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”

CHOICE The copper IUD is about 10 times more effective than oral emergency contraception 1 in 1000 will get pregnant after emergency copper IUD 1 in 100 will get pregnant after oral emergency contraception

Oral emergency contraception

Oral EC ; free from GPs 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 for age 16 and over ( Boots £27, superdrug and Tesco £13.50) 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 £35

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 UPA; 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 has no effect once ovulation has occurred.

Actions different EC methods

How effective is it? IUD >99% effective LNG up to 95% within 24 hrs Ineffective >96 hrs after UPSI UPA at least as effective as LNG up to 120 hours

UPA vs LNG UPA should always be considered first line oral EC if a woman has had UPSI within 5 days and during her fertile window… ……………because it works closer to the time of ovulation and has been shown to be more effective than LNG

UPA vs LNG If the UPSI was not likely to be during the fertile window ( especially if UPSI was at a time of very low risk of pregnancy), remember: Initiation of hormonal contraception has to be delayed for 5 days after UPA in the previous 7 days UPA could be less effective if a woman has taken a progestogen; including LNG . UPA is much more expensive than LNG

UPA vs LNG Both UPA and LNG can be given:- More then once in a cycle If very early pregnancy cannot be absolutely excluded There is evidence that oral EC does not disrupt an existing pregnancy and is not associated with fetal abnormality

What methods can be used together? LNG and UPA >1 per cycle LNG and IUD( recommended if considering IUD) UPA and IUD But avoid LNG for 5 days after UPA ? Avoid UPA for 7 days after LNG( as there may be progestogen still in circulation)

What about IUD? Copper IUD works by preventing implantation Copper is toxic to sperm and eggs Copper creates an endometrium that is hostile to implantation It is immediately effective for ongoing contraception

When can a copper iud be inserted for EC?

Emergency contraception has to work Before a pregnancy has implanted … so that it complies with the law A pregnancy doesn’t implant During the first 5 days after fertilisation…. ..and fertilisation can’t happen until sperm arrive. So a copper iud for EC can be inserted within 5 days after the First UPSI in a cycle

EC has to work before a pregnancy is implanted ..so that it complies with the law. 84% of pregnancies implant 8-10 days after ovulation. The earliest implantation was observed at 6 days after ovulation.. So to be on the safe side, a copper IUD for EC can be inserted up to 5 days after the earliest likely ovulation

In summary… A copper IUD can be inserted for EC Within 5 days of the first UPSI since the LMP OR within 5 days of the earliest estimated day of ovulation….. ….Whichever is the later.

If copper iud cannot be inserted immediately… Give oral EC and arrange fitting copper IUD later as long as within the effective time frame.

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.

Ongoing contraception? Oral EC delays ovulation and doesn’t provide ongoing contraception; So a woman is at risk of pregnancy if she has more UPSI around the time that she ovulates later in the same cycle

It is essential after oral EC that a woman commences ongoing contraception.

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. Start hormonal contraception immediately

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 ? Will she start her pill or come back for her CHC POP Nexplanon (depo) ----5 days wait- --7 days condoms, ( 2 days for POP) ? Will she start her pill or come back for her Nexplanon or depo after 5 day wait.

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 double dose LNG 3mg( 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. Double dose UPA is not recommended. Also ;avoid UPA if severe asthma uncontrolled with oral steroids.

Body weight? If BMI >26 or weight>70kg give double dose LNG.

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.

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. see FSRH algorithm

Summary UPA best option For those between 72-120 hours UPSI who do not want copper IUD. For those who have UPSI in the 5 days before 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

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.

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.

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)

Case 3 Amy How likely is it that Amy will get pregnant from this UPSI? 16 yrs old Using no contraception UPSI 2d ago Also UPSI 10d ago LMP 15d ago Cycle always exactly 28d long She doesn’t want to be pregnant How likely is it that Amy will get pregnant from this UPSI? When is she likely to ovulate? Earliest likely ovulation was yesterday; day 14 When is ovulation in relation to UPSI? UPSI was the day before ovulation Amy is at very high risk of pregnancy

Case 3 Amy Is she elligible for Cu-IUD? 16 yrs old UPSI 2d ago Also UPSI 10d ago LMP 15d ago Cycle always exactly 28d long Is she elligible for Cu-IUD? Is she within 5 days of first UPSI? No Is she within 5 days of the earliest likely ovulation? Yes. Amy is elligible for IUD Her age is not a contraindication

Case 3 Amy Amy doesn’t want a Cu-IUD. 16 yrs old UPSI 2d ago Also UPSI 10d ago LMP 15d ago Cycle always exactly 28d long Amy doesn’t want a Cu-IUD. Which oral EC should you offer and why? It could be too later for any oral EC to work; tell her again. UPA has the best chance of still being able to delay ovulation if it happened late this month. But she had UPSI 10d ago; can I still give her UPA? Yes

Case 3 Amy Amy opts for UPA What is the most important next step? Sort out ongoing contraception Amy wants an implant for contraception. When can this be inserted? Amy must wait 120 hrs after taking UPA before having implant. She need to use condoms until then ….. And for how long after that? Condoms for another 7 days after insertion

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.