Emergency Contraception

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Emergency Contraception
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• Emergency contraceptive pills (ECPs) provide a
  short, high dose of combined estrogen and
  progestin, or progestin alone and are 75
  effective in preventing pregnancy within 72 hours
  after unprotected intercourse

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• Indications include
• unprotected intercourse
• failure of a barrier method
• sexual assault
• potential pill failures
• recent use of suspected teratogens

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• Emergency contraception works in three ways. It
  slows down ovulation, it stops the fertilization
  of the egg, and it stops the attachment of the
  egg to the wall

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• Emergency contraceptive pills do not affect an
  established pregnancy and numerous studies of the
  teratologic risk of conception during regular use
  of oral contraceptives (including the use of
  older, higher-dose preparations) found no
  increase in risk.

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• Emergency contraception is safe. The ACOG stated
  in 1996 that no published studies have reported
  evidenced based criteria contraindicating use of
  ECPs

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• The World Health Organization noted that because
  ECPs are given over such a short time period,
  experts believe they have no clinical effect on
  conditions such as cardiovascular disease,
  angina, acute focal migraine and severe liver
  disease.

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• Both the World Health Organization, and the
  International Planned Parenthood Federation have
  stated that there are no absolute
  contraindications to use of emergency
  contraceptive pills except pregnancy

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• The pregnancy exception relates to the fact that
  the regimen is not effective during pregnancy,
  not to any teratogenic effects

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• On February 25, 1997, the FDA announced the use
  of certain combined oral contraceptives
  containing ethinyl estradiol and levonorgestrel
  as safe and effective for the prevention of
  pregnancy

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• The pills are given in two doses. To prevent
  pregnancy, the first dose of pills must be taken
  by mouth as soon as possible, ideally within 3
  days (72 hours), but no later than 5 days (120
  hours) of having unprotected sex. A second dose
  is taken 12 hours after the first dose. The
  number of pills in the dose depends on the brand
  of pill used. For progestin-only pills, both
  doses can be taken at the same time or 1224
  hours apart

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• On September 3, 1998, the Food and Drug
  Administration (FDA) accepted a commercially
  available product containing ethinyl estradiol
  and levonorgestrel designated for use as an
  emergency contraceptive

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• On July 28, 1999 the FDA approved the first
  progestin-only contraceptive. The new product's
  efficacy in reducing pregnancies is 83 with less
  incidence of nausea and vomiting compared to the
  combined oral contraceptive containing ethinyl
  estradiol and levonorgesterel.

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• There are two distinct pill types, the brand name
  "Preven" and the brand name "Plan B". Preven
  contains the same hormones as regular birth
  control, estrogen and progestin. It causes more
  instances of nausea and vomiting than Plan Bs,
  and decreases the chances of pregnancy by 75.
  However, Preven can be used as an ongoing form of
  birth control. Plan B only contains the hormone
  progestin. It is more effective, decreasing
  chances of pregnancy by 89, and has less of a
  chance for side effects. These pills can be taken
  immediately after the sex, or up to 72 hours
  later.

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• Dose Two doses of 100ug ethinyl estradiol and
  500ug levonorgestrel taken 12 hours apart. 
• 4 tablets stat of Nordette or Microgynon 30 (or
  generic equivalent) and another 4 tablets 12
  hours later

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• As nausea and vomiting are very common with the
  Yuzpe method, an anti emetic, to be taken 30-60
  minutes prior to the hormonal doses, should be
  supplied/prescribed with this regimen

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• Less common side effects including headache,
  breast tenderness and lower abdominal pain can
  occur with this method.1
• No adverse effects on foetal development have
  been reported with the method in cases where
  pregnancy has occurred

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• Two methods of birth control can be used for
  emergency contraception. The most commonly used
  method is pills (also known as the morning-after
  pill). Birth control pills contain the hormones
  estrogen and progestin or, in some cases,
  progestin only. The progestin-only method is more
  effective and is less likely to cause nausea. The
  intrauterine device (IUD) also can be used for
  emergency contraception

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• Dose Two doses of levonorgestrel 750 ug taken 12
  hours apart. 
• Postinor-2 one tablet and another tablet 12 hours
  later 
• Microlut or Microval twenty-five (25) tablets and
  twenty-five (25) tablets 12 hours later.

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• Both levonorgestrel and Yuzpe methods have been
  shown to be most effective when commenced within
  12-24 hours of sexual intercourse, with
  commencement of the first dose recommended before
  72 hours

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• A recent study, using the Yuzpe regimen, found
  that emergency contraception may still be
  effective (though to a lesser degree) in
  preventing pregnancy, when commenced up to 120
  hours after intercourse

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The IUD for Emergency Contraception

• The IUD can be used as emergency contraception.
  It works best if inserted within 5 days of having
  unprotected sex. The presence of the IUD prevents
  the fertilized egg from attaching to the wall of
  the uterus

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• A benefit of the IUD is that it can be left in
  for long-term use. The IUD may be a good choice
  if you cannot take birth control pills. The IUD
  does not prevent sexually transmitted diseases

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• Copper bearing IUCDs provide an effective method
  of postcoital contraception. The failure rate is
  less than 1. Careful assessment and counselling
  should take place before insertion is decided
  upon. The IUCD is not suitable for women who have
  risk factors for pelvic inflammatory disease

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• An emergency IUCD can be inserted at any time in
  the cycle provided the earliest episode of
  unprotected intercourse occurred no more than 5
  days previously. Where the earliest episode of
  unprotected intercourse was more than 5 days
  previously, an IUCD can be considered up to 5
  days after the calculated earliest day of
  ovulation (ie. up to day 19 of a 28 day shortest
  cycle by history)

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• This limit is well within the period before
  implantation. If the woman does not wish to
  continue using the IUCD as a contraceptive
  method, it may be removed at the time of the next
  period. If hormonal contraception has been
  commenced, the IUCD may be removed after 7 active
  pills have been taken

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Frequency of Use

• Emergency contraceptive pills (ECP) should not
  replace the use of regular contraception, as the
  cumulative pregnancy rate for frequent use of ECP
  is higher than with regular contraception.
  However, if unprotected sex occurs in a cycle
  where the ECP has already been used it can be
  used again

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• Women should understand that the use of the ECP
  cannot protect them from the possibility of
  pregnancy if unprotected intercourse occurs later
  in the cycle.
• In cycles, where unprotected intercourse has
  occurred more than once, ECP can be used,
  although efficacy will be influenced by the time
  interval since the first act of unprotected
  intercourse. The woman must understand that, if a
  pregnancy has already occurred, the ECP will not
  be effective

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Drug interactions

• Hepatic enzyme inducing drugs
• Hepatic enzyme inducing drugs enhance the
  metabolism of levonorgestrel and ethinyl
  estradiol. If a woman taking these drugs (e.g.
  phenytoin, carbamazepine, rifampicin,
  griseofulvin) uses emergency hormonal
  contraception the recommendation is to double
  each dose. This increases the risk of side
  effects

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• Antibiotics
• Antibiotics taken concurrently with hormonal
  emergency contraception are unlikely to alter its
  efficacy and no alteration in dose is advised.
  The exceptions are the enzyme inducers rifampicin
  and griseofulvin as detailed above

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