Emergency Contraception Dr Caroline Marfleet Consultant in SRH Colchester Hospital University Foundation Trust

Indications for e.c. UPSI/ split condoms Failure to use additional precautions when starting hormonal methods Failure to use additional precautions when using enzyme inducers or within 28 days of use Missed pills; if 2 or more active pills are missed POP – Late or missed pills POI – Late injection (> 14 weeks since last Depo or Sayana) IUC – removal without immediate replacement; partial or complete expulsion; threads missing and location unknown Rape/ sexual assault/use of teratogenic agents

Risk of conception Conception is most likely to occur on the day of ovulation or in preceding 24 hrs The probability of conception from a single act of intercourse in the 1st 3 days of the cycle appears to be negligible

History Reason for requesting e.c Regular partner; casual ; consensual? Need for sexual health check? Timing of all episodes of UPSI in current cycle Most likely date of ovulation based on LMP and usual cycle Use of medications that may affect contraceptive efficacy Any other relevant medial history

Methods of e.c. Hormonal Copper IUDs Levonorgestrel e.c. – Levonelle (1.5 mg ) Ullipristal acetate e.c. – UPA 30 mg (ellaOne) Copper IUDs

Indications LNG e.c. – licensed for use within 72 hrs of UPSI UPA – licensed for use within 120 hrs of UPSI CuIUD – within 5 days of 1st UPSI in a cycle or within 5 days from the earliest date of ovulation LNG e.c. - ? Some efficacy up to 120 hrs, but efficacy less certain after 96 hrs

Method of action of LNG e.c. Incompletely understood but primary action is to inhibit ovulation Appears to prevent follicular rupture or cause luteal dysfunction If taken prior to luteal surge, causes ovulatory dysfunction in the next 5 days No better at placebo at suppressing ovulation when given immediately prior to ovulation and not thought to be effective once fertilisation has occurred

Method of action of UPA Progesterone receptor modulator Inhibition or delay of ovulation Suppresses growth of lead follicle Can prevent ovulation after the LH surge has started, delaying follicle rupture until up to 5 days later Ineffective at time of LH peak or after

Menstrual cycle

Method of action of CuIUD Cu is toxic to ova and sperm Primarily inhibits fertilisation If fitted within 5 days of fertilisation, will prevent implantation Effective immediately after insertion

Calculating the last menstrual cycle day when an IUD can be fitted for e.c. Timing of IUD insertion Can be fitted up to 5 days after earliest expected ovulation 26 day cycle Day 17 of cycle 28 day cycle Day 19 of cycle 30 day cycle Day 21 of cycle 32 day cycle Day 23 of cycle Can be inserted on any day if all UPSI occurred within previous 120 hrs

Efficacy of e.c. Cu IUD >99% efficacy LNG e.c. – 52-94% efficacy; better if taken soon after UPSI and shown to be effective to 96 hrs ellaOne – 98% effective No evidence of reduced effect with obesity

Side effects with e.c. Cu-IUD LNG and UPA Insertion pain Risks of infection in 20 days post insertion Risks of expulsion, perforation, ectopic pregnancy (CEU Guidance IUC Apr 2015) Headache Nausea <20% Vomiting <1% Altered bleeding patterns If vomits with 3 hrs of LNG, take a further dose asap; if vomits within 3 hrs of UPA, take a further dose Most bleed within 7 days of usual time; can be 1-2 days earlier after LNG and 1-2 days later after UPA; in 20%, menses delayed by 7 days after UPA

Contraindications Cu-IUD Hormonal e.c. Use of IUD for e.c. has same CIs as routine insertion Risk of STIs, previous ectopic, age, nulliparity are not CIs LNG – no medical CIs including breast feeding UPA – Hypersensitivity to UPA Severe uncontrolled asthma Caution if hepatic dysfunction; hereditary galactose intolerance; lactose deficiency; glucose-galactose malabsorption

UPA and breast feeding e.c. not indicated until day 21 onwards post partum LAM is >98% effective if < 6 months postpartum, amenorrhoeic and fully breast feeding UPA can be detected in breast milk for up to 5 days after UPA so women should avoid breast feeding for 7 days after UPA

Use of oral e.c. more than once in cycle LNG UPA Can be used more than once in cycle If further UPSI occurs within 12 hrs of LNG, further Rx is not required CEU supports use of UPA more than once in cycle or if there has been another episode of UPSI outside the treatment window (>120 hrs) UKMEC 1 Can give LNG after UPA if another episode occurs, but efficacy may be reduced

Drug interactions Women taking EIDs ( or who have stopped within the last 28 days) should be advised that a CuIUD is the only method of e.c. not affected by these drugs Women taking EIDs including post exposure HIV prophylaxis after UPSI or who have stopped within the last 28 days and who decline or are not eligible for a CuIUD should be advised to take a dose of 3 mg LNG (2 Levonelle)asap within 120 hours of UPSI (outside the product licence). The efficacy after 96 hours is uncertain Women taking EIDs should be advised not to use UPA during or within 28 days of stopping this medication Women should be advised not to use UPA if they are currently taking drugs that increase gastric pH (eg, antacids, proton pump inhibitors, Histamine H2 anatagonists)

Contraception after hormonal e.c. Women may prefer to wait until pregnancy can be excluded before starting a hormonal method of contraception CEU supports quick starting CHC (excluding Co-Cyprindiol), POP or Implant. POI should only be quick started if other methods are unacceptable or not appropriate The LNG-IUS should not be started after hormonal e.c. and a bridging method should be offered

Contraception following LNG e.c. Additional precautions or abstinence should be advised for 7 days when continuing or starting CHC; 2 days for POP or Implant and 9 days for Qlaira

Contraception following UPA e. c Contraception following UPA e.c. CEU advises that women should not start a hormonal method for 5 days after UPA UPA= day 0 Methods (day UPA + 5) Requirement for additional contraception UPA then wait at least 5 days CHC (except Qlaira) 7 days Qlaira 9 days POP (traditional and DSG) 2 days POI or Implant

Aftercare Women may be offered follow up if they want a pregnancy test, STI screening, Cu-IUD removal or have any concerns/ difficulties with their contraception Failure of a Cu-IUD should be managed as per Faculty Guidance Failure of hormonal e.c. does not need to be managed differently from other pregnancies If a woman chooses to continue a pregnancy after exposure to UPA, it should be reported to the manufacturer