1. Emergency Contraception Laurie Hornberger, MD, MPH Assistant Professor of Pediatrics University of Missouri, Kansas City

2. 2 “I was waiting for my period so I could get started on my birth control pills. Well, things with my boyfriend went further than they should have Saturday night. We didn’t have a condom. I’m worried that something could have happened.”

3. 3 “I was at this party night before last and got really wasted. I woke up in this bedroom. Some of my clothes were on the floor. I think I might have had sex with somebody, but I don’t really know.”

4. 4 “I was the only one of my friends who hadn’t done it. So on Saturday night I did it with this guy I know, just to find out what it was like. He said he had a condom on but I was too scared to look. There was this stuff coming out of me later. Could I have gotten pregnant?”

5. 5 What is emergency contraception? Emergency contraception, or postcoital contraception, is the use of hormonal pills following an episode of unprotected intercourse to reduce the risk of an unintended pregnancy.

6. 6 Why provide emergency contraception?  Reduces number of unplanned, undesired pregnancies u Reduces number of abortions u Provides an opportunity to counsel on more effective family planning options u Gives girls and women (and their partners) a second chance

7. 7 Emergency contraception is nothing new…. u1500 BC: Ancient Egyptians described postcoital preparations u1800s: Postcoital douching (remember the soda pop douche?)  1967: First use of high-dose estrogens for postcoital contraception

8. 8 Yuzpe Regimen u1974: Canadian obstetrician Albert Yuzpe describes the use of combination birth control pills (estrogen and progestin) following unprotected intercourse to reduce risk of pregnancy uWidely used “off-label” for >20 years uFeb 1997: recognized as safe and effective by FDA uSept 1998: PREVEN™ approved by FDA

9. 9 How does the Yuzpe regimen work? u Alters the endometrium to prevent implantation of the ovum u Inhibits the midcycle hormonal surge that triggers ovulation u Thickens cervical mucus u Alters transport of ovum in fallopian tubes

10. 10 What the Yuzpe regimen does not do:  Cause the abortion or miscarriage of an implanted ovum u Cause birth defects in a developing embryo

11. 11 What are the side effects?  Nausea (46-70%) u Vomiting (22-30%) u Headaches (2%) u Dizziness (2%) u Breast tenderness (1%) u Menstrual irregularity

12. 12 A new and improved emergency contraception regimen  Research into progestin-only emergency contraception began in 1970s u July 1999: FDA approved Plan B™ u Reduced side-effect profile u Increased efficacy u Presumably similar mechanism of action

13. 13 What is the efficacy of emergency contraception? Percentage of expected pregnancies prevented Time of tx Yuzpe Progestin-only < 24 hrs 77% 95% 24-48 hrs 36% 85% 48-72 hrs 31% 58% Effectiveness beyond 72 hours?

14. 14 Use of emergency contraception  Rule out pre-existing pregnancy u Premedicate with antiemetic 30-60 minutes prior to each hormone dose u Dispense two doses of hormonal pills, 12 hours apart u Reevaluate if no menses within 21 days

15. 15 When should emergency contraception be considered?  Condom not used u Condom was not available u Afraid to ask partner to use a condom u Condom broke or slipped u Missed birth control pills or Depo Provera shots u Coerced or forced sexual intercourse

16. 16 Timing of menstrual cycle should not be a factor in use of emergency contraception  Menstrual history may be incorrect u Cycles may be irregular and unpredictable u Immature/adolescent cycles u Misuse of hormonal contraception

17. 17 Is there anyone who shouldn’t use emergency contraception?  No absolute contraindications u For Yuzpe regimen, may use same considerations one uses for estrogen- containing birth control pills. However, there is no evidence that problems occur with short-term emergency contraception use. u Useless if already pregnant

18. 18 Why isn’t emergency contraception widely used yet?  Lack of awareness among care providers u Misunderstandings among care providers u Mistrust of patients u Lack of awareness among public u Misunderstandings among public u Lack of access to health care

19. 19 Shouldn’t emergency contraception be available to all Job Corps students? It makes sense!