Emergency Contraception Ruth Adams Clinical Educator Leicester Sexual Health

Aim To be able to advise, signpost and, if appropriate supply the most appropriate type of emergency contraception

Objectives To look at the different types of emergency contraception available To show how to work out the risk time of a lady’s cycle To discuss where emergency contraception can be accessed

What is unprotected sex? No contraception used Condom fell off or split Condom might have fallen off My friends told me I had sex but I was too drunk to remember Missed pills or D&V No condom used when extra precautions were required eg in first week of implant Withdrawal

Three types of emergency contraception Intra-uterine device – most effective Ella One tablet Levonelle tablet – least effective

Emergency IUD 99% effective Also acts as long term contraception Can be fitted up to 120 hours after one episode of UPSI Can be used later than 120 hours or if multiple episodes in certain circumstances Does require an uncomfortable procedure with internal examination Advise food and pain relief 1hour prior and arrange someone to drive home

Emergency hormonal contraception Levonorgestrel also known as Levonelle Less effective than IUD and Ella One approx. 90% Delays an egg being released Equally effective up to 96 hours Product licence up to 72 hours Easy to take and available from school nurse/ pharmacies No effect on foetus so safe to use if previous risk of pregnancy Ineffective if diarrhoea and vomiting Interacts with some medication May be ineffective if too late to delay ovulation

Progestagen Modulator Ulipristal Acetate, brand name Ella One Less effective than IUD, more effective than levonorgestrel approx. 95% Delays an egg being released No decline in effectiveness up to 120 hours Easy to take Unknown effect on foetus Interaction with numerous drugs including contraception Ineffective in case of vomiting and severe diarrhoea

Discussion When was LMP? When was last UPSI? Was this only UPSI? If no periods any other UPSI in last 3 weeks? If multiple UPSI when was first episode? Postnatal/ breastfeeding? Any interacting medication or other medical problems? If no periods or last one abnormal may need a pregnancy test first

Fraser competence Child Sexual Exploitation Child safeguarding referral Vulnerable adult referral Things to consider

How to work out if it is a high risk time Does she have an app on her phone that records her periods and ovulation? Does she know what her cycle is like? Is it regular? Does she know when her last period was? High risk is up to 5 days before expected ovulation and up to 72 hours afterwards If she has a regular cycle and knows her LMP this can be calculated

When is high risk time of cycle? A woman releases an egg 2 weeks before her next period If a woman has a regular cycle ovulation can be estimated by date of her LMP For a woman with a 28 day cycle she will ovulate on day 14 Sperm survives up to 7 days but mostly die off within 3-5 days Her high risk time will be day The nearer to day 14 the higher the risk If a lady has a 35 day cycle her high risk time would be day If a lady has an irregular cycle or not sure it is difficult to tell

Which type of emergency contraception? If one episode or all UPSI within timeframe IUD is most effective and should be offered within 120 hours of UPSI or expected ovulation If patient is interested in PCC IUD call option 4 for advice If oral emergency contraception available still give this in case they do not attend clinic for IUD Advise food and painkillers prior to fitting

Oral emergency contraception for single UPSI Is this a high risk time of cycle? Ella One is more effective and should be first choice so there as there is only one episode If low risk time of cycle Levonelle can be used If only Levonelle available consider likelihood of person attending elsewhere for Ella One, may be better to give Levonelle anyway

Multiple UPSI May be able to fit PCC IUD depending on cycle – ring for advice May be able to give unlicensed levonelle if last UPSI within 96 hours Pharmacies and school nurses may not be able to give unlicenced Levonelle If last sex >96 hours and not for IUD will need to arrange when to do pregnancy test

Where to access emergency contraception See our website for details School nurses GP Urgent care Sexual health clinics CHOICES under 25 clinics Free Levonelle for under 25s at selected pharmacies Bought over the counter at pharmacies, Levonelle approx. £25. Ella one approx. £35

Other Actions Offer or signpost for STI screening Advise re ongoing contraception including LARC Offer quick start method if feasible NOT if taking Ella One Discuss when to do pregnancy test

Professional advice Sexual health professional advice line for information on contraception and sexual health option 4 To arrange PCC IUD call above number For PCC IUD advise eat and analgesia 1 hour prior arrange for someone to take them home

Case study 1 A 16 year old girl requests a pregnancy test Her first ever sex was 80 hours ago She takes lansoprazole

Case study 2 A 16 year old girl attends for emergency contraception Her last UPSI was 24 hours ago Her first UPSI this cycle was 1 week ago Her LMP was 17 days ago

Case study 3 A 16 year old girl requests emergency contraception and wants to start ongoing contraception Her last UPSI was 80 hours ago This was the only UPSI this cycle

References CEU Guidance – Quick Starting Contraception (2010) Faculty of Sexual and Reproductive Health Emergency Contraception Guidance (2012) Faculty of Sexual and Reproductive Health Emergency Contraception. Leicestershire Health Community Formulary search for emergency contraceptionhttp://Leicestershire.formulary.co.uk