1. Progestin-Only Pills (POPs)
Session I: Characteristics of POPs

2. Progestin-Only Pills Objectives
Participants will be able to:
List key messages for POPs
Describe the characteristics of POPs in a manner that clients can understand:
What POPs are and how they work (mechanism and onset of action)
Effectiveness
General characteristics, especially as compared to combined oral contraceptive pills
Health Benefits
Possible side effects
Relationship to breastfeeding
Discussion (10 min.)
The session is designed to address the POP-related objectives listed in Slides 2-3.
Review objectives with participants <click the mouse to reveal the each objective>
Discuss that these are the objectives for the whole training and are spread across three slide decks.
Explain that the learning objectives will be assessed through knowledge assessments, role plays and the use of skills checklists.
Solicit input about whether the planned objectives match participant’s expectations of the training.
Objectives are continued on the next slide.

3. Progestin-Only Pills Objectives
Participants will be able to:
Demonstrate how to screen clients for eligibility for POP use
Describe when to start POPs
Explain how to use POPs, what to do when pills are missed, and when to return
Address common concerns, misconceptions, and myths
Explain how to manage side effects
Identify clients in need of referral to a higher-level health care provider for POP-related complications
Identify conditions that require switching to another method
The session is designed to address the POP-related objectives listed in Slides 2-3.
Review objectives with participants <click the mouse to reveal the each objective>
Discuss that these are the objectives for the whole training and are spread across three slide decks.
Explain that the learning objectives will be assessed through knowledge assessments, role plays and the use of skills checklists.
Solicit input about whether the planned objectives match participant’s expectations of the training.
Distribute the pre-test when done reviewing objectives.

4. POPs Key Points for Providers and Clients
Very safe.
Pills are not harmful for most women’s health.
They do not cause any serious health problems, cancer, or infertility or large changes in blood pressure.
Contains only progestin (sometimes called progestogen) hormones. Okay for women who cannot take estrogen.
Works mainly by thickening cervical mucus and also by stopping ovulation
Take a pill at the same time every day.
“Would you remember to take a pill at the same time each day?”
No need to do anything at time of sexual intercourse.
No break between packs.
Good method while breastfeeding
For breastfeeding women, they do not affect the quality or quantity of breastmilk. They are not harmful to the baby’s health and do not affect infant growth.
Very effective if taken every day at the same time, especially combined with breastfeeding. But if woman forgets pills, even if she is breastfeeding, she may become pregnant.
Explain: (Slide 3 and 4): The key points to remember about POPs are that: they are very safe, including for women who cannot take estrogen; one pill must be taken every day at the same time each day; POPs are a good method for women who are breastfeeding because they are very safe for women and babies and breastfeeding increases the effectiveness of POPs; some women have side effects, particularly bleeding changes, at first, but these are not harmful); POPs don’t provide protection against STIs or HIV/AIDS; and POPs can be given to a woman to start later, during her next monthly bleeding, if you are unable to rule out pregnancy. Continued on the next slide. Adapted from WHO’s Decision-making tool for family planning clients and providers.

5. POPs Key Points for Providers and Clients
Bleeding changes are common but not harmful.
Typically pills lengthen how long breastfeeding women have no monthly bleeding
For women having monthly bleeding, frequent or irregular bleeding is common
Side-effects often go away after first 3 months.
No protection against STIs or HIV/AIDS.
For STI/HIV/AIDS protection, also use condoms.
Can be given to a woman at any time to start later
If pregnancy cannot be ruled out, a provider can give her pills to take later when her monthly bleeding begins.
Adapted from WHO’s Decision-making tool for family planning clients and providers.

6. What Are POPs? Content and Types
Only one hormone, progestin. Do NOT contain estrogen. Sometimes called the “mini-pill”
Types
Common: norethistrone (norethindrone), levonorgestrel, desogestrel,
Less Common: etynodial diacetate, lynestrenol
Have similar effectiveness, safety, characteristics, and eligibility criteria
Pills per pack
28: all active pills 35: all active pills
(no break between packs)
Ask the participants: (Slide 6): What are POPs? <allow participants to answer; click the mouse to reveal the following traits>
POPs only contain one hormone, progestin. They do not contain estrogen.
There are different types of POPs. There are no clinically significant differences in effectiveness, characteristics, eligibility criteria or safety between these.
POPs are packaged with either 28 or 35 pills per pack.  
Both contain all active pills. Every pill contains the same amount of hormone.
There are no hormone free intervals or breaks between packs. A woman starts the next pack of pills the next day after she finishes the current pack.
Ask the participants: Which brands of POPs are available in the facility where they work (or in their country, pharmacy, or program). Allow participants to answer and add to the participants’ responses as needed.  Explain the difference in case someone asks

7. POPs: Mechanism of Action
Suppresses
hormones
responsible for
ovulation
Explain that progestin-only injectables prevent pregnancy in two ways:
The primary mechanism of action is to suppress ovulation. Progestin causes the hypothalamus and the pituitary gland to reduce production of the hormones that are necessary for ovulation. Without ovulation, there is no egg to be fertilized.
Progestin also thickens the cervical mucus. The thickened mucus makes it more difficult for sperm to enter the uterine cavity. In the unlikely event that a woman does ovulate, this mucus barrier greatly reduces the chance that the egg will be fertilized.
Other contraceptive methods that work this way are injectables, implants and combined oral contraceptives (COCs).
POPs do not disrupt an existing pregnancy and do not harm a fetus if a woman is accidentally given this method when she is already pregnant. However, if it is determined that a woman who is using POPs is, indeed, pregnant, she should stop receiving injections.
For women who are interested in this method, how will you explain how POPs work?
Brainstorming instructions:
Ask participants to brainstorm ideas about how to explain how POPs work to prevent pregnancy, using simple language the client will understand. For example, “Your body stops producing eggs for as long as you take the pill so you cannot get pregnant.” Encourage participants to use pages or illustrations from counseling tools to help with their explanations.
Illustration credit: Salim Khalaf/FHI
Thickens
cervical mucus to block sperm
POPs have no effect on an existing pregnancy.

8. Effectiveness of POPs
In this progression of effectiveness, where would you place combined oral contraceptives (POPs)?
Less effective
More effective
Implants
Male Sterilization
Female Sterilization
Intrauterine Devices
Progestin-Only Injectables
Combined Oral Contraceptives
Male Condoms
Standard Days Method
Female Condoms
Spermicides
Inform: The list on these slides categorizes contraceptive methods from most effective to least effective as commonly used. In this list, spermicides are the least effective method and the most effective methods are contraceptive implants, sterilization, and IUDs.
Ask participants: Where would you put POPs on this list? Is it different for breastfeeding women and non-breastfeeding women.
After participants respond, click the mouse to reveal the answer
Conduct Counseling Role Plays conveying information about method effectivness.
Conclude by emphasizing that POPs are at the top of the second tier of methods, as they are very effective methods of contraception. They are more effective for breastfeeding women than non-breastfeeding women because in breastfeeding women they combine with the effects of lactational amenorrhea.
Emphasize that effectiveness depends on getting injections regularly. The risk of pregnancy is greatest when a woman misses an injection.
POPs (breastfeeding)
POPs (not breastfeeding)

9. Relative Effectiveness of FP Methods
# of unintended pregnancies among
1,000 women in 1st year of typical use
No method
850
Withdrawal
220
Female condom
210
Male condom
180
Pill (COCs and POPs)
80 (COCs)
70 (POPs alone)
10 (POPs and breastfeeding)
Injectable 60
IUD (CU-T 380A / LNG-IUS)
8 / 2
Female sterilization 5
Vasectomy
1.5
Implant
0.5
Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) , Elsevier Inc. with POP+BF addition from Family Planning: A Global Handbook for Providers
Explain that there is another way to look at effectiveness. In this slide we look at how effective FP methods are as they are commonly used. The slide shows the number of women who would get pregnant if 1,000 women used a method for one year. So, if 1,000 fertile women who were having sex, but not using any protection from pregnancy, 850 of them would become pregnant. But, if the same 1,000 women were using a POP while breastfeeding 10 would become pregnant and if the same 1,000 women were using a POP while not breastfeeding 70 would become pregnant. Ask participants- what if these same women were using an IUD, how many would become pregnant? As part of good counseling, it is important to inform clients about how effective each method is.

10. POPs: Characteristics
Require taking one pill, every day, with no break between packs, and at the same time every day, especially if not breastfeeding
Very effective when used correctly, especially for breastfeeding women
Safe for breastfeeding women and their babies
Bleeding changes are common but not harmful.
Can be stopped at any time
No delay in return to fertility
Controlled by the woman
Do not interfere with sex
Very few health risks
Do not provide protection from STIs/HIV
Have some potential side effects
Instructions for facilitator:
Characteristics of group work activity: Ask participants to brainstorm first a list of positive characteristics (advantages) and then negative characteristics (limitations) of progestin-only injectables. Write these suggested characteristics on a flip chart. Then show the slides of characteristics of progestin-only injectables and compare them to the list generated through brainstorming.
If you use the terms advantages and limitations, mention that the same characteristic of a FP method may be an advantage for one person and a limitation to another.
Discuss and correct any misconceptions and counter any myths that may arise about progestin-only injectables.
Remind participants that people with similar characteristics in similar situations may have very different reasons for making choices about contraceptive methods. When counseling clients it is important to help them consider how these method characteristics fit with their lifestyles and reproductive health goals and desires.
Do not show this slide until you have completed the “Characteristics of POPs” work group activity. As you review this slide and the next few in the presentation, refer to the lists that the participants developed as part of their “Characteristics of POPs” work group activity.
Source: Hatcher, 2011; WHO, 2010; CCP and WHO, 2018; Trussell , 2011.

11. Breastfeeding and POPs:
POPs have no effect on:
Onset or duration of lactation
Quantity or quality of breast milk
Health and development of infant
POPs can be taken immediately after delivery by both breastfeeding and non-breastfeeding women.
Use slide to present the following:
No impact of POPs on milk quality or quantity, duration of breastfeeding, or infant growth or well-being
No concerns about use POPs for breastfeeding women and their infants 
Breastfeeding  and non-breastfeeding women may begin POPs any time after delivery. This is a change from previous versions of the MEC, which suggested breastfeeding women wait 6 weeks before starting POPs to allow milk supply to be fully established. New data has shown this is not necessary and women can begin immediately.
Source: CCP and WHO 2018;

12. POPs vs. COCs: Advantages
All pills the same-no pill color changes or days without pill taking
May be taken by women who cannot use estrogen
May by taken by breastfeeding women
Lower risk of complications such as stroke and blood clots
No impact on quality or quantity of milk for breastfeeding moms
The purpose of this activity is to give participants an opportunity to think about how the particular characteristics of POPs and COCs differ in order to provide better counseling to patients about which one may be more appropriate for them. You should link this to the brainstorming participants already did about characteristics of POPs.
Ask participants to think about some reasons why women might want to or need to use a POP instead of COC. For example, consider why women in different situations may prefer or avoid use of COCs because of a particular characteristic. For example, a woman who wants to take pills but is over 35 and smokes many cigarettes a day may take a POP but could not take a COC.
Source: Hatcher, 2011; WHO, 2010, CCP and WHO, 2018; Trussell , 2011.

13. POPs vs. COCs: Disadvantages
For non-breastfeeding women:
POPs are not as effective as COCs and other hormonal methods
More likely to have menstrual bleeding changes (irregular, more frequent, or heavier bleeding) than women on COCs
More likely to develop ovarian follicles than on COCs, though these usually go away on their own.
Both need to be taken every day, but it is more important to take POPs at exactly the same time each day, especially for non-breastfeeding women.
POPs do not increase the risk of ovarian and endometrial cancers but not reduce the risk. COCs reduce the risk of ovarian and endometrial cancers.
Ask participants to think about some benefits of COCs that POPs do not have. Remind participants that women with similar characteristics in similar situations may have very different reasons for making method choices. When counseling women it is important to help clients consider how these method characteristics fit with their lifestyles and reproductive health goals and desires.
Source: Hatcher, 2011; WHO, 2010; CCP and WHO, 2018; Trussell , 2011.

14. Possible Side-Effects
If a woman chooses this method, she may have some side- effects. They are not usually signs of illness.
Many women do not have any side-effects.
Side-effects often go away after a few months and are not harmful.
Common (when not breastfeeding): irregular bleeding or spotting (bleeding at unexpected times), heavy or prolonged bleeding (twice as much as usual or longer than 8 days), no monthly bleeding
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Possible Side Effects of POPs
Lecturette (10 min.)
Remind participants that as with all contraceptive methods, there are some side effects associated with POPs that are not harmful but may be unpleasant.
Women’s preferences for certain methods are often related to side effects. Ask the participants: What side effects of POPs have you heard about?
POPs may cause bleeding changes.
Most women experience a reduction in the amount of menstrual bleeding. The majority of women have regular menstrual bleeding while taking POPs; however, some women may experience amenorrhea (no monthly bleeding).
Breakthrough bleeding, or irregular bleeding between periods. This is bleeding at unexpected times that bothers the clients. It ranges from spotting to light bleeding episodes. This is less common in breastfeeding women.
Because some cultures or religions restrict sexual and religious activities during menstruation, breakthrough bleeding may interfere with a woman’s daily life. Breakthrough bleeding is generally not harmful to a woman’s health.
Heavy or prolonged bleeding may also occur. This is bleeding that is twice as much as usual or longer than 8 days. It usually goes away on its own after a few months, and is not harmful.
Other common side effects may include nausea, dizziness, headaches, breast tenderness, or abdominal pain due to ovarian follicles or cysts.
It is important to remember that many POP users do not experience any side effects. Those who do experience side effects may experience one or two of these side effects, but not all of them.
Typically, side effects diminish within a few months after a woman begins POP use.
Because these side effects may have an important impact on users’ experience with POPs, they should be addressed during counseling and follow-up visits.
Less common: nausea, headache, tender breasts, dizziness, abdominal pain