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Contain estrogen and progestin- at least 1mg of LNG and 200mcg of ... control pills containing only progestin. 2 doses of 1 Plan B tablet or 20 Ovrette tablets ...

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slide2

Emergency Contraception

A Well Kept Secret

Tony Ogburn, MD

University of New Mexico Health Sciences Center

objectives
Objectives
  • Understand the need for EC
  • Review the current methods of EC available in the U.S.
  • Understand the barriers to use that exist for EC.
  • Be familiar with approaches to improve EC utilization.
slide4

The few things I really want you to know!

  • What form of EC is most effective
  • Talk to every reproductive age woman at risk for pregnancy about EC
  • Provide EC in advance
  • Support EC to be available over the counter.
slide5
A 27 yo G3 P3, married patient calls your office saying she and her husband noted the condom was broken after sex the night before. What should she do??
slide6

The Setting

  • ~3.0 million unintended pregnancies annually
    • half (48%) of all pregnancies
  • Half (48%) of women aged 15-44 have had an unintended pregnancy
  • Unintended pregnancy is a major public health problem that affects individuals and society
  • Emergency contraception has the potential to reduce unintended pregnancy significantly

Source: Henshaw 1998, Trussell et al. 1997

slide7

3 Million Unintended Pregnancies

  • ONE HALF . . .couples using no method of contraception 3 million couples
  • ONE HALF. . .couples using a reversible method imperfectly, or experiencing a method failure24 million couples

Source: Henshaw 1998; Abma et al. 1997

slide8

EC: Potential Impact

  • Reduce unintendedpregnancies by 1.5 million
  • Reduce abortions 0.7 million

Source: Trussell et al. 1992; Henshaw 1998

slide9

Emergency Options in theUnited States

  • Oral contraceptive pills containing only progestin
  • Oral contraceptive pills containing estrogen and progestin
  • Emergency Copper-T IUD insertion
slide10

Emergency Contraceptive Pills: Combined

  • Regular birth control pills- Yuzpe method
  • Contain estrogen and progestin- at least 1mg of LNG and 200mcg of ethinyl estradiol
  • 2 doses of 2, 4, or 5 pills, depending on brand
  • First dose within 72(120) hours
    • Second dose 12 hours later(or maybe not!)
  • Side effects: nausea (50%) and vomiting (20%)

Trussell et al. Women’s Health Prim Care 1998;1:55

slide11

Emergency Contraceptive Pills: Combined

Preven

(No longer available)

slide12

Emergency Contraceptive Pills: Progestin-only

  • Birth control pills containing only progestin
  • 2 doses of 1 Plan B tablet or 20 Ovrette tablets
  • First dose within 72(120) hours after intercourse
    • Second dose 12 hours later(or maybe not!)
  • Less nausea/vomiting than combined ECPs

Task Force. Lancet 1998;352:428

slide14

Emergency Copper IUD Insertion

  • Copper-T IUD (ParaGard)
  • Insertion within 5 days after unprotected intercourse
  • 10 more years of highly effective contraception
  • Much more effective than ECPs
  • Not recommended for women at risk of sexually transmitted infections (STIs)
slide16

Combined ECP Effectiveness: Single Use

100 women have unprotected sex in

the 2nd or 3rd week of their cycle

8 will become pregnant without

emergency contraception

2 will become pregnant using combined ECPs

(75% reduction)

Source: Trussell, Rodríguez and Ellertson 1998

slide17

Progestin-only ECP Effectiveness: Single Use

100 women have unprotected sex in

the 2nd or 3rd week of their cycle

8 will become pregnant without

emergency contraception

1 will become pregnant using progestin ECPs

(88% reduction)

Source: WHO 1998

slide18

IUD Effectiveness - Single Use

1000 women have unprotected sex in

the 2nd or 3rd week of their cycle

80 will become pregnant without

emergency contraception

1 will become pregnant after IUD insertion

(99% reduction)

Source: Trussell and Ellertson 1995

slide19

Emergency Contraceptive Effectiveness

If 1000 women have unprotected sex once in the second or third week of their cycle

concerns about ec
Concerns about EC
  • It’s an abortion pill
  • It will keep woman from using more effective means of contraception and have “risky sex”
  • It’s not safe and can cause serious side effects
slide21

Definition of Pregnancy

  • NIH/FDA
    • Pregnancy encompasses the period of time from confirmation of implantation until expulsion or extraction of the fetus.
  • ACOG
    • Pregnancy is the state of a female after conception and until termination of the gestation. Conception is the implantation of the blastocyst. It is not synonymous with fertilization; it is synonymous with implantation.

Source: US Government 1983; Hughes 1972

mechanisms of action
Mechanisms of Action
  • Inhibit ovulation
  • Trap sperm in thickened cervical mucus
  • Inhibit tubal transport of egg or sperm
  • Interfere with fertilization, early cell division, or transport of embryo
  • Prevent implantation by disrupting the uterine lining
slide23

Does Providing ECPs Increase Risk-Taking?

  • Three randomized trials comparing advance provision vs. education only
    • Use was appropriate
    • Patients did not abandon or decrease the use of their regular contraceptives
    • Decrease in unintended pregnancies
safety
Safety
  • No evidence based contraindications to progestin only ECP or IUDs
  • Four case reports of cerebrovascular accidents with combined ECP
other issues
Other issues
  • How long after is too long?
  • One dose or two?
  • Nausea/vomiting
  • Spotting
  • Starting contraception
  • Menses
how long after the morning after
How Long After the Morning After?
  • Initial recommendations were to administer first dose within 72 hours
  • Several trials have found no decrease in efficacy if given within 120 hours

von Hertzen et al, Lancet, 2002, Ellertson et al, Obstet Gynecol, 2003

one dose or two
One dose or two?
  • Recommendations call for two doses 12 hours apart
  • Studies indicate that giving the same total as one dose is as effective

von Hertzen et al, Lancet, 2002, Ellertson et al, Obstet Gynecol, 2003

slide28

Reducing the Risk of Nausea

  • Meclizine significantly reduces the risk of nausea and vomiting associated with the Yuzpe regimen of emergency contraception.
  • Significantly increases the risk of drowsiness.

Raymond et al. Obstet Gynecol 2000;95:271

slide29

Spotting

Ellertson et al. Obstet Gynecol 6/2003

slide30

Number of Days of Spotting

Ellertson et al. Obstet Gynecol 6/2003

starting contraception after ec
Starting contraception after EC

Oral contraceptives, patches, and vaginal rings

  • Regular start: use backup until next period, then begin pills/patches/rings according to regular patient instructions
  • Jump start: take 2 ECP doses. Start a new pack of OCs, or use a patch/ring the next day (use backup for first 7 days)
starting contraception after ec32
Starting contraception after EC

Depo-Provera®

  • Regular start: use backup until next period, then start Depo-Provera according to regular patient instructions
  • Jump start: take 2 ECP doses. Start Depo-Provera the next day (use backup for first seven days)
slide33

Menses after ECP Use

  • Similar for combined and progestin-only regimens
  • Relative to anticipated onset of next menses
    • 13% have a delay of 8+ days
    • 15% have a delay of 4-7 days
    • 61% have menses within  3 days
    • 11% have early onset (>3 days early)
  • A follow-up visit is warranted if menses do not return within three weeks following treatment

Source: WHO 1998