At each subsequent POI, health care professionals should ask about unscheduled bleeding.  If it is unacceptable to the patient, they may consider co-prescribing 3 months of COC (if medically eligible) while bleeding pattern settles down.  There is little evidence about the safety of co-prescribing this longer than 3 months, so is up to clinical judgement.  FSRH also suggests 5-day mefenamic acid co-prescribing to halt bleeding, although at the time of writing this module, mefenamic acid has become very expensive and some trusts warn against it. 

Long-term users need to be reviewed every 2 years by a prescriber to discuss the risks versus benefits of continual use.  It is usually recommended women consider switching at 50 years of age, due to increased risks on health, though many women may choose to continue with POI until the menopause.  This is acceptable, provided the woman is fully informed about the risks to her health (particularly bone health).  Women should be encouraged to attend their cervical smears, monitor for breast lumps and keep active with reasonable calcium intake.  Patients who have developed multiple cardiovascular risk factors should be switched to a more appropriate contraception.

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