Problems Reported as Side Effects or Problems With Use

May or may not be due to the method.

• Problems with side effects affect women’s satisfaction and use of POPs. They deserve the provider’s attention. If the client reports side effects or problems, listen to her concerns, give her advice and support, and, if appropriate, treat. Make sure she understands the advice and agrees.
• Encourage her to keep taking a pill every day even if she has side effects. Missing pills can risk pregnancy.
• Many side effects will subside after a few months of use. For a woman whose side effects persist, give her a different POP formulation, if available, for at least 3 months.
• Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

No monthly bleeding

• Breastfeeding women:
  • Reassure her that this is normal during breastfeeding. It is not harmful.
• Women not breastfeeding:
  • Reassure her that some women using POPs stop having monthly bleeding, and this is not harmful. There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not pregnant or infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding.)

Irregular bleeding (bleeding at unexpected times that bothers the client)

• Reassure her that many women using POPs experience irregular bleeding—whether breastfeeding or not. (Breastfeeding itself also can cause irregular bleeding.) It is not harmful and sometimes becomes less or stops after the first several months of use. Some women have irregular bleeding the entire time they are taking POPs, however.
• Other possible causes of irregular bleeding include:
  • Vomiting or diarrhea
  • Taking anticonvulsants or rifampicin (see Starting treatment with anticonvulsants, rifampicin, or rifabutin)
• To reduce irregular bleeding:
  • Teach her to make up for missed pills properly, including after vomiting or diarrhea (see Managing Missed Pills).

  • For modest short-term relief she can try 800 mg ibuprofen 3 times daily after meals for 5 days, or other nonsteroidal anti-inflammatory drug (NSAID), beginning when irregular bleeding starts. NSAIDs provide some relief of irregular bleeding for implants, progestin-only injectables, and IUDs, and they may also help POP users.

  • If she has been taking the pills for more than a few months and NSAIDs do not help, give her a different POP formulation, if available. Ask her to try the new pills for at least 3 months.
• If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see "Unexplained vaginal bleeding").

Heavy or prolonged bleeding (twice as much as usual or longer than 8 days)

• Reassure her that some women using POPs experience heavy or prolonged bleeding. It is generally not harmful and usually becomes less or stops after a few months.
• For modest short-term relief she can try NSAIDs, beginning when heavy bleeding starts. Try the same treatments as for irregular bleeding.
• To help prevent anemia, suggest she take iron tablets and tell her it is important to eat foods containing iron, such as meat and poultry (especially beef and chicken liver), fish, green leafy vegetables, and legumes (beans, bean curd, lentils, and peas).
• If heavy or prolonged bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see "Unexplained vaginal bleeding").

Missed pills

• See Managing Missed Pills.

Ordinary headaches (nonmigrainous)

• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.
• Any headaches that get worse or occur more often during POP use should be evaluated.

Mood changes or changes in sex drive

• Ask about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give her support as appropriate.
• Some women experience depression in the year after giving birth. This is not related to POPs. Clients who have serious mood changes such as major depression should be referred for care.
• Consider locally available remedies.

Breast tenderness

• Breastfeeding women:
  • See Chapter 24 – Maternal and Newborn Health, Sore Breasts.
• Women not breastfeeding:
  • Recommend that she wear a supportive bra (including during strenuous activity and sleep).
  • Try hot or cold compresses.

  • Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.

  • Consider locally available remedies.

Severe pain in lower abdomen

• Abdominal pain may be due to various problems, such as enlarged ovarian follicles or cysts.

  • A woman can continue to use POPs during evaluation and treatment.

  • There is no need to treat enlarged ovarian follicles or cysts unless they grow abnormally large, twist, or burst. Reassure the client that they usually disappear on their own. To be sure the problem is resolving, see the client again in 6 weeks, if possible.

• With severe abdominal pain, be particularly alert for additional signs or symptoms of ectopic pregnancy, which is rare and not caused by POPs, but it can be life-threatening (see Questions and Answers about Progestin-Only-Pills, Question 13).
• In the early stages of ectopic pregnancy, symptoms may be absent or mild, but eventually they will become severe. A combination of these signs or symptoms should increase suspicion of ectopic pregnancy:

  • Unusual abdominal pain or tenderness

  • Abnormal vaginal bleeding or no monthly bleeding—especially if this is a change from her usual bleeding pattern

  • Light-headedness or dizziness

  • Fainting
• If ectopic pregnancy or other serious health condition is suspected, refer at once for immediate diagnosis and care (for more on ectopic pregnancies, see Chapter 12 – Female Sterilization, Managing Ectopic Pregnancy).

Nausea or dizziness

• For nausea, suggest taking POPs at bedtime or with food.
• If symptoms continue, consider locally available remedies.

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New Problems That May Require Switching Methods

May or may not be due to the method.

Unexplained vaginal bleeding (that suggests a medical condition not related to the method)

• Refer or evaluate by history and pelvic examination. Diagnose and treat as appropriate.
• She can continue using POPs while her condition is being evaluated.

• If bleeding is caused by a sexually transmitted infection or pelvic inflammatory disease, she can continue using POPs during treatment.

Starting treatment with anticonvulsants, rifampicin, or rifabutin

• Barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, rifampicin, rifabutin, and ritonavir may make POPs less effective. If using these medications long-term, she may want a different method, such as progestin-only injectables or a copper-bearing IUD or LNG-IUD.

• If using these medications short-term, she can use a backup method along with POPs.

Migraine headaches (see Identifying Migraine Headaches and Auras)

• A woman who has migraine headaches with or without aura can safely start POPs.

• If she develops migraine headaches without aura while taking POPs, she can continue to use POPs if she wishes.

• If she develops migraine aura while using POPs, stop POPs. Help her choose a method without hormones.

Certain serious health conditions (suspected blood clots in deep veins of legs or lungs, liver disease, or breast cancer). See Appendix B – Signs and Symptoms of Serious Health Conditions.

• Tell her to stop taking POPs.
• Give her a backup method to use until the condition is evaluated.
• Refer for diagnosis and care if not already under care.

Heart disease due to blocked or narrowed arteries (ischemic heart disease) or stroke

• A woman who has one of these conditions can safely start POPs. If, however, the condition develops after she starts using POPs, she should stop. Help her choose a method without hormones.
• Refer for diagnosis and care if not already under care.

Suspected pregnancy

• Assess for pregnancy, including ectopic pregnancy.
• Tell her to stop taking POPs if pregnancy is confirmed.
• There are no known risks to a fetus conceived while a woman is taking POPs (see Question 4).