Emergency Contraception



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Emergency Contraception

If hormonal contraception (2 or more pills, a patch or a ring) is missed ANYTIME during the cycle, AND recent sexual activity (within 5 days), copper IUD or levonorgestrel should be given.

Patient on, but missed OCP, patch or ring?

No contraindications & desires IUD?

Consider adolescent medicine or OBGYN consultation

< 120 hours since sexual activity?

Inclusion Criteria
  • Female
  • Sexually active, plans to become sexually active, rape or contraception failure
Exclusion Criteria
  • Known or suspected pregnancy

Consensual sexual activity?

Begin sexual assault managment

Consider adolescent medicine or OBGYN consultation

Urine Pregnancy, Urine
GC/CT NAAT

Ulipristal (Ella)

Effectiveness

  • Possibly less effective in obese and overweight women ( consider copper IUD instead)
  • Effective for 5 days (120 hours) after unprotected sex

Advantages

  • It can be used for emergency contraception up to 120 hours after intercourse.

Disadvantages

  • Only available by prescription PH--question--Can this be dispensed in the ED? rather than a prescription, obviating the need for this statement of disadavantage

Note

  • For women taking Ulipristal for emergency contraception, starting (within 5 days) a hormonal method containing progesterone after taking ulipristal could make ulipristal less effective by competitive binding to the progestin receptors. (ulipristal works by an antagonistic mechanism to progesterone)

Pregnancy testing

  • Pregnancy testing is not required to prescribe emergency contraception unless it is suspected by history, symptoms or missed menstrual period. Before prescibing the copper IUD however, a pregnancy test should be done as it may pose risk to the ongoing pregnancy.
  • A history of ectopic pregnancy is not a contraindication to use emergency contraception.

Initiation of therapy

  • A physical examination or any laboratory tests are NOT necessary before providing oral emergency contraception.

Vomiting of oral emergency contraception

  • If ulipristal or levonorgestrel is vomited within 3 hours of administration, an anti-emetic (i.e. ondansetron, metoclopramide) should be given and the dose repeated.
  • Additionally levonorgestrel may be administred intravaginally.

Indications for using emergency contraception

  • When no contraceptive was used during vaginal intercourse within the previous 120 hours
  • Sexual assault has occurred with vaginal penetration
  • When there is a contraceptive failure or incorrect use of a contraceptive within the previous 120 hours, including:
  • Condom breakage, slippage, or incorrect use
  • If 2 or more pills missed anytime in the cycle (offer copper IUD or give levonorgestrel rather than ulipristal)
  • Progestin-only pill (minipill) taken more than three hours late
  • More than two weeks late for injection of depot-medroxyprogesterone acetate
  • Dislodgment, breakage, tearing, or early removal of a diaphragm or cervical cap
  • Dislodgment, delay in placing, or early removal of a contraceptive hormonal skin patch or vaginal ring (offer copper IUD or give levonorgestrel rather than ulipristal)
  • Failed coitus interruptus (eg, ejaculation in vagina or on external genitalia)
  • Failure of a spermicide tablet or film to melt before sexual intercourse
  • Miscalculation of the periodic abstinence method or failure to abstain on fertile day of cycle
  • Expulsion of intrauterine contraception

  • Place, or arrange for copper IUD placement as soon as possible (within 5 days max) by consulting gynecology
  • Outpatient repeat pregnancy test if bleeding has not occurred within three to four weeks or if there is abdominal pain or irregular bleeding.

  • Prescribe emergency contraception to have on hand in case of future failure
  • Recommend a barrier method or abstinence for the remainder of the cycle (or minimum 7 days) AFTER starting or resuming regular contraception
  • Outpatient repeat pregnancy test if bleeding has not occurred within three to four weeks or if there is abdominal pain or irregular bleeding.

Levonorgestrel tabs

Probability of pregnancy after unprotected intercourse by timing of coitus

Days from ovulation

Probability of pregnancy

- 3

15%

- 1 to 2

30%

0

12%

+ 1 to 2

~0%

Overweight and obese patients

  • There is some data that in women with a BMI above 26 kg/m2 or at weight ≥75 kg (165 pounds) that the effectiveness of levonorgestrel is decreased. In these women, they should be counseled about this possible decreased effectiveness and offered a copper IUD or ulipristal primarily, but if unable to use these methods they should STILL be offered levonorgestrel as it does continue to have some effect, even if decreased.

Copper IUD

  • Contraindications
  • Severe uterine distortion
  • Active pelvic infection
  • Copper allergy
  • Known or suspected pregnancy
  • Advantages
    • Provides continuing contraception after the initial event and it is more effective than oral regimens, especially in overweight/obese women
  • Disadvantages
    • Requires a trained provider for placement or an office visit for insertion within 5 days of the episode of unprotected sex

Levonorgestrel (Plan B One Step or lots of generics 1.5 mg)

Advantages

  • Available OTC, well tolerated

Disadvantages

  • Less effective when BMI ≥ 26, and up to 4 fold failure rates with obesity MBI >/= 30 (when one should consider IUD or ulipristal)
  • It has decreasing efficacy with time since unprotected intercourse. Although inital approval was for only 72 hours, it likely continues to have efficacy past this point in time and the WHO advocates for use up to 120 hours.

Notes

  • For women taking levonorgestrel, any contraceptive method can be started immediately after the use of the emergency contraceptive. In addition, barrier methods of contraception (eg, condom or diaphragm) or abstinence are required during the first seven days of use of the resumed method.
  • It is unlikely that the same contraindications associated with long-term progestin-only contraceptives apply to the levonorgestrel emergency contraception dose regimens (per CDC Medical Eligibility Criteria for Contraceptive Use).

  • Prescribe emergency contraception to have on hand in case of future failure
  • Progesterone containing contraceptives (pill/patch/ring/implant) should NOT be used with ulipristal or for five days following ulipristal use because the progesterone would decrease ulipristal's effectiveness.
  • Recommend a barrier method or abstinence for the remainder of the cycle (or minimum 7 days) AFTER starting or resuming regular contraception
  • Outpatient repeat pregnancy test if bleeding has not occurred within three to four weeks or if there is abdominal pain or irregular bleeding.

Ulipristal tabs



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