1. Emergency Contraception Update
Dr Lynda Turner
June 2015

2. Disclosure
Honorarium from HRA Pharma

3. Learning objectives. By the end of the session you will be able to:
Describe the methods and effectiveness of all methods of emergency contraception.
Recognise where there is a risk of pregnancy and advise appropriately
Specify key points in history taking, counselling and follow up for safe and effective use of EC.
Identify needs for future contraception and when this can be started as well as any risk of STI and advise appropriately

4. Plan for session Presentation: Emergency Contraception update
Case studies: Small group work

6. What is emergency contraception?
Use of any drug or device after unprotected sexual intercourse to prevent an unintended pregnancy
Acts prior to implantation – pregnancy begins at implantation, therefore EC is not an abortifacient
Implantation is assumed to occur no sooner than 6 days after ovulation

7. Reasons for requesting emergency contraception

9. Menstrual Cycle

10. Factors Influencing Risk of Pregnancy following unprotected sex
Ovum survives 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

11. From ovulation, to fertilisation, to pregnancy

12. Emergency contraception
What is currently available?
How do they work?
How effective are the methods?

13. What is currently available?
Copper IUD
Levonelle (Levonorgestrel 1.5mg)
ellaOne (Ulipristal acetate 30mg)

14. Copper IUD Best method of EC - more than 99% effective
Spermicidal/toxic to ovum – prevents fertilisation
Also has some anti-implantation effect
Can be fitted up to 120hrs (5 days) after UPSI or within 5 days of the earliest predicted date of ovulation.
Offer all eligible women IUD as most effective EC Method

15. Calculating ovulation date

16. ellaOne Selective progesterone receptor modulator
Primary mode of action –inhibition or delay of ovulation
Can prevent ovulation after the LH surge has started, delaying follicular rupture for up to 5 days
Licensed for up to 120hrs after UPSI

17. Levonorgestrel 1.5mg Progestogen Thought to delay or inhibit ovulation
If taken prior to the LH surge can result in ovulatory dysfunction in the subsequent 5 days
NO better at suppressing ovulation than placebo when given immediately prior to ovulation
Licensed for use for 72hrs after UPSI
Shown to be effective up to 96hrs after UPSI

18. How do EHCs work? Both Ulipristal acetate and levonorgestrel act by delaying ovulation:1
levonorgestrel has been shown to be no better than placebo at inhibiting ovulation when given immediately prior to ovulation1 ⌂
Ulipristal
Ulipristal is effective right up to the point of ovulation, even if lutenising hormone (LH) levels have already begun to rise1,2
Ulipristal is effective even after onset of the LH surge2
References: 1. Emergency Contraception. Clinical Effectiveness Unit. Faculty of Sexual & Reproductive Healthcare Clinical Guidance. Available at fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf. Last accessed January Brache V et al., Hum Reprod 2010; 25: 2256–63.

19. 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

21. Contraindications to Cu IUD
Pregnancy
Less than 4 weeks postpartum
Undiagnosed vaginal bleeding
Gynae cancers – Cervical, Endometrial, Ovarian
Acute Pelvic infection
Any congenital or acquired uterine abnormality causing distortion of the uterine cavity eg fibroids

22. Levonorgestrel 1.5mg
FSRH Clinical Guidelines on EC does not identify any medical condition that limits the use of Levonorgestrel 1.5mg

23. ellaOne 30mg Precautions
Use in women with severe asthma treated by oral glucocorticoids is not recommended
Breast feeding women must not breast feed for 1 week after taking ellaOne 30mg

24. Cu IUD – information to client
Discuss fitting procedure
Discuss possible side effects
Can be removed AFTER next period if preferred
Can continue with IUD for 5 -10yrs
STI screen and prophylactic antibiotics will be offered
Give EHC even if IUD going to be fitted by GP or other service

25. Safety profile of oral EC
Ulipristal
References: 1. Glasier AF et al., Lancet 2010; 375: 555–62.
2. HRA Pharma UK Ltd. ellaOne® 30 mg tablet Summary of Product Characteristics.
Prescribing information is available on slide 19.

26. Adverse effects of ellaOne and Levonelle
Nausea
Vomiting 1% - if within 2hrs of taking LNG or 3hrs of taking ellaOne further dose required
Headache
Both can affect timing of next menstrual period
Do pregnancy test if not had a normal menstrual period 3 weeks after UPSI

27. Potential drug interactions for ellaOne
Liver enzyme inducing medications used currently or up to 28 days previously
e.g. rifampicin, phenytoin, phenobarbital, carbamazepine, St John’s wort (Hypericum perforatum)
Products that increase gastric pH taken in the preceding 24hours
e.g. proton pump inhibitors, antacids, H2-receptor antagonists
Use in women with severe asthma treated by oral glucocorticoids is not recommended
ellaOne may interfere with oestrogen and progestogen methods of contraception including Levonelle

28. Potential drug interactions for Levonelle
Liver enzyme inducing medications used currently or up to 28 days previously
e.g. some antiepileptic drugs, some treatments for TB and HIV and some herbal remedies eg St John’s wort
For this group, the best choice EC is Copper IUD
If declined or contraindicated, you can use double dose Levonelle (off licence)

29. Facts about Emergency Hormonal Contraception
Has no effect on future fertility
Does not interrupt an established pregnancy
If mistakenly given in early pregnancy, does not harm a developing foetus
Does not protect against STIs
Does not provide contraception for further UPSI in the days after EHC has been taken

30. When should EC be used? When no contraceptive method used
When failure or potential contraceptive failure of method used – e.g.
Split or slipped condom
Forgotten progestogen only pills
Forgotten combined pills or patch or ring
When Depo-provera late
IUD/IUS expelled or expired
Nexplanon expired

31. What EC options are suitable for this client?
Was any method of contraception used?
If yes, reason for failure/potential failure of method?
First day of LMP
Cycle length (if variable, shortest and longest)
When did they last have UPSI?
Were there any other episodes of UPSI in current cycle?
EC previously used this cycle?
Medical history
Drug history including any OTC
Allergies

32. Indications for EC POP Depo-provera
>27 hours since last POP (Micronor, Noriday, Norgeston) and UPSI in next 48 hours
>36 hours since last desogestrel only pill (Cerelle and Cerazette) and UPSI in next 48 hours
Depo-provera
Late injection (>14 weeks) and UPSI after this time.

33. Missed COC Pills FSRH Clinical guidance on missed pills
1 pill can be missed anywhere in the pill pack with no need for extra protection or EC
If 2 pills or more are missed, then extra protection should be used for 7 days and EC may be required

34. Missed COC pills – minimising the risk of pregnancy
Need to think hard about pills missed in week 1 and week 3
Pills 1-7 Consider EC if UPSI (including in PFI) if 2 pills missed. After EC continue pills and use condoms for 7 days if LNG taken and 14 days if UPA taken
Pills 8-14 No need for EC if UPSI Continue pills and use condoms for 7 days
Pills No need for EC if UPSI but continue pills, avoid PFI and use condoms for 7 days

35. Quick starting hormonal contraception after oral EC – how long is barrier contraception needed?
EC Option
COCP
POP
QLAIRA
LNG
7 days
2 days
9 days
UPA
14 days
16 days
FSRH Quick starting contraception 2010
ellaOne SmPC instructions
"If a woman wishes to start or continue using hormonal contraception, she can do so after using ellaOne, however, she should be advised to use a reliable barrier method until the next menstrual period".

36. Key points for EC Consultation
Assessing the risk of pregnancy
Discuss the EC options appropriate for the circumstances
STI risk assessment
Any other issues to consider?
e.g. Fraser competent, Safeguarding. Was sex consensual?
Drugs / alcohol involved?
Ongoing contraception
Arrange follow up for further STI screening and Pregnancy Testing

37. Session Key Points 3 methods of EC – Levonelle, ellaOne and Cu IUD.
Cu IUD is the most effective
Always check medical eligibility for EC
Always ask about medications taken including OTC, which may make oral EHC less effective.
Always address ongoing contraception
STI risk assessment is an essential part of EC consultation.
Use this opportunity to explore any issues relating to non- consensual sex, sexual assault or abuse and domestic violence