1. Emergency Contraception, Quick Start & a bit about LARCS
Dr Jackie Abrahams

2. Pregnancy and Emergency Contraception (EC)
‘All women of reproductive age are pregnant until proven otherwise’
Think about possibility of pregnancy or need for EC
With every request for contraception
With every request for a pregnancy test.
With any other consultation

3. Emergency Contraception
Remember
There is a failure rate with Levonelle 1500 and EllaOne
There is virtually no failure rate with postcoital
(PC) Coil.
 All women should be offered the option of PC Coil (especially if they are mid cycle and/or over 48 hours)

4. NB No evidence that either have much effect after ovulation
ellaOne vs Levonelle
ellaOne more effective (failure rate 1.28% compared to 2.2% with Levonelle)
ellaOne can still inhibit/delay ovulation once LH surge started - ie in 48 hours pre-ovulation
ellaOne licensed for use up to 120 hours post UPSI and equally effective throughout that time period
ellaOne is a Progesterone Receptor Modulator and therefore interferes with ongoing hormonal contraception for the next 7 days
NB No evidence that either have much effect after ovulation

5. ellaOne vs Levonelle ellaOne more expensive - £16.95 vs £5.20
Approved by Joint Area Prescribing Committee (JPAC)
for women under 35 who are mid cycle (ovulation minus 6 days to ovulation plus 2 days)
For women presenting for EC between 73 and 120 hours post UPSI

6. Emergency Contraception
Over 72 hours? – PC Coil best option
up to 5 days after earliest ovulation (i.e., day 19 of a regular 28 day cycle) – regardless of how many episodes unprotected sexual intercourse (UPSI).
If beyond ovulation+5days - up to 5 days after UPSI
Unlicenced Use Levonelle 1500 or EllaOne
If coil not an option, can have Levonelle-2 or EllaOne as unlicensed use over same timescale as PC Coil (but much higher failure rate)

7. Emergency Contraception
And then ?Quickstart
If starting hormonal method consider immediate start oral contraception  small risk of pregnancy but ?worth it.
COC - not safe for 7 days after Levonelle – 14 days after EllaOne
POP – not safe for 2 days after Levonelle – 9 days after EllaOne
PT with EMU in 3-5 weeks – ideally PT 3 weeks after last risk (eg 5 weeks after EllaOne and quickstart COC as not protected by COC for first 2 weeks)

8. Emergency Contraception
Missed Pills
Take Levonelle and continue with pills (don’t stop and wait for next period – it might never come!)
Do Pregnancy test 3-4 weeks later (whether or not normal withdrawal bleed)
NB Levonelle better than EllaOne for missed pills (because of effect on progesterone receptors with EllaOne)

9. Late / Missed Pills
COC
Latest FPA Guidance (what we teach the patients)
can miss 1 pill anywhere in pack – no extra precautions needed
If miss 2 or more need extra precautions and active pills
for 7 days
‘pragmatic’ guidance (what we know)
Need to have taken 7 active pills
can miss up to 7 anywhere else in pack
need 7 active pills after missed pills
NB Extra precautions not needed with antibiotics
POP – Only need extra precautions until normal pill taking resumed for 48 hours (Late = 12
hours for Cerazette, 3 hours for other POP’s)

10. Late Depo Injection
Up to 14 weeks – give next Depo. No extra precautions needed
14 – 15 weeks – give next Depo. If any UPSI after 14 weeks also give PCC (Levonelle or PC IUD). Not safe for 7 days and need PT in 4 weeks
Over 15 weeks – need to exclude pregnancy before rpt Depo – unless no UPSI after 14 weeks (?COC or POP for 1 month and then next Depo with neg PT)
(according to most recent WHO guidelines can have repeat Depo up to 16 weeks and don’t need extra precautions for 7 days – UK Guidelines still say 14 weeks)

11. Quick Starting Contraception
Clinical Effectiveness Unit
September 2010
See Faculty website
for full guidelines

12. Quick Starting Contraception Key Recommendations
If a health professional is reasonably sure that
a woman is not pregnant or at risk of
pregnancy from recent unprotected sexual
intercourse (UPSI), contraception can be
started immediately unless the woman prefers
to wait until her next period.

13. Quick Starting Contraception Key Recommendations
If pregnancy cannot be excluded (e.g. following
administration of EC) but a woman is likely to
continue to be at risk of pregnancy, immediate
‘quick starting’ of CHC, the POP or progestogen
only implant may be considered.
The woman should be informed of the
potential risks and the need to have a
pregnancy test at the appropriate time.

14. Quick Starting Contraception Key Recommendations
Women requesting the progestogen-only
injectable should ideally be offered a
bridging method if pregnancy cannot be
excluded, but immediate start is
acceptable if other methods are not
appropriate or acceptable.

15. Quick Starting Contraception Key Recommendations
If contraception is quick started in a
woman for whom pregnancy cannot be
excluded, a pregnancy test should be
advised no sooner than 3 weeks after the
last episode of UPSI.

16. Quick Starting Contraception Key Recommendations
If starting hormonal contraception
immediately after ulipristal acetate EC,
the CEU recommends condoms or
avoidance of sex for 14 days (9 days if
starting POP, 16 days for Qlaira)

17. LARC’s Long Acting Reversible Contraceptives
IUD/IUS
Progesterone subdermal implant (Nexplanon)
Depoprovera

18. IUD/IUS Key Messages Just as good for Nullips as Multips
No need for swabs with every fit
Do STI risk assessment and decide if necessary
If taking swabs only need to do 2 endocervical swabs for GC and Chlamydia
(an HVS is a diagnostic test – only necessary if has abnormal discharge)

19. IUD vs IUS IUD IUS Less problems than IUS if normal/light periods
Can be fitted up to ovulation + 5 days regardless of whether UPSI since LMP
If fitted over age 40 can stay in until menopause
Most effective emergency contraception
IUS
1st choice if heavy periods or had heavy periods with IUD
Amenorrhoea in only 25-30%
Can cause significant bleeding problems for up to 6 months
Other progesterone side effects
Cannot be used for emergency contraception

20. Nexplanon Most effective contraceptive method Failure rate 1/2000
No serious risks
Main challenge is management of side effects
Bleeding problems
Mood swings
Skin problems

21. Bleeding Problems with Nexplanon
Don’t usually need any investigation apart from STI risk assessment and/or screening
Usually respond to COC or POP
Often settle after 3 months of treatment
If recur on stopping can continue COC or POP longterm

22. DCHS Sexual Health Service Clinics
Central Booking Line for all Appointments Tel
We will accommodate requests for Emergency IUD’s at all of our clinics
Contact numbers to speak to a clinician
Dr Jackie Abrahams
Dr Stephen Searle

23. Diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH)
Details of the training requirements for DFSRH and Letters of Competence (LoC’s) in Intrauterine Techniques and Subdermal Implants are available on the Faculty website
DFSRH training involves three stages: e-learning for theory background; the e-SRH programme
Course of 5; five hours of small group workshops
Clinical experience and assessment

24. Course of 5 and Practical Training
Locally training is organised through
Course of 5 is run twice a year – next one is on 17th June 2013
Details of training elsewhere in UK is available on the Faculty website
Training for Health Department Phone:      
       
Website: