intercourse.
  • She is within the first 5 days of the onset of a normal (natural) menstrual period.
  • She is less than 21 days postpartum (non-breastfeeding women).
  • She is fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
  • She is within the first 5 days after abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease.
  • She has not had intercourse for more than 21 days and has a negative high-sensitivity urine pregnancy test (able to detect human chorionic gonadotrophin [hCG] levels around 20 mIU/ml).

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only pills  [CoSRH, 2023c].The information on switching from a progestogen-only implant to a progestogen-only pill is based on the CoSRH guideline Progestogen-only implant [CoSRH, 2023b].

Bleeding patterns associated with progesterone-only pills

The College of Sexual and Reproductive Healthcare (CoSRH) recommends that people considering use of a progesterone-only pill are advised that the bleeding pattern is unpredictable, but as a guide:

• For a levonorgestrel POP, over a 3-month period ending at about 12 months of use:
  • Fewer than 1 in 10 (only about 2%) users may be amenorrhoeic.
  • About 1 in 10 users may have infrequent bleeding (1−2 bleeding/spotting episodes).
  • About 8 in 10 users may have normal frequency bleeding (3−5 bleeding/spotting episodes).
  • About 1 in 10 users may have frequent bleeding (6 or more bleeding/spotting episodes).
  • Fewer than 1 in 10 users may have prolonged bleeding (bleeding/spotting episode(s) lasting more than 14 days).
• For a desogestrel POP, over a 3-month period ending at about 12 months of use:
  • About 4 in 10 users may have normal frequency bleeding (3–5 bleeding spotting/episodes).
  • About 2–3 in 10 users may be amenorrhoeic.
  • About 3 in 10 users may have infrequent bleeding (less than 3 bleeding/spotting episodes).
  • Fewer than 1 in 10 users may have frequent bleeding (6 or more bleeding/spotting episodes).
  • About 1 in 10 DSG POP users may have prolonged bleeding (bleeding/spotting episode(s) lasting more than 14 days).
• For a drospirenone POP:
  • They may or may not have “scheduled” bleeding/spotting during the 4-day hormone-free interval (HFI), and they may or may not have “unscheduled” bleeding/spotting at other times. 
  • Both scheduled and unscheduled bleeding/spotting may reduce in frequency over the first year of use. 
  • Over a 3-month period at around 6–9 months of use:
    • The total number of days of bleeding/spotting (scheduled plus unscheduled) may be similar to the number of days of bleeding/spotting with the desogestrel POP.
    • About 2–3 in 10 users may be amenorrhoeic.
    • Fewer than 1 in 10 users may have frequent bleeding.
    • Fewer than 1 in 10 users may have bleeding episode(s) lasting more than 14 days.

[CoSRH, 2023c]

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only pills  [CoSRH, 2023c] and Problematic bleeding with hormonal contraception [CoSRH, 2015], and the Summaries of Product Characteristics (SPCs) for Norgeston Tablets [EMC, 2021], Slynd 4mg film-coated tablets [EMC, 2023], Noriday 350 microgram Tablets [EMC, 2024] and Cerelle 75 microgram film-coated tablets [EMC, 2025a].

Menstrual irregularities

• The information on change in bleeding pattern POPs is based on the CoSRH guideline on progesterone only pills [CoSRH, 2023c].
• A comparative study of desogestrel and levonorgestrel progestogen-only pills (POPs) identified by the CoSRH reported that a variable pattern of bleeding was almost twice as common in desogestrel users than levonorgestrel users in the first 90 days. Bleeding problems decreased with increasing duration of use, and by 1 year almost 50% of desogestrel users had infrequent bleeding (1–2 bleeding/spotting episodes) or amenorrhoea compared with 10% of the levonorgestrel users. The incidence of prolonged bleeding (a bleeding/spotting episode lasting for more than 14 days) and frequent bleeding amongst desogestrel users (more than 6 bleeding/spotting episodes) also decreased with increasing duration of use [CoSRH, 2023c].

Depression and mood changes

• Depression and mood changes have been listed in the manufacturers' SPCs as possible adverse effects of POPs [EMC, 2021; EMC, 2023; EMC, 2024; EMC, 2025a], but the CoSRH states that available evidence does not establish a causal association [CoSRH, 2023c].
• The SPCs state that depression can be serious and is a well-known risk factor for suicidal behaviour and suicide. Therefore, women should be advised to seek medical advice in case of mood changes and depressive symptoms, including shortly after initiating the treatment [EMC, 2021; EMC, 2023; EMC, 2024; EMC, 2025a].

Headache and migraines

• These have been listed in the manufacturers' SPCs as possible adverse effects of POPs [EMC, 2021; EMC, 2023; EMC, 2024; EMC, 2025a].
• However, the CoSRH did not identify good evidence that investigated the influence of POP use on headache incidence, and the available evidence does not suggest an increased risk of migraine associated with the use of POPs [CoSRH, 2023c].

Weight changes

• Disturbance of appetite and changes in weight have been listed in the manufacturers' SPCs as possible adverse effects of POPs [EMC, 2021; EMC, 2023; EMC, 2024; EMC, 2025a], but the available evidence does not support a causal association between POP use and weight change [CoSRH, 2023c].
• Available evidence has not shown an increased risk of pregnancy in POP users with heavier body weight or a higher body mass index (BMI). There is insufficient evidence to support a dose of more than one pill per day for women who are heavy or overweight [CoSRH, 2023c].

Loss of libido

• Decreased (or increased) libido has been listed in the manufacturers' SPCs as possible adverse effects of POPs [EMC, 2021; EMC, 2023; EMC, 2024; EMC, 2025a].
• However, the CoSRH states that studies investigating the effects of POP on libido are lacking, so a possible effect cannot be excluded. However, no association has yet been demonstrated [CoSRH, 2023c].

Liver enzyme-inducing drugs

• Drugs that induce liver enzymes include:
  • Antibiotics
    • Rifampicin (potent inducer).
    • Rifabutin.
  • Antiepileptics
    • Carbamazepine.
    • Eslicarbazepine.
    • Oxcarbazepine.
    • Phenytoin.
    • Phenobarbital.
    • Primidone.
    • Rufinamide.
    • Topiramate (weak inducer).
  • Antiretrovirals
    • Protease inhibitors: ritonavir, atazanavir, darunavir, fosamprenavir, lopinavir, nelfinavir, saquinavir, and tipranavir.
    • Non-nucleoside reverse transcriptase inhibitors: efavirenz, nevirapine.
    • Always use the HIV Drug Interaction Checker to identify potential interactions.
  • Others
    • Bosentan.
    • Modafinil.
    • Aprepitant.
    • St John's Wort.

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only pills [CoSRH, 2023c], Drug interactions with hormonal contraception [CoSRH, 2022], Emergency contraception [CoSRH, 2023d], the CoSRH statement Glucagon-like peptide-1 (GLP-1) agonists and oral contraception [CoSRH, 2025a] and the summary of product characteristics for Mounjaro KwikPen 10 mg solution for injection in pre-filled pen [EMC, 2025b].

Continuing or starting hormonal contraceptives after ulipristal acetate emergency contraception

• Previously, it was recommended that progestogen-only contraception (pill, implant, and injectable) should be quick started immediately after oral emergency contraception (EC), with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure. This remains the advice after levonorgestrel EC administration, but not for ulipristal acetate.
• Evidence from a prospective, randomized, pharmacodynamic study (n = 71) identified by the CoSRH showed that starting a desogestrel progestogen-only pill (POP) immediately after ulipristal acetate EC reduces the ability of ulipristal acetate to delay ovulation [Brache, 2015]. There are currently no studies to investigate whether this affects pregnancy rates or whether quick starting other types of hormonal contraception after ulipristal acetate has the same effect.
• Extrapolating from this evidence, the CoSRH recommends that women should wait 5 days (at least 120 hours) after taking ulipristal acetate before continuing or starting progestogen-only contraception (pill, implant, or injectable). This ensures that the ulipristal acetate is as effective as possible in preventing pregnancy resulting from the episode(s) of unprotected sexual intercourse (UPSI) for which it was taken. Importantly, there is a risk of pregnancy if further UPSI occurs before ongoing contraception is started and becomes effective.

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only pills [CoSRH, 2023c], and what CKS considers to be good clinical practice.

How should I manage unscheduled bleeding in a woman using a progestogen-only pill?

• Exclude and/or manage situations that could result in unscheduled bleeding, particularly where there is a sudden change in bleeding pattern for an established user. For example:
  
  • Sexually transmitted infections (STIs) — as a minimum, test for Chlamydia trachomatis. The risk of STIs is increased if the woman is under 25 years, has a new sexual partner, or has had more than one sexual partner in the last year. For more information, see the CKS topic on Chlamydia - uncomplicated genital.
  • Pregnancy — perform a pregnancy test.
  • Cancer (for example, cervical or endometrial cancer) — if suspected, refer the woman using a suspected cancer pathway referral (for an appointment within 2 weeks). See the CKS topic on Gynaecological cancers - recognition and referral for more information.
  • A structural abnormality (such as endometrial polyps, fibroids or ovarian cysts) — consider the need for transvaginal ultrasound scan and/or hysteroscopy.
• Consider performing a speculum and pelvic examination:
  • For persistent bleeding beyond the first 3 months of use — unscheduled bleeding is common in the first 3 months of starting a new hormonal contraceptive method.
  • For new symptoms or a change in bleeding after at least 3 months of use.
  • If the woman has not participated in the NHS Cervical Screening Programme regularly. For more information, see the CKS topic on Cervical cancer and HPV.
  • If requested by the woman.
  • If there are other symptoms such as pelvic pain, dyspareunia, or post-coital bleeding. 
• If no other underlying cause of irregular bleeding is suspected and speculum and pelvic examination are normal, the bleeding can be assumed to be caused by the POP. Providing the woman has no other symptoms:
  • Reassure her that unscheduled bleeding is common in POP users.
  • Advise her that although bleeding may settle with time, there is no evidence to indicate which women may become amenorrhoeic, or which women may experience persistent irregular bleeding, or how this will continue.
  • For more information, see the section on Bleeding patterns.
  • If the bleeding is unacceptable to the woman, consider changing to:
    • A different POP, although there is no evidence that changing the progestogen type or dose improves bleeding.
    • A different type of contraceptive method. See the CKS topic on Contraception - assessment for information on other contraceptive methods.

How should I manage a woman who is found to be pregnant whilst using the progestogen-only pill?

• If a woman is found to be pregnant whilst using the progestogen-only pill (POP) and she wishes to continue with the pregnancy:
  • Advise her to stop taking the POP.
  • Inform her that there is no evidence of harm to the baby or the mother if pregnancy occurs while using the POP.
  • Be alert to the possibility of an ectopic pregnancy. See the CKS topic on Ectopic pregnancy for more information.
• If the pregnancy was conceived during established use of the POP (rather than prior to the POP becoming effective):
  • Check for drug interactions.
  • If true contraceptive failure of the POP is suspected, advise the woman to consider an alternative contraceptive method. See the CKS topic on Contraception - assessment for information on other contraceptive methods.

What missed pill advice should I give?

• Check which progestogen-only pill (POP) the woman is taking and the time since the last pill was taken.
  • For the desogestrel pill — a pill is missed if she is more than 12 hours late (that is, more than 36 hours since taking the last pill).
  • For the drospirenone pill – a pill is missed if it is taken 24 hours or more late (that is, 48 hours or more since the last pill was taken or more than 24 hours after a new packet should have been started after a hormone-free interval [HFI]). 
  • For all other progestogen-only pills — a pill is missed if she is more than 3 hours late (that is, more than 27 hours since taking the last pill).
• If the woman has missed a dose of her POP, advise that she should:
  • Take a pill as soon as possible. If more than one pill has been missed, only one should be taken.
    • For drospirenone, the HFI (placebo pills) should be omitted if any of the last 7 active pills are missed.
  • Take the next pill at the normal time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).
  • Avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days if taking drospirenone, or 2 days for all other POPs.
• For drospirenone, consider prescribing emergency contraception if:
  • Any active pill(s) were missed, and there was unprotected sexual intercourse (UPSI) from the time that the first pill was missed until correct pill-taking had resumed for 7 days
  • Pill(s) were missed on days 1–7 of the packet, and there was UPSI during the hormone-free interview (HFI) or week 1.
• For levonorgestrel, norethisterone and desogestrel POPs, consider prescribing emergency contraception if:
  • Unprotected sexual intercourse has taken place from the time that the first pill was missed until correct pill-taking had resumed for 48 hours.
  • See the CKS topic on Contraception - emergency for more information.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines and Problematic bleeding with hormonal contraception 

[CoSRH, 2015] and Progestogen-only pills [CoSRH, 2023c], 

Missed pill advice

• Traditional progestogen-only pills (POPs) only suppress ovulation in approximately 50% of cycles. Therefore, if more than 27 hours have elapsed between pills, there is a risk that the contraceptive effect of the cervical mucus will be lost, and additional precautions will be required to avoid pregnancy. However, ovulation suppression is maintained in desogestrel pill users who take their pills up to 12 hours late [CoSRH, 2023c].
• During regular traditional POP or desogestrel POP use, cervical mucus changes prevent sperm penetration into the upper genital tract and sperm in the lower genital tract do not survive for more than a few hours. Therefore, sex that occurs before a missed pill does not present a risk of pregnancy, and emergency contraception would not be required [CoSRH, 2023c].
• With the drospirenone POP, the contraceptive cervical mucus effect could be lost during the hormone-free interval (HFI). Emergency contraception could therefore be required if pills are missed when restarting after an HFI, and there has been unprotected sexual intercourse since the beginning of the HFI [CoSRH, 2023c].

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only pills [CoSRH, 2023c].

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only pills [CoSRH, 2023c] and Contraception for women aged over 40 years [CoSRH, 2025b].

Women aged over 55 years

• The CoSRH states that in general, all women can cease contraception at age 55 years as spontaneous conception after this age is exceptionally rare even in women still experiencing menstrual bleeding [CoSRH, 2025b].
• If a woman aged 55 years or over does not wish to stop a particular method, consideration can be given to continuation providing the benefits and risks have been assessed and discussed with the woman [CoSRH, 2025b].

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only implant [CoSRH, 2023b].

How should I start a progestogen-only implant?

The progestogen-only implant (Nexplanon®) must only be inserted by healthcare professionals who have been appropriately trained and accredited.

• In women who are not currently using contraception or with an expired copper intrauterine device (Cu-IUD):
  • Check that the last menstrual period (LMP) was a typical bleed at the expected time (or consider pregnancy testing).
  • On days 1–5 of a natural menstrual cycle:
    • Insert the implant immediately.
    • No additional precaution is required.
  • After day 5 of the menstrual cycle or if the woman is amenorrhoeic, and the last episode of unprotected sexual intercourse (UPSI) occurred before the start of the LMP:
    • Insert the implant immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days. 
  • After day 5 of the menstrual cycle or if the woman is amenorrhoeic, and the last episode of UPSI occurred since the start of LMP and 21 or more days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, insert the implant immediately.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days. 
  • After day 5 of the menstrual cycle or if the woman is amenorrhoeic, and the last episode of UPSI occurred since the start of LMP and less than 21 days ago:
    • Perform a pregnancy test.
    • Assess the need for emergency contraception (EC), and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • If the pregnancy test is negative, insert the implant immediately (or after 5 days if ulipristal acetate EC was given).
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
• In women who have an in-date Cu-IUD in situ:
  
  • Check that the LMP was a typical bleed at the expected time (or consider pregnancy testing).
  • On days 1–5 of a natural menstrual cycle:
    • Insert the implant immediately.
    • No additional precaution is required.
  • After day 5 of the menstrual cycle, if the last episode of UPSI occurred 7 or more days ago:
    • Insert the implant immediately.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days, or retain the IUD for 7 days.
  • After day 5 of the menstrual cycle, if the last episode of UPSI occurred less than 7 days ago:
    • Insert the implant immediately, and retain the IUD for 7 days.
• In postpartum women before day 21 postpartum:
  • Insert the implant immediately.
  • No additional precaution is required.
• In postpartum women from day 21 after delivery (if the lactational amenorrhea method [LAM] criteria are not met):
  • If the last episode of UPSI occurred after day 21 postpartum and 21 or more days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, insert the implant immediately.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
  • If the last episode of UPSI occurred after day 21 postpartum and less than 21 days ago: 
    • Perform a pregnancy test.
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • If the pregnancy test is negative, insert the implant immediately (or after 5 days if ulipristal acetate EC was given).
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
  • The LAM criteria are:
    • Fully or nearly fully breastfeeding day and night (no other liquids given or only water, juice or vitamins given infrequently in addition to breastfeeds; no long intervals between feeds day or night [for example, more than 4 hours during the day and more than 6 hours at night]).
    • Complete amenorrhoea. 
    • Less than 6 months postpartum.
• In postpartum women up to 6 months after delivery (if the LAM criteria are met): 
  • Insert the implant immediately.
  • No additional precaution is required.
• In women who have had a miscarriage, ectopic pregnancy, or abortion:
  • On days 1–5 (after miscarriage, ectopic or abortion):
    • Insert the implant immediately.
    • No additional precaution is required. 
  • After day 5 (following miscarriage, ectopic or abortion), if the last episode of UPSI occurred after day 5 and 21 or more days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, insert the implant immediately.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
  • After day 5 (following miscarriage, ectopic or abortion), if the last episode of UPSI occurred after day 5 and less than 21 days ago:
    • Perform a pregnancy test.
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • If the pregnancy test is negative, insert the implant immediately (or after 5 days if ulipristal acetate EC was given).
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
• If starting the progestogen-only implant after oral EC:
  • For levonorgestrel:
    • Insert the progestogen-only implant immediately.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
  • For ulipristal acetate:
    • Insert the progestogen-only implant 5 days after taking ulipristal acetate EC.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) until the implant is inserted and for 7 days after.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.

How should I switch to the progestogen-only implant from other methods of contraception?

• If switching from correctly taken combined hormonal contraception (CHC) to the progestogen-only implant:
  • On days 1–2 of the hormone-free interval (HFI):
    • Insert the implant immediately.
    • No additional precaution is required.
  • On days 3–7 of the HFI, if the last episode of unprotected sexual intercourse (UPSI) occurred before the HFI:
    • Insert the implant immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days, or continue CHC for 7 days.
  • On days 3–7 of the HFI, if the last episode of UPSI occurred since the start of the HFI:
    • Insert the implant immediately, and continue CHC for 7 days.
  • In week 1 of CHC use, if the last episode of UPSI occurred before the HFI:
    • Insert the implant immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days, or continue CHC until taken for 7 days after the HFI. 
  • In week 1 of CHC use, if the last episode of UPSI occurred since the start of the HFI:
    • Insert the implant immediately.
    • Continue CHC until taken for 7 days after the HFI. 
  • In weeks 2–3 (and later weeks of continuous CHC use):
    • Insert the implant immediately.
    • No additional precaution is required.
• If switching from incorrectly taken CHC to the progestogen-only implant:
  • If the last UPSI occurred 21 or more days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, insert the implant immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
  • If the last UPSI occurred less than 21 days ago:
    • Perform a pregnancy test.
    • Assess the need for emergency contraception (EC), and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • If the pregnancy test is negative, insert the implant immediately (or after 5 days if ulipristal acetate EC was given).
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
• If switching from a progestogen-only injectable to a progestogen-only implant:
  • Within 14 weeks of the last progestogen-only injection:
    • Insert the implant immediately.
    • No additional precaution is needed.
  • More than 14 weeks after the last injection if the last episode of UPSI occurred before 14 weeks:
    • Insert the implant immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
  • More than 14 weeks after the last injection if the last episode of UPSI occurred after 14 weeks and 21 or more days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, insert the implant.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days. 
  • More than 14 weeks after the last injection if the last episode of UPSI occurred after 14 weeks and less than 21 days ago: 
    • Perform a pregnancy test.
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • If the pregnancy test is negative, insert the implant immediately (or after 5 days if ulipristal acetate EC was given).
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
• If switching from a correctly taken progestogen-only pill (POP) to a progestogen-only implant:
  • For the traditional POP:
    • Insert the implant immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days, or continue the POP for 7 days.
  • For the desogestrel POP:
    • Insert the implant immediately.
    • No additional precaution is needed.
  • For the drospirenone POP:
    • During HFI (placebo pills, days 25–28) or days 1–7 (active pills) after HFI and no UPSI since start of HFI — start immediately and advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days. 
    • During HFI (placebo pills, days 25–28) or days 1–7 (active pills) after HFI and UPSI since the start of HFI — start immediately and restart/continue drospirenone until 7 consecutive pills taken.
    • Days 8-24 (active pills) — start immediately. No additional precautions required. 
• If the woman is switching from incorrectly taken POP to a progestogen-only implant:
  • If the last UPSI occurred 21 or more days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, insert the implant.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days. 
  • If the last UPSI occurred less than 21 days ago:
    • Perform a pregnancy test.
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • If the pregnancy test is negative, insert the implant immediately (or after 5 days if ulipristal acetate EC was given).
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
• If switching from an in-date levonorgestrel intrauterine system (LNG-IUS) to a progestogen-only implant:
  • If the last UPSI occurred 7 or more days ago:
    • Insert the implant immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days, or retain the IUS for 7 days.
  • If the last UPSI occurred less than 7 days ago:
    • Insert the implant immediately, retain the IUS for 7 days and advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
• If switching from an expired 52 mg LNG-IUS to a progestogen-only implant:
  • LNG-IUS in situ for 6–7 years, and the last UPSI occurred 7 or more days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, insert the implant.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days, or retain the IUS for 7 days.
    • Advise the woman to consider taking a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
  • LNG-IUS in situ for 6–7 years, and the last UPSI occurred less than 7 days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, insert the implant and retain the IUS for 7 days.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to consider taking a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
  • LNG-IUS in situ for more than 7 years, and the last UPSI occurred 21 or more days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, remove the LNG-IUS and insert the implant immediately.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
  • LNG-IUS in situ for more than 7 years, and the last UPSI occurred less than 21 days ago:
    • Perform a pregnancy test.
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • If the pregnancy test is negative, insert the implant immediately (or after 5 days if ulipristal acetate EC was given).
    • Consider retaining the IUS for 7 days if UPSI occurred within 7 days ago.
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
• If switching from other expired LNG-IUS to a progestogen-only implant:
  • If the last UPSI occurred 21 or more days ago:
    • Perform a pregnancy test.
    • If the pregnancy test is negative, remove the LNG-IUS and insert the implant immediately. 
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
  • If the last UPSI occurred less than 21 days ago:
    • Perform a pregnancy test.
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • If the pregnancy test is negative, insert the implant immediately (or after 5 days if ulipristal acetate EC was given).
    • Consider retaining the IUS for 7 days if UPSI occurred within 7 days ago. 
    • Advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
• If replacing an old progestogen-only implant with a new one:
  • If the implant has been in situ for up to 3 years:
    • Remove the old implant, and insert the new implant immediately.
    • No additional precaution is required.
  • If the implant has been in situ for more than 3 years but no longer than 4 years:
    • Perform a pregnancy test.
    • If the pregnancy test is negative and all episodes of UPSI occurred 21 days ago or longer, remove the old implant and insert the new implant immediately. Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • If the pregnancy test is negative but UPSI occurred within the last 21 days, remove the old implant and insert the new implant immediately. Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days and to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
  • If the implant has been in situ for over 4 years:
    • Perform a pregnancy test.
    • If the pregnancy test is negative and all UPSI occurred 21 days ago or longer, remove the old implant and insert the new implant immediately. Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • If the pregnancy test is negative but UPSI occurred within the last 21 days, consider EC — see the CKS topic on Contraception - emergency for more information. Remove the old implant, and insert the new implant immediately (or after 5 days if ulipristal acetate EC was given). Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days and to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.

How can I exclude pregnancy in a woman considering using a progestogen-only implant?

• Health professionals can be ‘reasonably certain’ that a woman is not currently pregnant if any one or more of the following criteria are met and there are no symptoms or signs of pregnancy:
  • She has not had intercourse since the start of her last normal (natural) menstrual period, since childbirth, abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease.
  • She has been correctly and consistently using a reliable method of contraception.
    • For the purposes of being reasonably certain that a woman is not currently pregnant, barrier methods of contraception can be considered reliable provided they have been used consistently and correctly for every episode of intercourse.
  • She is within the first 5 days of the onset of a normal (natural) menstrual period.
  • She is less than 21 days postpartum (non-breastfeeding women).
  • She is fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
  • She is within the first 5 days after abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease.
  • She has not had intercourse for more than 21 days and has a negative high-sensitivity urine pregnancy test (able to detect human chorionic gonadotrophin [hCG] levels around 20 mIU/ml).

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only implant [CoSRH, 2023b], and Progestogen-only pills [CoSRH, 2023c]. 

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only implant [CoSRH, 2023b] and on the Summary of Product Characteristic (SPC) for Nexplanon^® 68 mg implant for subdermal use [EMC, 2025c].

Weight gain and headache

• The CoSRH states that the available evidence is too limited to confirm or exclude a causal association between implant use and these adverse effects [CoSRH, 2023b]. However, they are listed in the manufacturer's SPC [EMC, 2025c].

Depression and mood changes

• The CoSRH states that the available evidence is too limited to confirm or exclude a causal association between implant use and depression [CoSRH, 2023b]. 
• However, the manufacturer's SPC states that depression can be serious and is a well-known risk factor for suicidal behaviour and suicide. Therefore, women should be advised to seek medical advice in case of mood changes and depressive symptoms, including shortly after initiating the treatment [EMC, 2025c].

Liver enzyme-inducing drugs

Drugs that induce liver enzymes include:

• Antibiotics:
  • Rifampicin (potent inducer).
  • Rifabutin.
• Antiepileptics:
  • Carbamazepine.
  • Eslicarbazepine.
  • Oxcarbazepine.
  • Phenytoin.
  • Phenobarbital.
  • Primidone.
  • Rufinamide.
  • Topiramate (weak inducer).
• Antiretrovirals:
  • Protease inhibitors: ritonavir, atazanavir, darunavir, fosamprenavir, lopinavir, nelfinavir, saquinavir, and tipranavir.
  • Non-nucleoside reverse transcriptase inhibitors: efavirenz, nevirapine.
  • Always use the HIV Drug Interaction Checker to identify potential interactions.
• Others:
  • Bosentan.
  • Modafinil.
  • Aprepitant.
  • St John's Wort.

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only implant [CoSRH, 2023b], Drug interactions with hormonal contraception [CoSRH, 2022], and Emergency contraception [CoSRH, 2023d].

Continuing or starting hormonal contraceptives after ulipristal acetate emergency contraception

• Previously, it was recommended that progestogen-only contraception (pill, implant, and injectable) should be quick started immediately after oral emergency contraception (EC), with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure. This remains the advice after levonorgestrel EC administration, but not for ulipristal acetate.
• Evidence from a prospective, randomized, pharmacodynamic study (n = 71) identified by the CoSRH showed that starting a desogestrel progestogen-only pill (POP) immediately after ulipristal acetate EC reduces the ability of ulipristal acetate to delay ovulation [Brache, 2015]. There are currently no studies to investigate whether this affects pregnancy rates or whether quick starting other types of hormonal contraception after ulipristal acetate has the same effect.
• Extrapolating from this evidence, the CoSRH recommends that women should wait 5 days (at least 120 hours) after taking ulipristal acetate before continuing or starting progestogen-only contraception (pill, implant, or injectable). This ensures that the ulipristal acetate is as effective as possible in preventing pregnancy resulting from the episode(s) of unprotected sexual intercourse (UPSI) for which it was taken. Importantly, there is a risk of pregnancy if further UPSI occurs before ongoing contraception is started and becomes effective.

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only implant [CoSRH, 2023b], the College of Sexual and Reproductive Healthcare (CoSRH) CEU statement: extension of use of the etonogestrel impant (Nexplanon®) to 5 years [CoSRH, 2026], and on what CKS considers to be good clinical practice.

How should I manage unscheduled bleeding in a woman using a progestogen-only implant?

• Exclude and/or manage situations that could result in unscheduled bleeding, particularly where there is a sudden change in bleeding pattern for an established user. For example:
  • Sexually transmitted infections (STIs) — as a minimum, test for Chlamydia trachomatis. The risk of STIs is increased if the woman is under 25 years, has a new sexual partner, or has had more than one sexual partner in the last year. See the CKS topic on Chlamydia - uncomplicated genital for more information.
  • Pregnancy — perform a pregnancy test.
  • Cancer (for example, cervical or endometrial cancer) — if suspected, refer the woman using a suspected cancer pathway referral (for an appointment within 2 weeks). See the CKS topic on Gynaecological cancers - recognition and referral for more information.
  • A structural abnormality (such as endometrial polyps, fibroids, or ovarian cysts) — consider the need for a transvaginal ultrasound scan and/or hysteroscopy.
• Consider performing a speculum and pelvic examination:
  • For persistent bleeding beyond the first 3 months of use — unscheduled bleeding is common in the first 3 months of starting a new hormonal contraceptive method.
  • For new symptoms or a change in bleeding after at least 3 months of use.
  • If the woman has not participated in the NHS Cervical Screening Programme regularly. 
  • If requested by the woman.
  • If there are other symptoms such as pelvic pain, dyspareunia, or post-coital bleeding. 
• If no other underlying cause of irregular bleeding is suspected, and speculum and pelvic examination are normal, the bleeding can be assumed to be caused by the progestogen-only implant. 
  • Providing the woman has no other symptoms, consider one of the following options, provided there are no contraindications:
    
    • Prescribe 500 mg mefenamic acid up to three times daily for 5 days.
    • Offer a combined oral contraceptive (COC) for 3 months. This can be taken in the usual cyclic manner or continuously without a hormone-free interval (off-label use). 
  • If the bleeding is unacceptable to the woman, consider changing to a different type of contraceptive method. See the CKS topic on Contraception - assessment for information on other contraceptive methods.

How should I manage a woman who cannot feel her implant?

• After checking that the implant cannot be felt in the other arm:
  • Advise the woman to take a pregnancy test and to use additional contraception until the presence of the implant is confirmed.
• Seek advice from the local specialist sexual and reproductive health services regarding the need for additional investigation, including localization of the implant by X-ray of the arm (note that Nexplanon^® is radio-opaque) or by ultrasound using a high-frequency linear array transducer (10 MHz or greater).
  • Advise that it is generally considered that a deeply sited implant (that has been confirmed to be present) can be relied on for contraception for 5 years after insertion.
• If the woman requests to have the implant removed:
  • Refer to specialist services for removal.
  • Do not attempt to remove an impalpable implant that has not been localized.

How should I manage a woman who is found to be pregnant whilst using the progestogen-only implant?

• If a woman is found to be pregnant whilst using the progestogen-only implant and she wishes to continue with the pregnancy:
  • Remove the implant.
  • Inform her that there is no evidence of harm to the baby or the mother if pregnancy occurs while using the implant.
  • Be alert to the possibility of an ectopic pregnancy. See the CKS topic on Ectopic pregnancy for more information.
• If the pregnancy was conceived during established use of the implant (rather than prior to the implant becoming effective):
  • Check for drug interactions.
  • If true contraceptive failure of the implant is suspected, advise the woman to consider an alternative contraceptive method. See the CKS topic on Contraception - assessment for information on other contraceptive methods.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Problematic bleeding with hormonal contraception 

[CoSRH, 2015], Progestogen-only implant [CoSRH, 2023b], and on the Summary of Product Characteristic (SPC) for Nexplanon® 68 mg implant for subdermal use [EMC, 2026].

Impalpable implant

• The CoSRH advises that the removal of an implant that is deeply sited in the arm should only be undertaken by a specialist trained in complex implant removal techniques [CoSRH, 2023b].

Pregnancy

• The CoSRH states that [CoSRH, 2023b]:
  • Contraceptive failure during the use of the progestogen-only implant is rare, so published evidence regarding outcomes in pregnancies exposed to the implant is limited to a few case reports. However, there is no evidence that suggests a teratogenic effect.
  • If pregnancy is diagnosed in a woman with the implant in situ and she wishes to continue with the pregnancy, it is established practice that the implant should be removed.
  • If the woman opts for abortion, the implant can remain in situ during medical or surgical abortion to provide contraception afterward. See the CoSRH guideline on Contraception After Pregnancy for more information.

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only implant [CoSRH, 2023b] and the Summary of Product Characteristics (SPC) for Nexplanon^® 68 mg implant for subdermal use [EMC, 2026].

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only implant [CoSRH, 2023b], College of Sexual and Reproductive Healthcare (CoSRH) CEU statement: extension of etonogestrel implant use (Nexplanon®) to 5 years [CoSRH, 2026], and Contraception for women aged over 40 years [CoSRH, 2025b] and on the Summary of Product Characteristics (SPC) for Nexplanon^® 68 mg implant for subdermal use [EMC, 2026].

Women aged over 55 years

• The CoSRH states that in general, all women can cease contraception at age 55 years as spontaneous conception after this age is exceptionally rare even in women still experiencing menstrual bleeding [CoSRH, 2025b].
• If a woman aged 55 years or over does not wish to stop a particular method, consideration can be given to continuation providing the benefits and risks have been assessed and discussed with the woman [CoSRH, 2025b].

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only injectable [CoSRH, 2023a].

How should I start a progestogen-only injectable?

• In women having menstrual cycles:
  • On days 1–5 of the menstrual cycle:
    • Give the injection immediately.
    • No additional precaution is required.
    • It is advisable to check that the woman's menstrual period is typical of the woman's usual bleeding pattern in terms of duration, heaviness, and timing.
  • After day 5 of the cycle, if it is reasonably certain that the woman is not pregnant:
    
    • Give the injection immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days. 
  • After day 5 of the cycle, if there has been a risk of pregnancy:
    • Assess the need for emergency contraception (EC), and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • Quick start the injection (off-label use) — delay for 5 days if ulipristal EC was given.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of unprotected sexual intercourse (UPSI).
• In women who are amenorrhoeic:
  • At any time, if it is reasonably certain that the woman is not pregnant:
    • Give the injection immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days. 
  • At any time, if there has been a risk of pregnancy:
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • Quick start the injection (off-label use) — delay for 5 days if ulipristal EC was given.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
• In women who are postpartum (breastfeeding and non-breastfeeding):
  • Up to day 21 postpartum:
    • Give the injection immediately.
    • No additional precaution is required.
  • After day 21 postpartum, if menstrual cycles have returned and it is reasonably certain that the woman is not pregnant:
    • Start as for other women having menstrual cycles.
  • After day 21 postpartum, if menstrual cycles have returned and there has been a risk of pregnancy:
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • Quick start the injection (off-label use) — delay for 5 days if ulipristal EC was given.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
  • After day 21 postpartum, if menstrual cycles have not returned and it is reasonably certain that the woman is not pregnant:
    • Give the injection immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
  • After day 21 postpartum, if menstrual cycles have not returned and there has been a risk of pregnancy:
    
    • Assess the need for EC, and prescribe if necessary. See the CKS topic on Contraception - emergency for more information.
    • Quick start the injection (off-label use) — delay for 5 days if ulipristal EC was given.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
• In women post first- or second-trimester abortion:
  • On days 1–5 post first- or second-trimester abortion:
    • Give the injection immediately.
    • No additional precaution is required.
    • Women should ideally start on the day or day after a first- or second-trimester abortion.
  • At any other time, if it is reasonably certain that the woman is not pregnant:
    • Give the injection immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days. 
  • The injectable can be initiated after the first part of a medical abortion.
• If quick starting the progestogen-only injection after oral EC or in other situations in which pregnancy cannot be excluded:
  • Ideally, use a bridging method of contraception until a negative pregnancy test at 3 weeks.
  • If a bridging method is inappropriate or unacceptable:
    • Consider quickly starting the injectable (delay for 5 days if ulipristal EC was given).
    • Advise the woman to avoid sexual intercourse or use additional precautions for 7 days after injection and to take a pregnancy test no sooner than 3 weeks after the most recent UPSI.
• If a repeat injection is due:
  • See the section on Timing of repeat injections for more information.

How should I switch to the progestogen-only injectable from other methods of contraception?

• If switching from combined hormonal contraception (CHC; if taken correctly) to the progestogen-only injectable:
  • On days 1–2 of the hormone-free interval (HFI):
    • Give the injection immediately.
    • No additional precaution is required.
  • On days 3–7 of the HFI or week 1 following the HFI, if it is reasonably certain that the woman is not pregnant:
    • Give the injection immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
  • On days 3–7 of the HFI or week 1 following the HFI, if unprotected sexual intercourse (UPSI) has occurred after day 2 of the HFI:
    • Give the injection immediately, and continue the CHC method for at least 7 days.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
  • In weeks 2–3 of pill, ring, or patch:
    • Give the injection immediately.
    • No additional precaution is required, provided the CHC method has been used consistently and correctly for 7 consecutive days before switching.
    • There is evidence to suggest that taking hormonally active pills for 7 consecutive days prevents ovulation. Therefore, as long as there have been 7 days of CHC use, 7 hormone-free days can occur without any effect on contraceptive efficacy.
• If switching from a traditional progestogen-only pill (POP; if taken correctly) or levonorgestrel intrauterine device (LNG-IUS) to the progestogen-only injectable:
  • Give the injection at any time.
  • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days. 
  • If the UPSI occurred in the last 7 days, retain the LNG-IUS for 7 days after giving the injection. (The continuing method provides contraceptive cover while the effects of the injectable are established.)
• If switching from the desogestrel POP (if taken correctly) to the progestogen-only injectable: 
  • Give the injection at any time.
  • No additional precaution is required.
• If switching from the drospirenone POP (if taken correctly) to the progestogen-only injectable:
  • During HFI (placebo pills, days 25–28) or days 1–7 (active pills) after HFI and no UPSI since start of HFI — start immediately and advise the woman to abstain from sex or use a barrier method of contraception (such as condoms) for 7 days. 
  • During HFI (placebo pills, days 25–28) or days 1–7 (active pills) after HFI and UPSI since the start of HFI — start immediately and restart/continue drospirenone until 7 consecutive pills taken.
  • Days 8-24 (active pills) — start immediately. No additional precautions required. 
• If switching from a progestogen-only implant to the progestogen-only injectable: 
  
  • If the implant has been in situ for up to 3 years:
    • Remove the implant, and give the injection immediately.
    • No additional precaution is required.
  • If the implant has been in situ for more than 3 years but no longer than 4 years:
    • Perform a pregnancy test.
    • If the pregnancy test is negative and all episodes of UPSI occurred 21 days ago or longer, remove the implant and give the injection immediately. Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • If the pregnancy test is negative but UPSI occurred within the last 21 days, remove the implant and give the injection immediately. Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days and to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
  • If the implant has been in situ for over 4 years:
    • Perform a pregnancy test.
    • If the pregnancy test is negative and all UPSI occurred 21 days ago or longer, remove the implant and give the injection immediately. Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • If the pregnancy test is negative but UPSI occurred within the last 21 days, consider emergency contraception (EC) — see the CKS topic on Emergency Contraception for more information. Consider bridging with CHC, POP, or the progestogen-only implant. If bridging is unacceptable or unsuitable, remove the implant and give the injection immediately (or after 5 days if ulipristal acetate EC was given). Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days and to take a pregnancy test no sooner than 3 weeks after the last episode of UPSI.
• If switching from the copper intrauterine device (Cu-IUD) to the progestogen-only injectable:
  • On days 1–5 of the menstrual cycle:
    • Remove the Cu-IUD, and give the injection immediately.
    • No additional precaution is required.
  • At any other time, if it is reasonably certain that the woman is not pregnant:
    • Remove the Cu-IUD, and give the injection immediately.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
  • At any other time if UPSI occurred in the last 7 days:
    • Give the injection immediately.
    • Retain the Cu-IUD for 7 days after the injection.

How often should I repeat the progestogen-only injection?

• If it is up to 14 weeks since the last depot medroxyprogesterone acetate (DMPA) injection or up to 10 weeks since the last norethisterone enantate (NET-EN) injection:
  • Give the injection.
  • No additional contraception is required (sex that occurs up to week 14 or week 10 is protected).
• If it has been 14 weeks plus 1 day or more since last DMPA injection or 10 weeks plus 1 day or more since last NET-EN injection, management will depend on the risk of pregnancy:
  • If there has been no episode of unprotected sexual intercourse (UPSI):
    • Give the injection.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days. 
  • If there has been UPSI within the last 5 days:
    • Consider emergency contraception (EC) with the copper intrauterine device (Cu-IUD) or levonorgestrel EC. The effectiveness of ulipristal acetate EC could theoretically be reduced by residual circulating progestogen. See the CKS topic on Contraception - emergency for more information.
    • Offer a bridging method of contraception.
    • If a bridging method is not acceptable, give the injection — delay for 5 days if ulipristal EC was taken.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
  • If there have been multiple episodes of UPSI less than 5 days ago and more than 5 days ago:
    • Perform a pregnancy test.
    • Offer EC with the copper intrauterine device (Cu-IUD) or levonorgestrel EC. The effectiveness of ulipristal acetate EC could theoretically be reduced by residual circulating progestogen. See the CKS topic on Contraception - emergency for more information.
    • Offer a bridging method of contraception.
    • If a bridging method is not acceptable, give the injection — delay for 5 days if ulipristal EC was taken.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
  • If there have been multiple episodes of UPSI more than 5 days ago but within 3 weeks ago:
    • Perform a pregnancy test.
    • Offer a bridging method of contraception.
    • Give the injection if a bridging method is not acceptable.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days.
    • Advise the woman to take a pregnancy test no sooner than 3 weeks from the last episode of UPSI.
  • If there have been multiple episodes of UPSI more than 3 weeks ago:
    • Perform a pregnancy test.
    • If the test is negative, administer the injectable.
    • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days. 
• If the timing of a woman’s previous DMPA injection is unknown:
  • Administer the injectable if it is reasonably certain that the woman is not pregnant.
  • Advise the woman to avoid sexual intercourse or use a barrier method of contraception (such as condoms) for 7 days. 
  • If there is a risk of pregnancy, offer EC, a bridging method of contraception, or quick start of the injectable, as appropriate.
  • Advise the woman to do a pregnancy test no sooner than 3 weeks from the last episode of UPSI.

How can I exclude pregnancy in a woman considering using a progestogen-only injectable?

• Health professionals can be ‘reasonably certain’ that a woman is not currently pregnant if any one or more of the following criteria are met and there are no symptoms or signs of pregnancy:
  • She has not had intercourse since the start of her last normal (natural) menstrual period, since childbirth, abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease.
  • She has been correctly and consistently using a reliable method of contraception.
    • For the purposes of being reasonably certain that a woman is not currently pregnant, barrier methods of contraception can be considered reliable provided they have been used consistently and correctly for every episode of intercourse.
  • She is within the first 5 days of the onset of a normal (natural) menstrual period.
  • She is less than 21 days postpartum (non-breastfeeding women).
  • She is fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
  • She is within the first 5 days after abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease.
  • She has not had intercourse for more than 21 days and has a negative high-sensitivity urine pregnancy test (able to detect human chorionic gonadotrophin [hCG] levels around 20 mIU/ml).

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only injectable [CoSRH, 2023a]. The recommendations on switching from a progestogen-only implant to a progestogen-only injectable are based on the CoSRH guideline Progestogen-only implant [CoSRH, 2023b].

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only injectable [CoSRH, 2023a] and Summaries of Product Characteristic (SPCs) for Depo-Provera® 150 mg/ml Injection Sterile suspension for injection [EMC, 2025d] and Sayana Press® 104 mg/0.65 ml suspension for injection [EMC, 2025e].

Depression and mood changes

• Depression and mood changes have been listed in the manufacturers' SPCs as possible adverse effects of the progestogen-only injection [EMC, 2025d; EMC, 2025e], but the CoSRH states that there is no evidence of a causal association [CoSRH, 2023a].
• The SPCs state that depression can be serious and is a well-known risk factor for suicidal behaviour and suicide. Therefore, women should be advised to seek medical advice in case of mood changes and depressive symptoms, including shortly after initiating the treatment [EMC, 2025d; EMC, 2025e].

Acne, decreased libido, headache, hot flushes, and vaginitis

• The CoSRH states that there is little evidence that the use of the progestogen-only injectable causes these adverse effects [CoSRH, 2023a]. However, they are listed in the manufacturers' SPCs as possible adverse effects of the progestogen-only injection [EMC, 2025d; EMC, 2025e].

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only injectable [CoSRH, 2023a] and Emergency contraception [CoSRH, 2023d].

Continuing or starting hormonal contraceptives after ulipristal acetate emergency contraception (EC)

• Previously, it was recommended that progestogen-only contraception (pill, implant, and injectable) should be quick started immediately after oral EC, with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure. This remains the advice after levonorgestrel EC administration, but not for ulipristal acetate.
• Evidence from a prospective, randomized, pharmacodynamic study (n = 71) identified by the CoSRH showed that starting a desogestrel progestogen-only pill (POP) immediately after ulipristal acetate EC reduces the ability of ulipristal acetate to delay ovulation [Brache, 2015]. There are currently no studies to investigate whether this affects pregnancy rates or whether quick starting other types of hormonal contraception after ulipristal acetate has the same effect.
• Extrapolating from this evidence, the CoSRH recommends that women should wait 5 days (at least 120 hours) after taking ulipristal acetate before continuing or starting progestogen-only contraception (pill, implant, or injectable). This ensures that the ulipristal acetate is as effective as possible in preventing pregnancy resulting from the episode(s) of unprotected sexual intercourse (UPSI) for which it was taken. Importantly, there is a risk of pregnancy if further UPSI occurs before ongoing contraception is started and becomes effective.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only injectable [CoSRH, 2023a] and on what CKS considers to be good clinical practice.

How should I manage unscheduled bleeding in a woman using a progestogen-only injectable?

• Exclude and/or manage situations that could result in unscheduled bleeding, particularly where there is a sudden change in bleeding pattern for an established user. For example:
  • Sexually transmitted infections (STIs) — as a minimum, test for Chlamydia trachomatis. The risk of STIs is increased if the woman is under 25 years, has a new sexual partner, or has had more than one sexual partner in the last year. See the CKS topic on Chlamydia - uncomplicated genital for more information.
  • Pregnancy — perform a pregnancy test.
  • Cancer (for example, cervical or endometrial cancer) — if suspected, refer the woman using a suspected cancer pathway referral (for an appointment within 2 weeks). See the CKS topic on Gynaecological cancers - recognition and referral for more information.
  • A structural abnormality (such as endometrial polyps, fibroids or ovarian cysts) — consider the need for transvaginal ultrasound scan and/or hysteroscopy.
• Consider performing a speculum and pelvic examination:
  • For persistent bleeding beyond the first 3 months of use — unscheduled bleeding is common in the first 3 months of starting a new hormonal contraceptive method.
  • For new symptoms or a change in bleeding after at least 3 months of use.
  • If the woman has not participated in the NHS Cervical Screening Programme regularly. For more information, see the CKS topic on Cervical cancer and HPV.
  • If requested by the woman.
  • If there are other symptoms such as pelvic pain, dyspareunia, or post-coital bleeding. 
• If no other underlying cause of irregular bleeding is suspected and speculum and pelvic examination are normal, the bleeding can be assumed to be caused by the progestogen-only injection.
  • Providing the woman has no other symptoms, consider one of the following options, provided there are no contraindications:
    
    • Prescribe 500 mg mefenamic acid up to three times daily for 5 days.
    • Offer a combined oral contraceptive (COC) for 3 months. This can be taken in the usual cyclic manner or continuously without a hormone-free interval (off-label use). Longer-term use of the injectable and COC has not been studied and is a matter of clinical judgement.
  • For women who experience bleeding towards the end of the injection interval, consider giving the injection from 10 weeks after the last injection.
  • If the bleeding is unacceptable to the woman, consider changing to a different type of contraceptive method. See the CKS topic on Contraception - assessment for information on other contraceptive methods.

How should I manage a woman who is found to be pregnant whilst using the progestogen-only injectable?

• If a woman is found to be pregnant whilst using the progestogen-only injectable and she wishes to continue with the pregnancy:
  
  • Inform her that there is no evidence of harm to the baby or the mother if pregnancy occurs while using the injectable.
  • Be alert to the possibility of an ectopic pregnancy. See the CKS topic on Ectopic pregnancy for more information.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only injectable [CoSRH, 2023a] and Progestogen-only implant [CoSRH, 2023b].

Unscheduled bleeding

• This recommendation is also based on the CoSRH guideline Problematic bleeding with hormonal contraception [CoSRH, 2015].
• No studies were identified that examined whether or not reducing the injection interval helps with unscheduled bleeding. However, for women who experience bleeding towards the end of the injection interval, CoSRH guidance would suggest that the injection can be given from 10 weeks after the last injection [CoSRH, 2023a].

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Progestogen-only injectable [CoSRH, 2023a] and on what CKS considers to be good clinical practice.

Basis for recommendation

These recommendations are based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Progestogen-only injectable [CoSRH, 2023a] and Contraception for women aged over 40 years [CoSRH, 2025b].

Women aged over 55 years

• The CoSRH states that in general, all women can cease contraception at age 55 years as spontaneous conception after this age is exceptionally rare even in women still experiencing menstrual bleeding [CoSRH, 2025b].
• If a woman aged 55 years or over does not wish to stop a particular method, consideration can be given to continuation providing the benefits and risks have been assessed and discussed with the woman [CoSRH, 2025b].