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In 2005, the Clinical Effectiveness Unit (CEU) of the then Faculty of Family Planning and Reproductive Health Care adopted the World Health Organization (WHO) ‘missed pills’ guidance (Figure 1).1 Many clinicians criticised this change2,–,5 as these new rules appeared to be complex and caused confusion at the grass roots level.6,–,8 There were also concerns that liberalising the ‘missed pills’ guidance (Box 1)9 would lead to additional unplanned pregnancies among pill-takers and did not support safer sex messages or the importance of correct and consistent pill-taking.2 3 5
Advice from 2005 for women missing combined oral contraceptives (30–35 µg and 20 μg ethinylestradiol formulations).1
Box 1 ‘Missed pill’ rules in the Summary of Product Characteristics9
▶ If the forgotten tablet is taken within 12 hours, no further precautions are necessary, further tablets should be taken at the usual time.
▶ If one or more tablets are forgotten for more than 12 hours, contraceptive protection will be reduced. The patient should take the last forgotten tablet, even if this means taking two tablets in 1 day, and then continue to take tablets at the normal time. Additional contraceptive precautions should be taken for the next 7 days, and the patient should follow ‘the 7-day rule’.
Unfortunately the 2005 changes appeared to have been based on old papers since superseded.10,–,16 Even at that time there was evidence contradicting a relaxing of the rules.17,–,19 The CEU admitted they did not consider recently published evidence from 2003 and 2004,10 which was worrying as Pierson et al.19 demonstrated presumed ovulation in 13–19% of 30–35 μg triphasic pill-users following a 3-day dosing error thereby extending the pill-free interval.
Since then further evidence has been published suggesting that hormone-free intervals of …