1. Emergency Contraception Sue Turner: Clinical Nurse Specialist: Sexual Health 1

2. Menstrual cycle made simple!!!! The ovaries contain about 2 million follicles at birth which develop between 3 and 7 months gestation The follicles are suspended in development until puberty The ovaries also secrete oestrogen and progesterone.

3. Pre-Ovulatory (follicular phase) Follicle-stimulating hormone (FSH) from anterior pituitary stimulates follicular development During each cycle 3-30 follicles start to develop and produce oestrogen One follicle becomes the dominant follicle Rising oestrogen levels cause a mid-cycle surge in Luteinising Hormone (LH) LH surge causes ovulation – about 9 hours later

4. Postovulatory (Luteal Phase) Ovulation leaves behind the Corpus Luteum, which secretes progesterone. Unless the ovum is fertilised within 7 days, corpus luteum degenerates, progesterone production decreases and the endometrium breaks down and is shed. Decreased levels of oestrogen and progesterone stimulate FSH production which starts off the recruitment of follicles and the cycle starts again Length of luteal phase (ovulation to menstruation) relatively consistent at 14 days

6. The Menstrual Cycle

7. Calculating Ovulation Most likely date of ovulation = 14 days before next menstrual period. Use individuals cycle length to calculation estimated date of next period 7

8. Calculating Ovulation 8 JanuaryFebruaryMarchApril SMTWTFSSMTWTFSSMTWTFSSMTWTFS 123451212123456 67891011123456789345678978910111213 141516171819101112131415161011121314151614151617181920 212223242526171819202122231718192021222321222324252627 28293031242526272824252627282930282930 31 MayJuneJulyAugust SMTWTFSSMTWTFSSMTWTFSSMTWTFS 12341123456123 56789101123456787891011121345678910 1213141516171891011121314151415161718192011121314151617 19202122232425161718192021222122232425262718192021222324 262728293031232425262728292829303125262728293031 30 SeptemberOctoberNovemberDecember SMTWTFSSMTWTFSSMTWTFSSMTWTFS 123456712345121234567 89101112131467891011123456789891011121314 15161718192021131415161718191011121314151615161718192021 22232425262728202122232425261718192021222322232425262728 2930272829303124252627282930293031

9. WHAT IS EMERGENCY CONTRACEPTION? A means of preventing unintended pregnancy following unprotected sex. Acts prior to implantation – pregnancy begins at implantation, therefore EC is not an abortifacient Implantation is assumed to occur no sooner than 5 days after ovulation 9

10. Factors Influencing Risk of Pregnancy following unprotected sex Ovum survives 24-36 hour. Sperm can survive up to 7 days (in the uterus) Where in cycle sex occurs from 8% risk early in cycle to 36% on day of ovulation. Drops rapidly following ovulation Fertility of both partners (unknown) There is no time in the cycle when you can withhold emergency contraception on physiological grounds 10

11. WHO NEEDS EMERGENCY CONTRACEPTION? Any Unprotected intercourse within 120hr Rape Coitus interrupts Contraceptive accidents – what are these? 11

12. Diaphragm/Cap problems Condom failure Failure to use additional precautions when starting hormonal methods of contraception 2 or more missed combined oral contraceptive pills (see slide 14) Late or missed POP (>3hrs late/12hr Desogestrel) and UPSI occurs within 2 days following this (see slide 15) Missed or late Evra patches (48 hrs) Missed or late NuvaRings (3 hrs) Partial expulsion of IUD/IUS or removal mid-cycle Late attendance for Depo Provera( >14 weeks) Expired devices – IUD/IUS, implants Combined hormonal contraception (pills, patches & rings) & progestogen only pills & implants - failure to use additional precautions, barrier method failure or UPSI whilst using or within 28 days of stopping enzyme inducers including St John’s Wort. Contraceptive accidents 12

13. Missed pill guidelines

14. 1 missed pill( more than 24hrs late & up to 48hrs) 2 or more missed pills (> 48hrs late Continuing contraceptive cover The missed pill should be taken as soon as remembered The remaining pills should be continued at the usual time Minimising the risk of pregnancy Emergency contraception is not usually required but may need to be considered if pills have been missed earlier in the packet or in the last week of the previous packet Continuing contraceptive cover The most recent pill should be taken as soon as possible The remaining pills should be continued at the usual time Condoms should be used or sex avoided until 7 active pills have been taken. This advice may be overcautious in the 2 nd & 3 rd weeks, but the advice is a backup in the event that further pills are missed Minimising the risk of pregnancy If pills are missedIf pills are missedIf pills are missed in the 1 st weekin the 2 nd weekin the 3 rd week (pills 1-7)(pills 8-14)(pills 15-21) ………………………………………………………………………………………………… EC should be No indicationOMIT THE PILL considered If for EC if the pillsFREE INTERVAL unprotected sexin the precedingby finishing the occurred in the7 days have been pills in the current pill free intervaltaken consistentlypack (or discarding or first week of & correctly (assumingany placebo pill takingthe pills thereafter tablets) & starting are taken correctly &a new pack the additional contraceptivenext day precautions are used) FSRHC Combined Pill Guidance 2011

15. FSRHC Progesterone Only Pill Guidance 2009 late pill Take a pill as soon as remembered. If more than one pill missed just take one pill. Take the next pill at the usual time. This may mean making taking 2 pills in 1 day. This is not harmful An additional extra method of contraception, (condoms or abstinence) is advised for the next 2 days (48 hrs after the POP has been taken). late pill Take a pill as soon as remembered. If more than one pill missed just take one pill. Take the next pill at the usual time. This may mean making taking 2 pills in 1 day. This is not harmful An additional extra method of contraception, (condoms or abstinence) is advised for the next 2 days (48 hrs after the POP has been taken). > 12 hours late (36 hours since the last pill was taken) > 12 hours late (36 hours since the last pill was taken) Traditional POPs (Micronor, Noriday, Norgeston, Femulen) Traditional POPs (Micronor, Noriday, Norgeston, Femulen) Desogestrel – Only (Cerazette/Cerelle) Desogestrel – Only (Cerazette/Cerelle) > 3 hours late (> 27 hours since the last pill was taken) > 3 hours late (> 27 hours since the last pill was taken)

16. Does this client need EC? Jasmine 24 years. Forgot to return for her depo. Now 13 weeks and 4 days No Sophie 17 years using Microgynon 30; missed the last 2 pills which are in the middle of the pack. Had sex – no condom last night No – should use condoms until 7 days of consecutive pills taken 16

17. Does this client need EC? Samantha 19 years. Missed her pill yesterday – no idea what pill but takes every day & all pills same colour. Had sex – no condom last night Yes – but resume pills immediately & use a condom Tracey 26. Stopped Cerelle due to moodiness 2 days ago. Had taken for past 2 months. Had sex - no condom 3 days ago and requests EC No – Needs to sort future contraception 17

18. Does this client need EC? Anne-Marie 14. Had sex last night – boyfriend very careful and pulled out before ejaculation Yes Stacey 27. Condom split. Using Gedarel 20 and no missed pills, but always uses condoms as on a low oestrogen pill No 18

19. Types of Emergency Contraception Copper IUD – All eligible women should be offered this as it is the most effective emergency contraception > 99% effective Levonelle – Licensed for up to 72 hours following UPSI ellaOne – Licensed for up to 120 hours following UPSI 19

20. Emergency IUD Copper IUD most effective EC > 99% !!! Should contain more than 380mm Cu. For women wanting the most effective method. Those considering IUD as long term contraception. 20

21. Mode of Action Copper is toxic to the ovum & sperm & works primarily by preventing fertilization if inserted early in cycle. Pre & post fertilisation effects contribute to efficacy If fertilisation has occurred - anti implantation effect. Therefore must be fitted before implantation begins Mirena IUS must not be used as EC 21

22. IUD - timing of insertion At any time in cycle if < 5 days (120hrs) of first episode of UPSI OR Within 5 days from the earliest estimated date of ovulation e.g. not after day 19 in a 28 day cycle if there have been multiple risks always check cycle length - base calculation on shortest cycle remember COC bleed is not a normal period –base calculation on first day of pill free interval 22

23. IUD must not be used if existing pregnancy is possible Allergy to copper Wilsons Disease Distorted or small uterine cavity PID Cannot promise an IUD can be fitted therefore always give emergency contraceptive pill unless fitting is immediate Contraindications to IUD 23

24. Information to Client Discuss fitting procedure Discuss side effects (if wants to keep long term) Can be removed AFTER next period if preferred Can remain in and become ‘fit and forget method for 5 to 10 years depending on IUD. Chlamydia screen essential, but prophylactic antibiotics will be given Also give EHC unless IUD can be fitted immediately (i.e. do not even send client back into waiting room without EHC) 24

25. Levonelle 25

26. Mode of Action Incompletely understood, efficacy thought to be primarily due to inhibition of ovulation. Appears to prevent follicular rupture or cause luteal dysfunction. If taken prior to the luteinising surge can result in ovulatory dysfunction in the subsequent 5 days by which time sperm will have become non viable. However NO better at suppressing ovulation than placebo when given immediately prior to ovulation Unknown endometrial effect on implantation 26

27. Efficacy of Levonelle Not effective immediately prior to or on day of ovulation. Efficacy demonstrated up to 72 hours (licensed use) Efficacy remains the same 0-96 hours i.e. Day 0 – 4 (off-license 72-96) 96-120 hours pregnancy risk increases x 6 27

28. Contraindications to Levonelle There are no medical contraindications to Levonelle including breastfeeding. However, there are exclusion criteria concerning your practice as a nurse working within your PGD and/or local policy. 28

29. Levonelle - Special Considerations Pregnancy – not abortifacient, no known harm to the woman, or the foetus, but will not be effective if woman is already pregnant. Hypersensitivity to LNG or components UKMEC 3 for gestational trophoblastic neoplasia with abnormal hCG Acute Porphyria Drug interactions – enzyme inducers, ciclosporins N.B New generic brand available i.e. Upstelle®

30. Levonelle off-license use Can be used more than once in a cycle or if previous episode of UPSI in cycle Over 72 hour (if ellaOne unsuitable) Women taking enzyme inducing drugs 3mg (2 tablets) can be issued (if IUD declined) NB Repeated doses of Levonelle may be effective and are safe. Repeated episode within 12 hours of giving Levonelle does not require further dose 30

31. Information for client Return if vomits in 2 hours side effect of headache, nausea, altered bleeding, abdo pain, dysmenorrhoea. Doesn’t give protection for rest of cycle No adverse effects on foetus should treatment fail May have spotting a few days after treatment this is not a period Start OC on day 2 of next period OR If ‘quick start’ resuming OC use condoms (COC 7 days, POP 2 days) Return in 3 weeks for pregnancy test if period absent/abnormal or following ‘quick start ’ 31

32. ellaOne (Ulipristal acetate) 32

33. ellaOne Mode of action Selective progesterone receptor modulator Primary mode of action - inhibition or delay of ovulation Given immediately prior to ovulation – can suppress growth of lead follicle Can prevent ovulation after the LH surge has started, delaying follicular rupture for up to 5 days Ineffective in delaying follicular rupture if given at time of LH peak or after Unknown endometrial effect on implantation 33

34. Efficacy of ellaOne As effective as Levonelle between 0-72 hours, but more effective 72-120 hours Effective prior to ovulation as able to prevent ovulation even after LH surge has started Unknown efficacy at point of or following ovulation 34

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36. Contraindications/Cautions Pregnancy (no known adverse effects but limited evidence to date Hypersensitivity to drug component Patients with severe asthma insufficiently controlled on oral glucocoroids Caution in severe renal or hepatic impairment Hereditary galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption Excretion in breast milk not known so recommended not to feed for 7 days after taking Can only be given once in a cycle 36

37. Drug Interactions Efficacy of ellaOne is reduced in women on enzyme inducers, anti fungals & drugs which increase gastric pH e.g. proton pump inhibitors and antacids ellaOne interferes with action of progestogens therefore reducing contraceptive efficacy. Extra precautions therefore required for much longer than with Levonelle Cannot be given concomitantly with Levonelle 37

38. Information to clients - ellaOne Return if vomits in 3 hours side effect of headache, nausea, altered bleeding, abdo pain, dysmenorrhoea. Doesn’t give protection for rest of cycle May have spotting a few days after treatment. Period should be within 7 days of expected date. No known adverse effects on foetus if treatment fails (limited data) Start OC on day 2 of next period (NB ellaOne reduces efficacy of OC therefore will need condoms for 7 days after EC treatment) If ‘quick start’ or resuming OC use condoms (COC 14 days, POP 9 days) Return in 3 – 4 weeks for pregnancy test if period absent/abnormal or following ‘quick start’ 38

39. STI Screening & Investigations All clients should be encouraged to have a Chlamydia screen Client choosing IUD - Chlamydia test essential and prophylactic antibiotics will be given All clients should be offered HIV screening NB Screening gives a baseline following EC and may need to be repeated 39

40. Quick Starting Contraception (FSRH Sept 2010) Starting contraception at the time a woman requests contraception rather than waiting for the NMP May reduce the time a woman is at risk of pregnancy May also mean starting a method immediately after EC Must be reasonably certain that the woman is not currently pregnant Use of pregnancy testing no earlier than 3 weeks following last sex ‘off-licence’

41. IUD – Don’t Forget IUD most effective form of emergency contraception (Over 99%) Can stay in as ongoing contraception and lasts up to 5 to 10 years & effective immediately (avoids off-licence quick start!!) Can be used when progestogens cannot be taken e.g. drug interaction Young people can have emergency IUD Still give EHC if referring a client for an IUD 41

42. What method should be offered? Factors for consideration Medical eligibility Efficacy of method Last menstrual period & cycle length Number and timing of unprotected sex Previous use of EC this cycle Need for additional precautions/ongoing contraception Drug interactions Individual choice &/or service proforma/PGD 42

43. Table 2: Eligibility for different methods of emergency contraception ( FSRH Update EC Provision June 2014 ) 43 Clinical ScenarioCu-IUDLNGUPA Single episode of UPSI within 72 hours√√√ Single episode of UPSI between 72 and 120 hours √ √ (outside product licence) FSRH supports use up to 96 hours and up to 120 hours if no other method appropriate √ Multiple episodes of UPSI within 120 hours√√√ Multiple episodes of UPSI Sex occurred 5 days √/X (Yes if presents within 5 days of ovulation. If presents more than 5 days following earliest estimated time of ovulation an IUD is not suitable) √X Using enzyme inducing drugs√ √ (3mg recommended- outside product licence) X Breastfeeding√√ √ (Can be given if the woman is willing to express for 7 days after taking) Already used oral EC in same cycle X (unless all episodes within 5 days of earliest expected ovulation) √X Women under 25 years of age√√√ Nulliparous women√√√

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46. Who to refer to sexual health services Clients interested in ‘IUD or quick start’ Clients not using any contraception or have persistent failures with their current method Clients who have used of EHC before/repeatedly Those with previous unplanned pregnancies Those with multiple partners Those attending for repeated pregnancy tests Those that you /they have concerns re STIs & the need for a full screen Those with gynaecological problems

47. Contact details -Conifer 01482 336336 -Text ‘conifer’ to 61825 ( normal network rates apply) www.conifersexhealth.co.uk Clinical Nurse specialists in young peoples sexual health East Riding: Kay – 07590 304 269 Sue – 07816 645 468 HU8 & HU9:Emma – 07590 304 278 HU6 & HU7: Amanda – 07909 906 198 HU1 to HU5:Tracy - 07702 366 596 47

48. Scenario 1: Emily – 16 years You see Emily at 1pm on Thurs the 1st August First ever sex on Monday 29 th July at 9pm LMP 28 th July– normal Regular 28 day cycle How many hours since UPSI What is expected date of next cycle? What is expected date of ovulation ? What emergency contraception would you offer & why? 48

49. Scenario 1 Emily First ever sex so no pregnancy risk 64 hrs LMP 28th July – normal Estimated date ovulation = 11 th August 3 days before and 2 days after = 12 th – 17th So not within dates of EDO Offer IUD Offer Levonelle 49

50. Scenario 2 – Leanne 26 You see Leanne at 1 pm on Thursday 1 st August Split condom on Tuesday around 11pm Periods irregular, Thinks LMP was about 4 weeks ago but not sure No other UPSI since LMP How many hours since UPSI What EC would you offer? Leanne also wants a pill what advice would you need to give? 50

51. Scenario 2 - Leanne 37hrs LMP not clear Offer IUD Irregular cycle & unknown date of LMP so needs ellaOne Use condoms for 7 days from treatment if starting OC on 2 nd day of cycle if ‘quick start’ condom use/abstain POP = 9 days, COC = 14 days. Pregnancy test In 3 - 4 weeks 51

52. Scenario 3 – Joanne 19 years You see Joanne at 1 pm on Thursday 1 st August Joanne stopped taking combined pill in the middle of her packet 2 weeks ago (took around 10 pills) when she fell out with boyfriend. She made up with him and had sex last night 11pm – no condom used. Last ‘period’ 2 weeks ago on stopping pills. No sex since stopping pill. She wants to start pills again but doesn’t know when to restart How would you manage Joanne? 52

53. Scenario 3 - Joanne 14hrs since UPSI Hasn’t had pills for 2 weeks so is unprotected Was protected until she forgot her pills so only at risk since Offer IUD < 120 hours since UPSI ?? Period on stopping pills was not true period Because we don’t know where she is in her cycle she should have ellaOne Re start pills immediately, condoms 14 days and pregnancy test in 3 weeks 53

54. Scenario 4- Kerry You see Kerry at 1pm on Thursday 1 st August Kerry had sex at a party on Saturday night 10pm, unsure if condom used. LMP 11 th July. No other UPSI since LMP. How many hours since UPSI? What EC would you give and why? 54

55. Scenario 4- Kerry 87 hrs plus Offer IUD ellaOne (What if she suffers from uncontrolled asthma and is on oral medication?) 55

56. Scenario 5 - Chloe You see Chloe at 1 pm on Thursday 1 st August. She went away with her boyfriend to a festival, but they ran out of condoms. Several episodes of unprotected sex since Saturday at 10 am. Her LMP 16 th July and she has a regular 28 day cycle. What EC should be offered? Chloe wishes to start the pill what information do you give? 56

57. Scenario 5 - Chloe 123 hrs NMP due 13 th August EDO 30 th July Within 5 days of ovulation (13 th final day) Offer/ refer for emergancy IUD 57

58. Scenario 6 - Hannah You see Hannah at 1pm on Thursday 1 st August Had sex and condom split Tuesday 30 th 9pm LMP 8 th July Had Levonelle on 15 th July Periods every 30 – 35 days. What emergency contraceptive options could Hannah have? 58

59. Scenario 6 - Hannah 16 Hours since UPSI NMP 7 th – 12 th August EDO 24 th – 29 th July Cannot use ellaOne due to previous EC in cycle Levonelle unlikely to be effective – but could be given. IUD can not be fitted as multiple episodes > 120 hours and not within 5 days of earliest ovulation time (28 th July) 59

60. References Faculty of Sexual & Reproductive Healthcare [Available from www.fsrh.org] Emergency Contraception (2011) (updated January 2012)www.fsrh.org Quick Starting contraception (2010) labelling of emergency contraception in Europe: Body weight and body mass index (BMI) and efficacy (2014) Use of Ulipristal Acetate (ellaOne®) in Breastfeeding Women: Update from the Clinical Effectiveness Unit (201 3) Specific Product Characteristics [Available from www.medicines.org.uk ]www.medicines.org.uk ellaOne (last updated 14/5/14) Levonelle (last update 27/11/12) Kubba A. Connolly A. Walling M. Proctor T. French K. Mansour D. (2012) Emergency contraception: towards a multidisciplinary consensus Primary Care: Women’s Health Journal Vol(4) Sup1 Available from www.pcwhj.comwww.pcwhj.com 60