Emergency Contraception

Offer it to:

  • Any women not wanting to conceive after unprotected sexual intercourse on any day of normal menstural cycle
  • Any women
    • from day 21 after childbirth (unless lactational ammenorrhia criteria are met)
    • from day 5 following abortion/miscarriage/atopic pregnancy/unterine evacuation
  • Any women who’s had unprotected sex if the contraception she was using was compromised or used incorrectly in some way

 

Be aware:

  • if you’re referring for Copper Intrauterine Device (Cu-IUD) as emergency contraception (EC) then need to give oral EC as well just incase it can’t be done or she changes her mind
  • Make the patient aware EC isn’t ongoing contraceptive cover

 

What’s most effective?

  • Cu-IUD is the most effective
  • Ulipristal acetate EC (UPA – EC) is effective for up to 120hours post sex
  • levonorgesterol (LNG-EC) is licensed up to 72hours and doesn’t work after 96hours
  • UPA-EC is probably more effective than LNG-EC
  • Oral EC within five days after ovulation is ineffective

To calculate when ovulation is: it usually happens on the 14th day of the cycle – with the first day of bleeding being the first. Best thing to do take the shortest cycle they have (say it’s 28 days) and take 14 from that – that gives you the day of ovulation – day 14 and then 5 days after that – so be aware the Oral contraceptive for them wont work between day 14 and day 19.

Does higher BMI make less effective?

  • The Cu-IUD is not effected by higher BMI
  • Oral EC is less effective with higher BMIs – especially LNG-EC

Drug Interactions

  • Enzyme inducing drugs can reduce the effectiveness of oral EC (UPA-EC and LNG-EC)
  • If they’re on enzyme inducers – it’s best to go for the copper IUD
  • If on enzyme inducers and can’t/don’t want Cu-ICD they could be offered 3mg of Levonorgesterol but it’s effectiveness in unknown (don’t double dose of Ulipristal acetate)
  • UPA-EC effectiveness is reduced by using progesterone in the 5 days following UPA-EC use – and potentially if she’s taken it in the 7 days prior to UPA-EC
  • UPA-EC can not be used by women with severe asthma taking oral glucocorticoids.

Breastfeeding

  • If they’re breastfeeding there’s a higher risk of perforation of the Cu-IUD – but the overall risk is still low
  • Breastfeeding women need to express and discard the milk for a week after UPA-EC
  • LNG probably ok (but limited evidence) for breastfeeding

 

What should I offer?

  • All women should be offered the Cu-IUD as it’s the most effective method of contraception
  • Cu-IUD can be inserted up to  5 days after UPSI in a normal cycle or up to 5days after the likely date of ovulation (whichever in later)
  • If Cu-IUD can’t be done/isn’t wanted/isn’t appropriate – oral EC should be taken asap within 5days of UPSI
  • UPA-EC is first line if it’s between 96hours (4days) and 120hours (5days) (or less than 96hours ago)
  • UPA-EC if UPSI in last 5 day if the UPSI was likely in the 5days prior to estimated day of ovulation
  • Oral EC is ineffective after ovulation
  • Adolescents get the same options as adults
  • Women after rape get the same options as everyone else including Cu-IUD

If a women’s had UPSI in the same cycle (over 5 days ago) can and then again in the last 5 days can she have oral EC?

  • Yes – it won’t protect against pregnancy from that previous UPSI but it’s not going to damage the fetus if there is one from that first UPSI and it will still protect against pregnancy now.

What about two rounds of EC in the same cycle?

  • UPA-EC & LNG-EC can be used more than once in the same cycle
  • But don’t switcharoony between the two
    • If they’ve had UPA-EC they shouldn’t have LNG-EC in the next 5 days
    • If they’ve had LNG-EC they shouldn’t have UPA-EC in next 7 days as it could be less effective.

Future Contraception

  • The Cu-ICD provides ongoing contraceptive cover
  • Oral EC methods don’t provide ongoing cover
  • They need to get onto decent contraception – but need to use condoms to start with
  • They can’t use hormonal contraception for 5 days after UPA-EC
  • They can use hormonal contraception straight away after LNG-EC – so if the UPSI is unlikely to have been during the fertile period they may opt for that.