Emergency contraception

Emergency Contraception Intervention aimed at preventing unintended pregnancy after unprotected sexual intercourse or potential contraceptive failure.

Usual scenario.... 20 yr old woman requests the “morning after pill” for upsi 36 hours ago. When you offer her a copper intrauterine device, ulipristal acetate or levornogestrel she looks surprised and says “can’t I just have the pill I had last time”

3 methods Effectiveness >99% at any time of cycle. Copper IUD; can be used up to 5 days following first UPSI in cycle or within 5 days from the earliest estimated day of ovulation. Effectiveness >99% at any time of cycle.

Oral emergency contraception

Levonorgestrel, LNG; free from GP’s Sexual health /young persons clinics Brook centres ( 25 and under) NHS walk in centres ( England only) Some A&E departments Some pharmacies for 16+ Licensed for use up to 72 hours after UPSI or contraceptive failure; may be used up to 120 hours ( off licence)

Levonelle LNG Can be purchased over the counter at cost of £25 for age 16 and over It is a single dose levornogestrel 1.5 mg.

Ulipristal/UPA “ellaOne” A selective progesterone receptor modulator; single dose 30 mg. Licensed for use up to 120 hours after UPSI or contraceptive failure. Cost £16.95 Available otc £43!!!

When is EC needed? Missed cocp Late POP ( >27 hrs for conventional POP,>36 hours for desogestrel) Condom not used/ condom accident Late depo >14w since last injection IUD removal, expulsion, lost threads Enzyme inducing drugs and failure to use extra precautions

How does it work? IUD; copper toxic to sperm and ovum; primarily inhibits fertilisation (and implantation) LNG; interferes with ovulation by inhibiting LH surge ellaOne; delays LH surge and has effect on follicular rupture; additional action

Levonorgestrel, levonelle Inhibits ovulation only if given before the LH surge. It has no effect if given after ovulation.

Ulipristal, EllaOne Suppresses lead follicles when given just before ovulation, including during the LH surge. It is unclear if it has any effect after ovulation

Actions different EC methods

How effective is it? IUD >99% effective LNG up to 95% within 24 hrs UPA at least as effective as LNG up to 120 hours

Evidence LNG v UPA Glasier; meta-analysis ( Lancet 2010) Looked at 2 randomised controlled trials Authors concluded that the pregnancy rate with UPA was significantly lower at all time periods analysed up to 120 hours.

Case one 22 year old Lucy has just started a new job. She attends your surgery on Tues am after bank holiday weekend. She got drunk at a party on the Thursday night and cannot remember using condom. She is requesting a “morning after pill” What other information do you need?

Case one Lucy has a predictable 28 day cycle and her last period started 12 days ago. She has not had any other acts of upsi this cycle. What treatment would you offer her?

Lucy UPSI 4+ days ago Currently day 12; so this occured around day 8 of 28 day cycle. Too late for levonelle Her options are between ellaOne and IUD.

Risk of pregnancy Risk is highest mid cycle( 5 days before and 1 day after ovulation) Risk is 20-30% Rest of cycle; risk is around 10% but due to unpredictable nature of ovulation there is no point at which one could guarantee that pregnancy won’t occur. Implantation is always at least 5 days after ovulation.

Case two Laura,18, no regular contraception. Sunday pm, on call centre. Had sex last night, condom came off. LMP started 10 days ago. She has a regular cycle, but can be up to 3 days early. She is very keen to avoid pregnancy as she is going to university after her gap year and is going on a college field trip tomorrow. What method do you feel would be most suitable for her?

Case two, Laura This is a mid cycle event; most risky time but she is only 24 hours after the event. In theory; LNG or UPA can be used UPA will offer a slight advantage due to its additonal effect on ovulation. Emergency IUD would be most effective option( you have until day 16 to fit this)

What are the side effects of EC? IUD; pain LNG and UPA; nausea, headache, altered bleeding pattern Vomiting in approx 1%( suggest repeat dose if vomit within 2 hrs LNG or 3 hours UPA) Repeat dose/offer IUD Next menses; on average 1.2 days earlier with LNG, 2 days later with UPA

When to do pregnancy test? If no period, pregnancy test should be positive 3 weeks after event of upsi.

Case three 16 year old Mary has a chaotic cycle. She had sex with her new boyfriend last night and he did not have a condom. On further questioning she took LNG 3 weeks ago after having sex with someone else and has not had a period since. What should you consider and how would you proceed?

16 year old Mary. Vulnerable young adult. At risk STI and pregnancy. Drugs and alcohol? Age boyfriend? Consensual? Provide condoms and encourage quick start method.

Can the method be used again in the same cycle? IUD can be used for multiple events in same cycle if fitted within 5 days earliest calculated date of ovulation LNG can be used more than once in same cycle; even if the earlier episode of upsi was outside the treatment window( outside product licence)

Can the method be used more than once in same cycle? UPA can not be used more than once in same cycle and cannot be used if LNG has been given earlier in the cycle. UPA cannot be used if there has been an earlier UPSI event earlier in the cycle outside the treatment window of 120 hours.

Case four Lorraine is 16. You saw her a week ago and provided LNG for her for upsi the night before. It is now 13 days since her last period which occur every 4 weeks. She admits when you ask that she also had sex 4 days ago but was afraid to mention it. Again she had not used a condom. What is her EC method of choice?

Case four Copper IUD deals with both episodes and is her best choice. LNG can be used but is only 50% effective. You have until day 19 in a 28 day cycle to fit IUD; ie you have 6 days to organise this. If you arrange for her to have IUD fitted in 2 days time what else would you do?

What methods can be used together? LNG>1 per cycle LNG and IUD( recommended if considering IUD) UPA and IUD But not; LNG and UPA in same cycle Or…….UPA>1 per cycle

Ongoing contraception; quick start. Methods which can be started immediately after oral EC include CHC, POP, implant. It is recommended that depo should only be quick started if all above options are considered to be unsuitable.

Quick start after LNG. CHC; use condoms for 7 days. Qlaira; use condoms for 9 days. POP; use condoms for 2 days.

Quick start after UPA There is the possibility that it may interfere with ongoing hormonal contraception . It is also possible that the hormonal contraception can reduce the efficacy of UPA……..

Quick start after UPA After taking UPA for EC, a woman should not start a hormonal contraceptive method for at least 5 days and be advised to use barrier methods or to abstain from sex until effective hormonal contraceptive cover has been achieved.

Quick start after UPA UPA, then wait at least 5 days; then as table Method ( UPA +5 days) Additional contraception COC/ ring/patch 7 days Qlaira 9 days POP 2 days Implant or injectable

Drug interactions with EC LNG; reduced efficacy with liver enzyme inducers and for 28 days after. Offer copper IUD or if this is unacceptable a single 3mg dose LNG( outside product licence) Eg St John’s Wort; use double dose Concomitant use cyclosporin; increases toxicity; IUD preferred

Drug interactions with EC UPA ; cannot be used if on liver enzyme inducers or for 28 days after this. UPA; requires acidic pH in stomach; cannot be used if on antacids, PPI, H2 blocker Also ;avoid UPA if severe asthma uncontrolled with oral steroids.

Investigations? STI testing including HIV Retest after appropriate window; 2 weeks for chlamydia Consider prophylactic antibiotics with emergency IUD; stat dose azithromycin to cover chlamydia.

Future contraception Oral EC does not provide contraceptive cover for further UPSi in same cycle. Consider “quick start”;cocp, pop or implant with extra precautions. IUD; can leave for future contraception/ remove when pregnancy excluded. If removing ensure adequate method/no sex for 7 days before removal.

What method should be offered? Copper IUD should be offered to ALL WOMEN and DOCUMENT this. Use of LNG > 72 hours would be unlicensed but supported by Clinical Effectiveness Unit for up to 96 hours UPA is the only oral method licensed for 72 to 120 hours and is the preferred method if elligible.

Summary UPA best option For those between 72-120 hours UPSI who do not want copper IUD. For those around ovulation who do not want copper IUD

Summary After copper IUD,levonelle next best option In those who are breast feeding In those who have missed pills and want to continue In those quick starting hormonal contraception

Case 5; Missed pills? You receive a telephone call on Friday pm on call; 28 yr old; ran out of Yasmin, wishes a prescription urgently. Only on questioning her; should have started her pill 2days ago. Had UPSI 4+ days ago in pill free interval. Unaware that she needs emergency contraception. Declines IUD, too late for levonelle.

Missed pills She opted to have Ellaone but advised needs to delay pill start for 5 days and to use condoms for 7 days of her next packet. Pregnancy test in 3 weeks from UPSI

Cost effectiveness? Ulipristal is a cost effective alternative to levornogestrel for all women requesting EC. Provision of EC however has not been shown to reduce the rate of unintended pregnancy or abortions.

Information required; summary Medical eligibility Efficacy of method LMP and cycle length Number episodes UPSI in cycle and when Previous use EC in same cycle Drug interactions Need for additional precautions/ ongoing contraception

Back up birth control Both levonelle and ellaOne are available from selected pharmacies for FUTURE as well as post coital use! Eg Superdrug offer on line and next day delivery service.