Beyond the minipill: a review of progestin-only oral contraception

Progestin-only pills (POPs) represent an underutilized contraceptive option despite expanding evidence for their safety, efficacy, and noncontraceptive applications. This article updates the 2022 review of progestin-only contraception by Liu et al., describing currently available POP formulations and their characteristics.

Contraceptive POPs vary substantially by formulation in mechanism of action, efficacy, and tolerability. The three available in the US contain norethindrone, norgestrel, and drospirenone. While current recommendations are largely based on outdated information, more recent research considers the more nuanced characteristics and noncontraceptive applications of different POPs. Typical-use failure rates are likely lower than historically reported, and the 3-h window (the recommended cutoff for a 'late' dose) has limited evidentiary support and does not apply uniformly across formulations. Drospirenone's unique antiandrogenic and antimineralocorticoid properties, improved bleeding profile, and ovulation suppression distinguish it from other POPs; recent data may support continuous dosing and expand off-label applications. Importantly, this review discusses specific safety considerations and highlights the availability of norgestrel over-the-counter as a major milestone in contraceptive accessibility.

Understanding the distinct contraceptive and noncontraceptive characteristics of each POP formulation allows clinicians to offer individualized counseling that aligns with each patient's reproductive and healthcare goals.