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Emergency contraception

Emergency contraception. Emergency Contraception. Intervention aimed at preventing unintended pregnancy after unprotected sexual intercourse or potential contraceptive failure. Usual scenario. 20 yr old woman requests the “ morning after pill ” for upsi 36 hours ago.

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Emergency contraception

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  1. Emergency contraception

  2. Emergency Contraception Intervention aimed at preventing unintended pregnancy after unprotected sexual intercourse or potential contraceptive failure.

  3. Usual scenario.... • 20 yr old woman requests the “morning after pill” for upsi 36 hours ago. • When you offer her a copper intrauterine device, ulipristal acetate or levornogestrel she looks surprised and says “can’t I just have the pill I had last time”

  4. 3 methods • Copper IUD; can be used up to 5 days following first UPSI in cycle or within 5 days from the earliest estimated day of ovulation. • Effectiveness >99% at any time of cycle.

  5. Oral emergency contraception

  6. Levonorgestrel, LNG; free from • GP’s • Sexual health /young persons clinics • Brook centres ( 25 and under) • NHS walk in centres ( England only) • Some A&E departments • Some pharmacies for 16+ • Licensed for use up to 72 hours after UPSI or contraceptive failure; may be used up to 120 hours ( off licence)

  7. Levonelle LNG • Can be purchased over the counter at cost of £25 for age 16 and over • It is a single dose levornogestrel 1.5 mg.

  8. Ulipristal/UPA “ellaOne” • A selective progesterone receptor modulator; single dose 30 mg. • Licensed for use up to 120 hours after UPSI or contraceptive failure. • Cost £16.95 • Available otc £43!!!

  9. When is EC needed? • Missed cocp • Late POP ( >27 hrs for conventional POP,>36 hours for desogestrel) • Condom not used/ condom accident • Late depo >14w since last injection • IUD removal, expulsion, lost threads • Enzyme inducing drugs and failure to use extra precautions

  10. How does it work? • IUD; copper toxic to sperm and ovum; primarily inhibits fertilisation (and implantation) • LNG; interferes with ovulation by inhibiting LH surge • ellaOne; delays LH surge and has effect on follicular rupture; additional action

  11. Levonorgestrel, levonelle • Inhibits ovulation only if given before the LH surge. • It has no effect if given after ovulation.

  12. Ulipristal, EllaOne • Suppresses lead follicles when given just before ovulation, including during the LH surge. • It is unclear if it has any effect after ovulation

  13. Actions different EC methods

  14. How effective is it? • IUD >99% effective • LNG up to 95% within 24 hrs • up to 85% within 25-48 hrs • up to 58% within 49-72 hrs • UPA at least as effective as LNG up to 120 hours

  15. Evidence LNG v UPA • Glasier; meta-analysis ( Lancet 2010) • Looked at 2 randomised controlled trials • Authors concluded that the pregnancy rate with UPA was significantly lower at all time periods analysed up to 120 hours.

  16. Case one • 22 year old Lucy has just started a new job. She attends your surgery on Tues am after bank holiday weekend. She got drunk at a party on the Thursday night and cannot remember using condom. She is requesting a “morning after pill” • What other information do you need?

  17. Case one • Lucy has a predictable 28 day cycle and her last period started 12 days ago. She has not had any other acts of upsi this cycle. • What treatment would you offer her?

  18. Lucy • UPSI 4+ days ago • Currently day 12; so this occured around day 8 of 28 day cycle. • Too late for levonelle • Her options are between ellaOne and IUD.

  19. Risk of pregnancy • Risk is highest mid cycle( 5 days before and 1 day after ovulation) Risk is 20-30% • Rest of cycle; risk is around 10% but due to unpredictable nature of ovulation there is no point at which one could guarantee that pregnancy won’t occur. • Implantation is always at least 5 days after ovulation.

  20. Case two • Laura,18, no regular contraception. Sunday pm, on call centre. Had sex last night, condom came off. LMP started 10 days ago. She has a regular cycle, but can be up to 3 days early. She is very keen to avoid pregnancy as she is going to university after her gap year and is going on a college field trip tomorrow. • What method do you feel would be most suitable for her?

  21. Case two, Laura • This is a mid cycle event; most risky time but she is only 24 hours after the event. • In theory; LNG or UPA can be used • UPA will offer a slight advantage due to its additonal effect on ovulation. • Emergency IUD would be most effective option( you have until day 16 to fit this)

  22. What are the side effects of EC? • IUD; pain • LNG and UPA; nausea, headache, altered bleeding pattern • Vomiting in approx 1%( suggest repeat dose if vomit within 2 hrs LNG or 3 hours UPA) Repeat dose/offer IUD • Next menses; on average 1.2 days earlier with LNG, 2 days later with UPA

  23. When to do pregnancy test? • If no period, pregnancy test should be positive 3 weeks after event of upsi.

  24. Case three • 16 year old Mary has a chaotic cycle. She had sex with her new boyfriend last night and he did not have a condom. On further questioning she took LNG 3 weeks ago after having sex with someone else and has not had a period since. • What should you consider and how would you proceed?

  25. 16 year old Mary. • Vulnerable young adult. • At risk STI and pregnancy. • Drugs and alcohol? • Age boyfriend? • Consensual? • Provide condoms and encourage quick start method.

  26. Can the method be used again in the same cycle? • IUD can be used for multiple events in same cycle if fitted within 5 days earliest calculated date of ovulation • LNG can be used more than once in same cycle; even if the earlier episode of upsi was outside the treatment window( outside product licence)

  27. Can the method be used more than once in same cycle? • UPA can not be used more than once in same cycle and cannot be used if LNG has been given earlier in the cycle. • UPA cannot be used if there has been an earlier UPSI event earlier in the cycle outside the treatment window of 120 hours.

  28. Case four • Lorraine is 16. You saw her a week ago and provided LNG for her for upsi the night before. It is now 13 days since her last period which occur every 4 weeks. She admits when you ask that she also had sex 4 days ago but was afraid to mention it. Again she had not used a condom. • What is her EC method of choice?

  29. Case four • Copper IUD deals with both episodes and is her best choice. • LNG can be used but is only 50% effective. • You have until day 19 in a 28 day cycle to fit IUD; ie you have 6 days to organise this. • If you arrange for her to have IUD fitted in 2 days time what else would you do?

  30. What methods can be used together? • LNG>1 per cycle • LNG and IUD( recommended if considering IUD) • UPA and IUD • But not; LNG and UPA in same cycle • Or…….UPA>1 per cycle

  31. Ongoing contraception; quick start. • Methods which can be started immediately after oral EC include CHC, POP, implant. • It is recommended that depo should only be quick started if all above options are considered to be unsuitable.

  32. Quick start after LNG. • CHC; use condoms for 7 days. • Qlaira; use condoms for 9 days. • POP; use condoms for 2 days.

  33. Quick start after UPA • There is the possibility that it may interfere with ongoing hormonal contraception . • It is also possible that the hormonal contraception can reduce the efficacy of UPA……..

  34. Quick start after UPA • After taking UPA for EC, a woman should not start a hormonal contraceptive method for at least 5 days and be advised to use barrier methods or to abstain from sex until effective hormonal contraceptive cover has been achieved.

  35. Quick start after UPA • UPA, then wait at least 5 days; then as table

  36. Drug interactions with EC • LNG; reduced efficacy with liver enzyme inducers and for 28 days after. Offer copper IUD or if this is unacceptable a single 3mg dose LNG( outside product licence) • Eg St John’s Wort; use double dose • Concomitant use cyclosporin; increases toxicity; IUD preferred

  37. Drug interactions with EC • UPA ; cannot be used if on liver enzyme inducers or for 28 days after this. • UPA; requires acidic pH in stomach; cannot be used if on antacids, PPI, H2 blocker • Also ;avoid UPA if severe asthma uncontrolled with oral steroids.

  38. Investigations? • STI testing including HIV • Retest after appropriate window; 2 weeks for chlamydia • Consider prophylactic antibiotics with emergency IUD; stat dose azithromycin to cover chlamydia.

  39. Future contraception • Oral EC does not provide contraceptive cover for further UPSi in same cycle. • Consider “quick start”;cocp, pop or implant with extra precautions. • IUD; can leave for future contraception/ remove when pregnancy excluded. If removing ensure adequate method/no sex for 7 days before removal.

  40. What method should be offered? • Copper IUD should be offered to ALL WOMEN and DOCUMENT this. • Use of LNG > 72 hours would be unlicensed but supported by Clinical Effectiveness Unit for up to 96 hours • UPA is the only oral method licensed for 72 to 120 hours and is the preferred method if elligible.

  41. Summary • UPA best option • For those between 72-120 hours UPSI who do not want copper IUD. • For those around ovulation who do not want copper IUD

  42. Summary • After copper IUD,levonelle next best option • In those who are breast feeding • In those who have missed pills and want to continue • In those quick starting hormonal contraception

  43. Case 5; Missed pills? You receive a telephone call on Friday pm on call; 28 yr old; ran out of Yasmin, wishes a prescription urgently. Only on questioning her; should have started her pill 2days ago. Had UPSI 4+ days ago in pill free interval. Unaware that she needs emergency contraception. Declines IUD, too late for levonelle.

  44. Missed pills • She opted to have Ellaone but advised needs to delay pill start for 5 days and to use condoms for 7 days of her next packet. • Pregnancy test in 3 weeks from UPSI

  45. Cost effectiveness? • Ulipristal is a cost effective alternative to levornogestrel for all women requesting EC. • Provision of EC however has not been shown to reduce the rate of unintended pregnancy or abortions.

  46. Information required; summary • Medical eligibility • Efficacy of method • LMP and cycle length • Number episodes UPSI in cycle and when • Previous use EC in same cycle • Drug interactions • Need for additional precautions/ ongoing contraception

  47. Back up birth control • Both levonelle and ellaOne are available from selected pharmacies for FUTURE as well as post coital use! • Eg Superdrug offer on line and next day delivery service.

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