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

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. Menstrual cycle

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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