Emergency Contraception Update

Dr Lynda TurnerJune 2015

Honorarium from HRA Pharma

Disclosure

By the end of the session you will be able to:

1. Describe the methods and effectiveness of all methods of

emergency contraception.

2. Recognise where there is a risk of pregnancy and advise

appropriately

3. Specify key points in history taking, counselling and follow up

for safe and effective use of EC.

4. Identify needs for future contraception and when this can be

started as well as any risk of STI and advise appropriately

Learning objectives.

Presentation: Emergency Contraception updateCase studies: Small group work

Plan for session

Use of any drug or device after unprotected sexual intercourse to prevent an unintended pregnancy

Acts prior to implantation – pregnancy begins at implantation, therefore EC is not an abortifacient

Implantation is assumed to occur no sooner than 6 days after ovulation

What is emergency contraception?

Reasons for requesting emergency contraception

Menstrual Cycle

Ovum survives 24-36 hour. Sperm can survive up to 7 days (in the uterus) Where in cycle sex occurs from 8% risk early in

cycle to 36% on day of ovulation. Drops rapidly following ovulation

Fertility of both partners (unknown)

There is no time in the cycle when you can withhold emergency contraception on physiological

grounds

Factors Influencing Risk of Pregnancy following unprotected sex

From ovulation, to fertilisation, to pregnancy

What is currently available? How do they work? How effective are the methods?

Emergency contraception

Copper IUD

Levonelle (Levonorgestrel 1.5mg)

ellaOne (Ulipristal acetate 30mg)

What is currently available?

Best method of EC - more than 99% effective Spermicidal/toxic to ovum – prevents

fertilisation Also has some anti-implantation effect Can be fitted up to 120hrs (5 days) after UPSI

or within 5 days of the earliest predicted date of ovulation.

Offer all eligible women IUD as most effective EC Method

Copper IUD

Calculating ovulation date

Selective progesterone receptor modulator

Primary mode of action –inhibition or delay of ovulation

Can prevent ovulation after the LH surge has started, delaying follicular rupture for up to 5 days

Licensed for up to 120hrs after UPSI

ellaOne

Progestogen Thought to delay or inhibit ovulation If taken prior to the LH surge can result in

ovulatory dysfunction in the subsequent 5 days NO better at suppressing ovulation than placebo

when given immediately prior to ovulation Licensed for use for 72hrs after UPSI Shown to be effective up to 96hrs after UPSI

Levonorgestrel 1.5mg

How do EHCs work?Both Ulipristal acetate and levonorgestrel act by delaying

ovulation:1

Ulipristal is effective even after onset of the LH surge2

• levonorgestrel has been shown to be no better than placebo at inhibiting ovulation when given immediately prior to ovulation1

• Ulipristal is effective right up to the point of ovulation, even if lutenising hormone (LH) levels have already begun to rise1,2

References: 1. Emergency Contraception. Clinical Effectiveness Unit. Faculty of Sexual & Reproductive Healthcare Clinical Guidance. Available at fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf. Last accessed January 2012. 2. Brache V et al., Hum Reprod 2010; 25: 2256–63.

⌂Ulipristal

Fig 1 Window of action of different emergency contraceptive methods in relation to ovulation.

Prabakar I , Webb A BMJ 2012;344:bmj.e1492

©2012 by British Medical Journal Publishing Group

Pregnancy Less than 4 weeks postpartum Undiagnosed vaginal bleeding Gynae cancers – Cervical, Endometrial, Ovarian Acute Pelvic infection Any congenital or acquired uterine abnormality

causing distortion of the uterine cavity eg fibroids

Contraindications to Cu IUD

FSRH Clinical Guidelines on EC does not identify any medical condition that limits the use of Levonorgestrel 1.5mg

Levonorgestrel 1.5mg

Precautions◦Use in women with severe asthma treated by

oral glucocorticoids is not recommended

◦Breast feeding women must not breast feed for 1 week after taking ellaOne 30mg

ellaOne 30mg

Discuss fitting procedure Discuss possible side effects Can be removed AFTER next period if preferred Can continue with IUD for 5 -10yrs STI screen and prophylactic antibiotics will be

offered Give EHC even if IUD going to be fitted by GP or

other service

Cu IUD – information to client

Safety profile of oral EC

References: 1. Glasier AF et al., Lancet 2010; 375: 555–62. 2. HRA Pharma UK Ltd. ellaOne® 30 mg tablet Summary of Product Characteristics.

Prescribing information is available on slide 19.

Ulipristal

Nausea Vomiting 1% - if within 2hrs of taking LNG or 3hrs

of taking ellaOne further dose required Headache Both can affect timing of next menstrual period Do pregnancy test if not had a normal menstrual

period 3 weeks after UPSI

Adverse effects of ellaOne and Levonelle

Liver enzyme inducing medications used currently or up to 28 days previously◦ e.g. rifampicin, phenytoin, phenobarbital, carbamazepine, St John’s wort

(Hypericum perforatum)

Products that increase gastric pH taken in the preceding 24hours◦ e.g. proton pump inhibitors, antacids, H2-receptor antagonists

Use in women with severe asthma treated by oral glucocorticoids is not recommended

ellaOne may interfere with oestrogen and progestogen methods of contraception including Levonelle

Potential drug interactions for ellaOne

Liver enzyme inducing medications used currently or up to 28 days previously◦ e.g. some antiepileptic drugs, some treatments for TB and HIV

and some herbal remedies eg St John’s wort

For this group, the best choice EC is Copper IUD

If declined or contraindicated, you can use double dose Levonelle (off licence)

Potential drug interactions for Levonelle

Has no effect on future fertility Does not interrupt an established pregnancy If mistakenly given in early pregnancy, does not

harm a developing foetus Does not protect against STIs Does not provide contraception for further UPSI in

the days after EHC has been taken

Facts about Emergency Hormonal Contraception

When no contraceptive method used When failure or potential contraceptive failure of

method used – e.g.◦Split or slipped condom◦ Forgotten progestogen only pills◦ Forgotten combined pills or patch or ring◦When Depo-provera late◦ IUD/IUS expelled or expired◦Nexplanon expired

When should EC be used?

Was any method of contraception used? If yes, reason for failure/potential failure of method? First day of LMP Cycle length (if variable, shortest and longest) When did they last have UPSI? Were there any other episodes of UPSI in current

cycle? EC previously used this cycle? Medical history Drug history including any OTC Allergies

What EC options are suitable for this client?

POP◦ >27 hours since last POP (Micronor, Noriday, Norgeston)

and UPSI in next 48 hours◦ >36 hours since last desogestrel only pill (Cerelle and

Cerazette) and UPSI in next 48 hours Depo-provera◦ Late injection (>14 weeks) and UPSI after this time.

Indications for EC

FSRH Clinical guidance on missed pills 1 pill can be missed anywhere in the pill pack with

no need for extra protection or EC If 2 pills or more are missed, then extra protection

should be used for 7 days and EC may be required

Missed COC Pills

Need to think hard about pills missed in week 1 and week 3◦Pills 1-7 Consider EC if UPSI (including in PFI) if 2 pills

missed.After EC continue pills and use condoms for 7 days if LNG taken and 14 days if UPA taken

◦Pills 8-14 No need for EC if UPSIContinue pills and use condoms for 7 days

◦Pills 15-21 No need for EC if UPSI but continue pills, avoid PFI and use condoms for 7 days

Missed COC pills – minimising the risk of pregnancy

EC Option COCP POP QLAIRA

LNG 7 days 2 days 9 days

UPA 14 days 9 days 16 days

Quick starting hormonal contraception after oral EC – how long is barrier contraception needed?

FSRH Quick starting contraception 2010

ellaOne SmPC instructions"If a woman wishes to start or continue using hormonal contraception, she can do so after using ellaOne, however, she should be advised to use a reliable barrier method until the next menstrual period".

Assessing the risk of pregnancy Discuss the EC options appropriate for the

circumstances STI risk assessment Any other issues to consider? e.g. Fraser competent, Safeguarding. Was sex consensual? Drugs / alcohol involved? Ongoing contraception Arrange follow up for further STI screening and

Pregnancy Testing

Key points for EC Consultation

3 methods of EC – Levonelle, ellaOne and Cu IUD. Cu IUD is the most effective Always check medical eligibility for EC Always ask about medications taken including OTC,

which may make oral EHC less effective. Always address ongoing contraception STI risk assessment is an essential part of EC

consultation. Use this opportunity to explore any issues relating to non-

consensual sex, sexual assault or abuse and domestic violence

Session Key Points