1. Emergency Contraception (Hormonal method)
PGD training
Pharmacists South Tyneside and Gateshead
Dr Janet Gallagher Assoc. Specialist Sexual Health Services Gateshead and South Tyneside

2. Covering Education / knowledge Information / new information
Reducing risk taking behaviour
Considering the unexpected/ onward referral, physical, emotional , harassment, exploitation, abuse
Reducing the need for EHC In the future?
Testing your understanding

3. UPSI =unprotected sexual intercourse
EC = emergency contraception
LNG-EC= levonorgestrel 1.5mg
QS= quick start of a suitable hormonal contraception
UPA-EC= ulipristal acetate 30mg
Cu-IUD= copper intrauterine device

4. What do you think? Is there any time
E C is not necessary because there is no risk?
How to decide in the pharmacy to offer EC and which is best?
What do you think?
Why should I discuss EC IUD if I can’t fit one?
What other risks are there
Should consider EllaOne and what about the price difference?
Do I have to refer onward
Is it safe? Will it ever do any harm?

5. Misconceptions I can use EHC as a method of contraception
It will cause an abortion
My boyfriend can get it for me…. Alarm Bells
I can take it any time
It will work every time I take it
I cannot take it as I have migraine
I am ‘ allergic’ to hormones

6. Risk of Pregnancy following UPSI
2-4% after a single act of UPSI anytime during the cycle
Highest risk if UPSI in 5 days before ovulation and that day of ovulation
No risk if before 21 days post natal
No risk days 1-4 after TOP, miscarriage, ectopic
More irregular cycle , greater length of risk of pregnancy but less over all.
Can you calculate exact risk, science or art?
What about their weight ( BMI)?
Peak day 13

7. No day when no risk but highest before ovulation

9. UPSI
Consensual sex
Failure of a method , compliance or not used at all
Rape /Sexual assault, non-consensual
Withdrawal method
Ejaculation on the genitalia
Remember to think about police or Reach for pateitn needs if they have been assaulted

10. Pitfalls in calculating risk
Sure of LMP- No woman has exactly 28 day cycle to the hour
Follicular and luteal phases are variable
Was there full ejaculation , did the condom slip of after
Has she taken hormones recently ( especially if UPA-EC considered)
How may times has she had sex
Variable natural fertility

11. Licensed Methods in UK Levonelle 1500 (introduced October 2005)
Now (P)
ellaOne
Copper IUD

12. How effective is Levonelle
Only evidence of efficacy at 96 hours none at 120 hours
Can be repeated in a single cycle
What are we treating,
Real risk
Anxiety
Both Levonelle and ellaOne work to delay ovulation
Reduced effect if BMI >26 or Weight > 70kg ( levonorgestrel unknown , ulipristal acetate)
No known effect after ovulation?

13. Caution? UKMEC 2016 category 2
These conditions benefits outweigh risks
Current VTE on anticoagulants
Current or Past history of breast cancer
Inflammatory bowel disease( particularly if known to have significant malabsorption or small bowel resection following Chron’s) Not affected by colectomy and ileostomy
Acute intermittent porphyria

14. Caution exclusions- No UKMEC 3 or 4 category
Acute intermittent porphyria may be used
Severe liver disease No Contraindication in UKMEC 2016
Severe malabsorption syndromes
Trophoblastic disease No Contraindication in UKMEC 2016
Remember enzyme inducing drugs ( allows for 2 to be taken)
Previous ectopic pregnancy There is no apparent increased risk of ectopic pregnancies following use of any EC method

15. UPA-EC More effective than LNG-EC Works before LH surge
Up to 120 hours from UPSI
Effectiveness reduced in takers of enzyme inducing drugs ( and for 28 days after stopped taking)
Not suitable for women who have severe asthma controlled by oral steroids
Unknown significance of esomeprazole on UPA-EC. Not studies of UPA-EC used. Lower level of ulipristal (when used for other reasons at different doses) shown to be altered by esomeprazole

17. News hot off the press highlights Apr 2017
Women not wanting to conceive should be offered EC after UPSI taken place on any day of natural cycle
EC providers who cannot offer all EC methods should give women information on other methods and signpost them to services that can provide them. If chosen CU IUD then oral EC should be given at time of referral in case IUD can not be inserted or woman changes mind or does not attend.
EC providers can offer UPA-EC or LNG-EC if she has had UPSI earlier in the same cycle as well as within the last 5 days. They will not disrupt an existing pregnancy and are not associated with fetal abnormality.

18. UPA-EC can be used again in same cycle after further UPSI
LNG-EC can be used again in same cycle after further UPSI
If already taken UPA-EC, LNG-EC should not be taken in next 5 days
If already taken LNG-EC , UPA-EC could be less effective it taken in 7 days after taking
After taking LNG-EC women should be encouraged to start contraception immediately or ASAP and use condoms or abstain until this method is effective
After taking UPA-EC women should wait 5 days before starting hormonal contraception and wait until this method is effective

19. If Cu IUD is not acceptable EC providers should consider UPA-EC as the first ling oral EC for a woman having UPSI within last 5 days and or if likely to have occurred in 5 days prior to estimated day of ovulation
Breast feeding women should express milk and discard for a week after taking UPA-EC
Breast feeding women to be informed that limited evidence that LNG-EC has no adverse effect in breast feeding or infants
Women to be informed that possible that higher weight or BMI could reduce the effectiveness of oral EC , particularly LNG-EC

20. New decision making took for EC
Identifying what to use
When to use
When to refer

21. Fig 1 Window of action of different emergency contraceptive methods in relation to ovulation.
Prabakar I , Webb A BMJ 2012;344:bmj.e1492
©2012 by British Medical Journal Publishing Group

23. Making decisions Algorithms for Emergency Contraception FSRH guidance 2017 Copper IUCD vs Oral EC ( adapted for pharmacists)
Currently < 120 hrs since UPSI
Yes No
Unknown
Additional UPSI > 120 hours ago?
Currently ≤ 5 days after earliest likely date of ovulation?
Currently ≤ 5 days after earliest likely date of ovulation?
Yes or unknown No
Yes
No or unknown
Yes
No or unknown
Currently ≤ 5 days after earliest likely date of ovulation?
Offer Cu IUD
If not acceptable offer EC* and discuss suitable on-going contraception
Offer Cu IUD
Oral EC* unlikely to be effective
Refer onward for
suitable quick start contraception
Cannot insert Cu IUD
Oral EC unlikely to be effective
Refer onward for suitable quick start contraception
Offer CU IUD
If not acceptable offer oral EC* and discuss suitable on-going contraception
Offer oral EC* and discuss suitable on-going contraception
Yes
No or unknown
Offer Cu IUD
If not acceptable offer oral EC* and discuss suitable on-going contraception
Consider pregnancy test if UPSI this cycle > 21 days ago
Offer oral EC* and discuss suitable on-going contraception
See next slide for oral EC choices
Note that there is no evidence that oral EC is effective if ovulation has already occurred

24. Decision making for oral EC Levonorgestrel E0C ( LNG EC) vs Ulipristal Acetated EC ( UP-A-EC
The Cu IUD is the most affective form of EC. IF criteria for insertion of a Cu IUD are not met , cannot be arranged within time or a Cu IUD is not acceptable to a woman, consider Oral EC
Last UPSI < 96 hours ago?
Yes
No or unknown
UPSI likely to have taken place ≤ 5 days prior to the estimated day of ovulation?
Last UPSI < 120 hours ago?
Yes or unknown No No
Yes or unknown
BMI > 26or weight > 70kg
Oral EC unlikely to be effective
Reconsider Cu IUD if currently within 5 days after likely ovulation
Or QS contraception
Yes No
UPA-EC
+ start contraception after 5 days
Reconsider Cu-IUD if all UPSI within 120 hours or if currently within 5 days after likely ovulation
If UPA-EC not suitable LNG-EC
+ immediate QS
UPA-EC
+ start contraception after 5 days Or
Double (3mg) LNG-EC
+ immediate QS
LNG-EC
+ immediate QS Or
UPA-EC
+ start contraception after 5 days
UPA-EC
+ Start contraception after 5 days
LNG-EC unlikely ti be effective
Reconsider Cu-IUD if all UPSI within 120 hours or if currently within 5 days after likely ovulation

25. Potential failure of contraceptive methods
Combined pills, late or missed pills by more than 48 hours since should have taken.
Progesterone-only pills, late or missed pills
Depo Provera, injection over due
Nexplanon overdue to be exchanged
Interactive drugs (Liver enzyme inducers)
Enzyme inducing drugs do not reduce effectiveness of Depo provera, Intrauterine systems, IUCDs
Intrauterine contraception , being expelled fully or partially
Evra patch fallen off
Barrier method, burst / not used most common
What about NuvaRing
REMEMBER IF TAKEN HORMONAL METHOD LNG-EC preferred

26. What is a missed pill?
If not complied with this advice remember EHC needs
Combined pills Missed or Late
Late by less than 24 hours since should have taken pill
Continue as normal with pill taking
Between 24 and less than 48 hours late since should have taken
ONE MISSED PILL
Take most recent pill now
Continue take rest of pack EHC not needed unless pills missed earlier in pack or at end of last pack
2 or more pills missed or started new pack 2 or more days late starting your last pack
Take last pill missed and continue taking rest of pack with condoms for 7 days. If you have had SI in the previous 7 days you may need Emergency contraception
Remember that PIL will have conflicting advice
Current guidelines and in FPA leaflet

27. When EHC is needed 2 or more pills missed > 48 hours late
Where are you in your pack of pills
Days 1-7
EC considered if UPSI in pill free interval or in this first week
Days 8-14
No need for EC if 7 pills already taken and those following pills taken correctly
Days 15-21
OMIT pill free week and once finished this pack go straight on to next pack ( consider ED pills)

28. Nexplanon user longer than 3 years IUD/ IUS use longer
than prescribed length of use see following
If UPSI consider
EC needs as if no
method used
IUD’s last between 5-10 years,
IUS 5 years.
Age at insertion
changes length of use.
Copper IUD’s inserted after 40 do not need replacing.
IUS, Mirena, inserted after 45, stays in until not needed if women has no periods
Negligible risk between 5-7 years of use IUS
Negligible risk years 3-4 for Nexplanon users
Caveat that have not yet found a pregnancy in those using Nexpalnon > 5 years
FSRH advice about IUS inserted < 45 and used between 5-7 years do PT at time change device and repeat PT at 3 weeks

29. Provide EC within 72 hours If multiple UPSI or > 72 hours
Late Depo Provera
and had UPSI
Late by up to 14 days
No need for EC
Late by > 14 days and
UPSI after > 14 days
since Depo due
Consider each episode
of UPSI.
Provide EC within 72 hours
If multiple UPSI or > 72 hours
Refer onward.
Be aware of lasting hormonal effect

30. Consideration for use of Mirena after 5 years…. Do they need EHC
Women who were under the age of 45 years at the time of Mirena insertion and who present for replacement of the device between 5 and 7 years after insertion may have immediate replacement if a pregnancy test is negative and another pregnancy test is advised no sooner than 3 weeks after the last episode of UPSI…
Means… they do not need EHC between 5-7 years use. They can have it replaced so long as the Preg test is neg and repeated at 3 weeks after the device is exchanged

31. Mirena And Jaydess
If a woman is under 45 years at the time of Mirena insertion and more than 7 years have elapsed since insertion, replacement should be delayed until the woman has a negative pregnancy test at least 3 weeks after the last UPSI. May need EHC depending on when UPSI has occurred. Level of Levonorgestrel twice as high at 5 years than Jaydess at 3
Women who retain their 13.5 mg LNG-IUS for more than 3 years should be advised to use additional precautions until pregnancy can be excluded, after which time a replacement device can be inserted ( Jaydess). They may need EHC

32. Who is it for? Women / girls 14 and over
Confirm Fraser competencies for 14, 15 year olds
Consider Women 16 years and older with learning difficulties or mental capacity problems
Consider child protection concerns
Domestic or emotional abuse
Child sexual exploitation
Remember professional curiosity
Fraser guidleints ensure that if no parental consent then advice and support can be given.

33. Confidential interview and advice
However……..
Inform carefully that any information causes concerns about their safely or the safely of others as a consequence of their actions would limit the confidentiality. You may therefore have to contact someone else and give them some information.
Aware that sex under 13 is a sexual offence and has to be reported, Sex under 16 is currently illegal however this is judged as confidential if there are no features that cause concern.

34. Fraser checks for under 16’s
Is a parent or guardian present?
If no parent/ guardian present, check who is with the under 16.
Are they mature enough to Understand the advice given and its implications
Try to Persuade them to talk to a parent or guardian about relationship and sexual health advice.
They are likely to continue being Sexually active with or without the advice
Without this advice or treatment their physical or mental Health would suffer
It is in their best Interest that treatment of advice is given without parental consent.
Remember UPSHI
If friend is present ensure confidentiality given for girl requesting Levonelle. If older boyfriend consider safelty if large age gap.

35. After care and follow up
Give written and verbal information on:-
Efficacy
Side-effects
Future contraception choices
STI screening where appropriate
Pregnancy test if > 5 days delay in period or lighter than usual, or no withdrawal bleed in Pill free week
Chlamydia screening….. Available NOW from all C&SH services for under 25’s and some GP’s and for yourselves
Taking tests only Urine for male and Female………… Risks Missing diagnoses

36. Timing of next menstruation
The next period after taking EHC may be early, on time, or delayed. Most women will start their next period within 3 days of the expected date
Women should be advised that menstrual irregularity can occur within the cycle after EHC use
If taken more than once in any cycle there will be greater disruption of menses and less effectiveness of subsequent EHC

37. Future contraception
Abstinence or Effective contraception for the rest of the cycle
REMEMBER LASTING AND REVERSIBLE CONTRACEPTION LARC
EC use after “Missed pills” resume pills within 12 hours of taking EC ( not UPA-EC)
Discuss initiating a regular method of contraception
Refer to a service that provides all methods for choice
Quick start of methods after emergency contraception except Depo Provera

38. Management of a request for Emergency Contraception
Where does it take place? Confidentiality to be ensured ??????? No conversations overheard No added embarrassment Privacy and dignity

39. What and why do we ask? - AIMS
To determine:- if they may be already pregnant
To estimate the level of risk of pregnancy, drugs or conditions that make EC less effective or increase health risks
Explore previous contraceptive use and plans for the future
Determine risk of STI, (especially if under 25’s recent partner changes)
Consider any issues of non- consensual SI
Legal guidance for Under 16’s
Consider child protection referral needs
Consider CSE

40. Summary …Assessment to identify inclusion and exclusion criteria
Accurate menstrual, medical and sexual history ( vague history)
Current drug / medication use (interacting drugs)
Consensual sex (potential rape/ abuse)
Current method of contraception (unknown type of pills) and future use
Fraser competency for under 16’s
Age of patient. (potentially younger than states, potentially looks older than is)
Behaviour of patient (sexualised behaviour, know all about SI and not worried, recording consultation, declining consultation)
Refer onward if any concerns
KNOW your local networks, telephone contacts, availability

41. What do you do if you are concerned
Concerned about age they look
Concerned about behaviour
Concerned about associates
Concerned about capacity to understand
Concerned they may be in danger
Concerned and need advice
Concerned if pressured into having SI by texting bullying, Sexting ( This is a criminal offence)

42. Keeping it simple Contact numbers ST office hours 0191 424 5010
ST out of office ours
During office hours (Monday - Thursday, 8:30am-5pm and Friday, 8:30am-4:30pm) (0191) or
Gateshead out of hours call emergency Duty team

43. Marac assessments MARAC Multi Agency Risk Assessment Conferences
Who to Contact for further enquiries?
MARAC Coordinator for South Tyneside
Northumbria Police
Public Protection Unit [PPU]
NE33 1RR 
Phone Number:
Marac coordinator Gateshead
Northumbria Area Command

44. Worried about something else
Gut feelings
Think < 13 ( statuary rape, cannot consent)
Signs of self harm
Seen them before
Remember girls or women of any age may be affected by domestic abuse or violence.

45. Some Signs, What may raise suspicions
May smell of alcohol
Lack of eye contact and engagement
Unexplained bruising, scalds, marks
Display knowledge or interest in sex inappropriate to age
Using sexualised language or have sexual knowledge you wouldn’t expect them to have
Have expensive phones, gifts , new possessions

46. Some more Have older boyfriend or girlfriend or associate
Missing from home regularly
Staying with friends, sleeping on sofas
Missing school regularly
Behaving aggressively
Demanding inappropriately
Spotting the signs

47. Child sexual Exploitation
Missing from home or care
Involved in offending
Drug/alcohol abuse
Repeat STI, pregnancies, TOPS
Mental health problems, self harm, physical injuries
Gifts from unknown source
Changes or inappropriate appearance or behaviour
Evidence of bullying
Estranged from family
Recruiting others into exploitative situations

48. Contact CSE or Child protection
If under 13 legally cannot consent to SI so is classed as sexual offence.
Ring 999
What time of day and who is available

49. (Low-High) Inform Police and Children & Families’ Social Care Refer to
specialist service/s for appropriate intervention
YPVA Service to be contacted for advice and guidance
Consider early help framework- if appropriate
Immediate Safeguarding concerns
Disclosure of direct victim domestic
abuse from a young person
Age years
Complete Young Peoples
DASH Risk Identification Checklist
(RIC)
This will indicate risk levels
(Low-High)
Immediate Safeguarding concerns
Low-med risk
High risk
Refer to Children & Families Social Care and YPVA Service- and MARAC (if victim and perpetrator are both aged 16+)
MARAC
Conference is arranged from MARAC referral
Social Worker allocated and YPVA service contacted by Children and Families Social Care
Case to be co-worked by Social Worker and the YPVA Service
Children & Families Social Care/YPVA engage young person and complete full needs assessment/DV safety plan
Children & Families Social Care assessment completed
MARAC
YPVA represents young person, at MARAC Conference supported by Children & Families Social care (if involved)
multi agency response
Multi agency planning meeting held
Plan implemented by social worker and supported by YPVA Service
South Tyneside Local Authority

50. Referral Pathway South Tyneside onward contraception
Referral Pathway South Tyneside onward contraception. Emergency IUCD or advice
South Tyneside
Reception open in clinic times
C&SH service provides all methods.
Some GP surgeries insert IUD’s (5) South Tyneside ( May not have appointment for emergency IUCD)
Some GP surgeries insert Nexplanon (5)
C&SH service open 6 days each week with
Emergency IUD insertion available each day Mon - Fri

51. Referral Pathway Gateshead for onward contraception and Emergency IUCD
Gateshead clinic reception
Emergency IUCD Mon- Fri
C&SH service open 6 days per week
GP surgeries inserting IUD and inter-practice referrals but may not have appointment for emergency
C&SH service provides all methods.
Some GP surgeries insert Nexplanon
C&SH service open 6 days each week

52. Documentation Locally defined
On line pharmoutcomes.
Transferring data
?? How do you do it

53. Advantages of hormonal EC summary
Effective
Easily available
Easy to administer
Can be taken up to 72+ hours of UPSI
Can be repeated in same cycle
Fewer side effects
Safe with no reported long term side-effects
No evidence of teratogenicity

54. Disadvantages of hormonal EHC summary
Licensed for only 72 (120) hours after UPSI
No evidence of effectiveness of Levonelle > 96 hours and after ovulation
Less effective than IUD
Nausea (14%) & Vomiting (1%)
Other side effects
Can disturb menstruation
Does not protect against STI
Not a substitute for lasting and reversible contraception methods or any other method used reliably

55. Normally takes Combined pills 9 am
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
9am takes pill
9 am takes pill
9 pm takes pill
A Monday is first pill in pack
B Monday is 10th pill in pack no previous missed pills
C Monday is 16th pill in pack no previous missed pills
When is Emergency Contraception needed A, B or C
What advice would you given after A, B and C

56. For each case study 5 consideration for each case.
Discuss in 2’s or 3’s
Each case discussed

57. Case 1 Age 15 Taking COC Hasn’t taken COC for 10 days
Was away at friends party
UPSI last night
What can you offer and what will you do?
Does she need EHC?
Where does the risk come from?
What should you be asking about what alarm bells ring
Sperm last 7 days

58. Case 2
Aged 47
LMP 5 weeks ago
UPSI 3 days ago
Has been using POP but not a very good taker
Risk of pregnancy?
What can you offer or advise.

59. Case 3 Aged 16 LMP 12 days ago Cycle 27 days UPSI day 11
What can she have?

60. Case 4 Aged 16 LMP 7 days ago Cycle 28 days
UPSI days 2 and 5 seen on Day 7
Given Levonelle and Nexplanon inserted QS
Seen again day 12
Had UPSI day 11
What can you offer

61. Case 5 Aged 16 LMP 17 days ago Cycle 30 days UPSI days 10 and 13
Risk of pregnancy?
What do you advise

62. Case 6 Aged 40 LMP 20 days ago Cycle 28 days UPSI day 16
Risk of pregnancy?
What do you advise

63. Case 7 Aged 18 On Depo no periods
Last injection 14 weeks and 4 days ago
UPSI 24 hours ago
Pregnancy risk
What can you offer and what advice

64. Case 8 Aged 51 Asks for pregnancy test LMP 3 months ago
UPSI 48 hours ago
What questions
Can you offer anything