Clinical Notes : Women's Health

10. Emergency and Quick Start Contraception

Emergency contraception is designed to be used after unprotected sexual intercourse (UPSI), in an attempt to prevent unwanted pregnancy.

It is not the same as termination of pregnancy, and emergency contraception is not abortifacient.

‘The morning-after pill’ was always an inaccurate and misleading description, but evidence (for example measuring the chance of conception at various times of the menstrual cycle) (1) has shown that there is more to consider than just the timing after intercourse.

The U.K. based Faculty of Sexual and Reproductive Healthcare (FSRH) guidance was last updated December 2017.(2)

 
 

When during the natural menstrual cycle the different methods of emergency contraception are effective 

Cu-IUD, ulipristal acetate (UPA-EC) and levonorgestrel (LNG-EC)

 

When is emergency contraception needed ?

  • If contraception has not been used.

  • If contraception has failed (or probably failed), eg broken condoms, missed pills, overdue injections, expired implants (2)

  • After pregnancy. Fertility may return 21 days after childbirth (unless the woman is fully breastfeeding) and five days after failed or terminated pregnancy.

 

Assessment

  • Record

    • Sexual history

    • details of contraceptive failure

    • other episodes of UPSI in cycle​

    • date of LMP, and calculated expected date of ovulation

 

  • Assess pregnancy risk

    • consider pregnancy testing only if >3 weeks since UPSI

    • At risk if

      • UPSI or condom accident without alternative contraception

      • Missed COCP 

      • Failure to use additional contraception when starting new contraception

      • Failure to use contraception whilst on liver enzyme inducing drugs or for 28 days afterwards

    • Not at risk if

      • Not had intercourse since last period

      • Correctly and consistently using a reliable method of contraception

      • Within first 7 days of normal menstrual period

      • Within 4 weeks post partum for non lactating women

      • Within first 7 days post termination or miscarriage

      • Fully or nearly fully breastfeeding, amenorrhoeic and < 6 months post partum

 

  • Assess STI risk

    • arrange for STI testing if appropriate

 

​​If at risk of pregnancy

  • Discuss all methods of suitable contraception and elicit preferred method

    • emergency contraception

    • quick start

    • ongoing

  • Recommend a pregnancy test 3 weeks after last UPSI

    • to rule out pregnancy

    • even once EC is prescribed

    • especially if period is delayed or light

 

Emergency contraception

There are three methods of emergency contraception:

  • Copper IUD 

    • Cu-IUD; NOT the hormonal intrauterine system such as Mirena

    • This is always the most effective method and provides continuing contraceptive cover

 

  • Uliipristal 

    • Oral ulipristal acetate 30mg, referred to as UPA-EC (ellaOne in the UK amd ROI)

    • This is a progesterone-receptor modulator

    • It is not the same as Esmya (ulipristal acetate 5mg), which is used in the management of uterine fibroids

 

  • Levonergestrel

    • Oral levonorgestrel 1.5mg, referred to as LNG-EC (such as Levonelle or the many generic equivalents, prices vary considerably)

    • It is a progestogen

 

Copper IUD

vs

oral Emergency Contraception (2)

 

Levonorgestrel emergency contraception (LNG-EC)

vs

Ulipristal acetate emergency contraception (UPA-EC) (2)

 

Copper IUD

The Cu-IUD4 is always the most effective method, and the new guidance stresses this.

Its primary mechanism of action is inhibition of fertilisation via a toxic effect on sperm and ova; if fertilisation does occur, it can also prevent implantation.

It can be inserted up to five days after the first UPSI in a natural cycle or up to five days after the earliest estimated date of ovulation (in a natural cycle or after failed contraception).

Inserting a Cu-IUD once a pregnancy is implanted may not work, and is illegal.

For IUD insertion, obviously, the woman needs to agree to the procedure, but other information (which may or may not be available) may also be required, for example:

  • The first day of her last period, and a reasonable idea of the regularity and length of her cycle (unless her only UPSI since her last period was in the last five days, or was more than 21 days ago and a pregnancy test is negative).

  • Where she was in her combined oral contraceptive pill packet when she forgot two or more pills (or the equivalent for the contraceptive patch or ring). Indeed, is she on the combined pill or a progestogen-only pill? The latter has much tighter requirements for efficacy; one pill three hours late or 12 hours late, depending on the type, may lead to failure (2)

  • When her last contraceptive injection was given or her implant was inserted (if not by your team) (2)

A fast and convenient referral system is also needed to ensure that a Cu-IUD is fitted in a timely fashion.

If the first clinician seeing the woman cannot offer the procedure (for example a GP in a practice that does not include a trained clinician), there should be an agreed system for accessing a nearby Sexual and Reproductive Health (SRH) clinic as a priority.

In case there is a problem, it is recommended that any woman who has to wait for an insertion is also offered an oral method immediately.

Note that adolescence is not a contraindication to a Cu-IUD, nor is sexual assault.

  • 20x more effective than oral emergency contraception

  • Prevents >99% of pregnancies and can be used for ongoing contraception

  • Prevents fertilization, anti-implantation and anti-sperm effects

  • Ideally fitted at presentation

  • Give EC in addition if referring elsewhere to be fitted

  • Can be inserted up to 5 days after the 1st episode of unprotected sexual intercourse

    • up to 5 days after the estimated date of ovulation

    • shortest cycle minus 9 days   (i.e. not after day 19 in a 28 day cycle)

  • Preferred option for women on enzyme inducing drugs

  • Can be removed at any time after the next period if no UPSI has occurred since

 

Oral Emergency Contraception methods

  • Oral emergency contraception methods should be used as soon as possible after UPSI.

    • They are less effective than the Cu-IUD and (unlike a Cu-IUD) do not provide ongoing contraception.

  • There are two types, both relying on disrupting the hormonal cycle responsible for ovulation.

    • Both act by inhibiting ovulation for at least five days, until the sperm from unprotected intercourse are dead.

    • However, ovulation may simply be delayed, and it is important that women realise that any further UPSI may easily result in pregnancy.

    • Neither of them acts by preventing implantation of the embryo.

  • Importantly, both EC methods are only effective before ovulation.

    • LNG-EC works up to the start of the luteinising hormone (LH) surge that triggers ovulation, and UPA-EC works until just before the peak of the surge and is therefore still effective if given closer to the time of ovulation (3) 

    • For UPSI in the five days before ovulation (the days of maximum risk for pregnancy), UPA-EC is likely to be more effective. 

    • UPA-EC is licenced for use up to 120 hours after UPSI, whereas LNG-EC is only licensed for up to 72 hours (although it may have some effect for 96 hours).

  • Unlike a Cu-IUD, no harm will be caused to the foetus if either oral method is in fact given after implantation.

Levonorgestrel (Levonelle) = progesterone only

  • For use within 72hours (3 days)

    • may have some effect up to 96 hours after intercourse

    • prevents 52-100% of pregnancies

  • Primarily inhibits ovulation.

    • less effective just prior to and after ovulation

    • less effective when further episodes of UPSI occur

  • 1.5mg taken as soon as possible after UPSI, and within 72hours

    • Repeat dose if vomiting occurs within 2hours of taking the dose

    • 3mg dose (2x1.5mg tablets) if on enzyme inducing drugs (Unlicensed)

  • May be used more than once in a cycle

    • but use does not provide contraceptive cover

  • No medical contraindications to use

    • will not interrupt an existing pregnancy

    • not known to have adverse effects on the fetus if pregnancy occurs

  • Caution if on warfarin

    • may increase INR by displacing warfarin from its binding site

  • Side effects include

    • N&V

    • breast tenderness

    • menstrual disturbances

    • dizziness

    • iredness

    • headache

 

Ulipristal Acetate ( EllaOne )

  • As effective as levonelle up to 120 hours (5 days)

  • May be more effective than levonelle if used just prior to expected ovulation

  • Delays or inhibits ovulation, and has endometrial effects

  • Single dose of 30mg ulipristal acetate(EllaOne)

    • repeat if vomiting occurs within 3hrs

  • Should not be given more than once in any cycle

  • Binds to progesterone receptors, so additional method needed if on COC (for 14days), POP (9days), Qlaira (16days)

  • Not effective if on enzyme inducing drugs within past month, or gastric acid suppressants​

 
 

Vomiting after EC

Women should be told to seek a repeat dose urgently if they vomit within three hours of taking oral emergency contraception.

 

Overweight women

​Evidence (not strong) suggests LNG-EC is less effective in women weighing >70Kg or with a BMI>26kg/m2

It is recommended that the dose of LNG-EC should be doubled to 3mg. for these women. 

 

Breastfeeding  women

​Breastfeeding is nearly completely effective as a contraceptive if

  • it is full (ie no occasional bottles, even of expressed milk),

  • the baby is less than six months old

  • the mother’s periods have not returned

Where breastfeeding women require emergency contraception (4) :

  1. UPA-EC can be used, but breast milk should be discarded for seven days afterwards.

  2. LNG-EC is safe for breastfeeding women.

  3. Cu-IUD insertion is not recommended from 48 hours to 28 days postpartum as there is a higher risk of uterine perforation, although absolute rates are still low.(5)

 

Quick start contraception

  • Offer

    • Immediately if not at risk of pregnancy

    • After counseling if at risk of prenancy and EC prescribed

  • Ensure the woman is

    • Likely to continue to be at risk of pregnancy or expressed a wish to start contraception immediately

    • Aware that there is a possibility of ongoing pregnancy

    • Informed of a potential theoretical risk to foetus if pregnant although most evidence shows no risk

    • Aware pregnancy cannot be excluded until a Pregancy Test is performed at least 3 weeks after last episode of UPSI

  • Additional precautions

    • Repeat pregnancy test at least 3 weeks after last UPSI

    • If Dianette or equivalent requested always wait until pregnancy excluded before starting due to potential foetal effects

    • If preferred method not available eg IUD, offer bridging contraception (pill, patch, ring) until able to see own GP/ FP clinic

    • If starting hormonal contraception immediately after Progesterone only emergency contraception, then condoms/ avoidance of sex should be advised based on the following table

 

Day 1         = 1st day of bleeding

                        (Does not apply to withdrawal bleeds if on established contraception)

POP           = progesterone only pill

POP EC     = progesterone only pill, emergency contraception

UPA EC     = Ulipristal, emergency contraception

IUS             = intrauterine system (IUD with hormone)

IUD             = intrauterine device (without hormone)

Ongoing contraception

Recommend this be discussed at follow up visit with own GP.

Ongoing contraception after UPA-EC

 
 

 

Ongoing contraception using depot medroxyprogesterone acetate (Depo Provera)

 
 

1. Li D, et al.

Benchmark pregnancy rates and the assessment of post-coital contraceptives: an update.

Contraception 2015;91(4):344–9.

Access


2. Faculty of Sexual and Reproductive Healthcare.

FSRH guideline. Emergency contraception. March 2017 (updated December 2017).

Access

3. Faculty of Sexual and Reproductive Healthcare.

FSRH clinical guidance. Fertility awareness methods. June 2015 (updated November 2015).

Access

4. Faculty of Sexual and Reproductive Healthcare.

FSRH guideline. Contraception after pregnancy. January 2017.

Access


5. Faculty of Sexual and Reproductive Healthcare.

FSRH clinical guidance. Intrauterine contraception. April 2015 (updated October 2015).

Access

A suitable COC for use immediately  after emergency contraception is Ovranette or Ovreena (ethynyleastradiol/levonorgestrel 30/150mcg)

 

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