Emergency Contraception “the morning-after pill”

Dr.Sujnanendra Mishra MD(O&G)

Emergency contraception (EC)

Emergency contraception (EC) is any method of contraception which is used after intercourse and before the potential time of implantation

Emergency Contraception

Also known as:• Morning-After Pills• Postcoital Contraception• Secondary Contraception

These terms do not convey the correct timing of use nor that these methods should be used only for emergencies.

Emergency contraception (EC) is any method of contraception which is used after intercourse and before the potential time of implantation

HISTORY of EC -

• "First immediately after ejaculation let the two come apart and let the woman arise roughly, squeeze and blow her nose seven times and call out in a loud voice. She should jump violently backwards seven to nine times."

» Abu Bakr Muhammad ibin Zakariya' al-Razi (865 AD-925 AD)

• Hormonal methods originated in mid-1920s with discovery that estrogenic ovarian extracts have anti-fertility effect

• High-dose estrogen (DES or EE) post-coitally as a treatment for rape survivors in the 1960s

How about a post-coital

Coca-Cola douche!

(The New England Journal of Medicine published a study on that one as late as the 1980s.)

CURRENT EC -

• Yuzpe’s original article – 1974

• Dosage was two doses of two Ovral tablets, 12 hours apart– within 72 hours of unprotected intercourse

• Effectiveness believed to be about 95%• Problems = nausea, time frame

Women Who May Need Emergency Contraception (Primary Users)

Women who:– Have unplanned, unprotected intercourse– Used a condom that may have leaked or broken– Missed multiple COC pills– Waited > 16 weeks beyond last injection (DMPA) – Failed in using withdrawal method of contraception

(ejaculation in vagina or external genitalia)– Failed to abstain when needed while using NFP– Incorrectly used a diaphragm or the diaphragm or

cervical cap dislodged, broke or tore, or was removed early

– Are rape victims

Other Situations When Emergency Contraception May Be Used (Secondary Users)

Although EC is intended for primary users, there may be other situations or circumstances when other users may need EC.The other users may be women who:

– Are sexually active adolescents in need of contraception

– Are currently not using a contraceptive– Have intercourse infrequently– Are postpartum (before menses returns)– Are over age 35 (presumed decreased fertility)– Are post abortion (before menses returns)

“the morning-after pill”EMERGENCY CONTRACEPTION

“the abortion pill” MIFEPRISTONE

WHAT DOESIT DO?

Prevents a pregnancy from occurring after unprotected sex.

Ends a pregnancy withoutsurgery.

WHAT IS IT? A high dose of birth control pills. One of two pills used to enda pregnancy without surgery.

WHEN CANI TAKE IT?

Effective within 5 days of unprotected sex, but the sooner the better.

Effective to terminate pregnancies up to 8 weeks duration.

IS IT SAFE? Yes. effective contraceptive for pregnancy prevention after unprotected sex.

Yes. effective for pregnancytermination.

WHAT’S THE DIFFERENCE ?Between “the morning-after pill” and “the abortion pill”

Emergency Contraception

• These methods have enormous potential for use as safe and effective postcoital contraceptives.

• If integrated with ongoing family planning information and services, may encourage new clients to come to clinic.

• Emergency contraception should be promoted to reduce unwanted pregnancies.

Emergency Contraception: Benefits• All are very effective (failure rate less than

2% in women who use it correctly)

• IUDs also provide long-term contraception

Source: Consortium for Emergency Contraception 1998.

Emergency Contraception: Methods Combined Oral Contraceptives (COCs):

– Low-dose (30–35 µg EE and 150 µg LNG), or

– High-dose (50 µg EE and 250 µg LNG)

Progestin-Only Pills (POPs): 750 µg LNG (preferred)30 µg LNG

37.5 µg LNG

75 µg norgestrel

IUDs:TCu 380A, Multiload 375, Nova TAntiprogestins

Emergency Contraception: COCs

• Mechanisms of action– May alter endometrium (mixed

proliferative/secretory pattern)– May block ovulation– May alter tubal motility

• Effectiveness– 2% failure rate when used correctly1

• Safety– No long-term problems in nearly all women– Nausea (and vomiting) most common short-term

side effect (due to estrogen)

1 Source: Consortium for Emergency Contraception 1999.

DOSE for Combine OCPLow-dose (30–35 µg EE and 150 µg LNG), Total = 8 tablets

High-dose (50 µg EE and 250 µg LNG)Total = 4 tablets1

STEP I Take 4 tablets of a low-dose COC (30–35 µg EE) orally within 72 hours of unprotected intercourse.

Take 2 tablets of a high-dose COC (50 µg EE) orally within 72 hours of unprotected intercourse.

STEP II Take 4 more tablets in 12 hours. Take 2 more tablets in 12 hours

STEPIII If no menses (vaginal bleeding) within 3 weeks, the client should consult the clinic or service provider to check for possible pregnancy.

DOSE for POP (Prog. Only Pills)Plan- B 750 µg LNG (preferred)

Total = 2 tablets30 or 37.5 µg of LNG or 75 µg of norgestrel Total = 40 tablets

STEP I Take 1 tablet (750 µg of LNG) orally within 72 hours of unprotected intercourse.

Take 20 tablets (30 or 37.5 µg of LNG or 75 µg of norgestrel) orally within 72 hours of unprotected intercourse.

STEP II Take 1 more tablet in 12 hours.

Take 20 more tablets in 12 hours.

STEP III If no menses (vaginal bleeding) within 3 weeks, the client should consult the clinic or service provider to check for possible pregnancy.

First single dose emergency contraceptive now OTC

The first one-tablet oral emergency contraceptiveas i-pill, Unwanted-72 , (1.5mg levonorgestrel), is now available as an over-the-counter medication.

Plan B One-Step

New emergency contraceptive Ulipristal is a selective progesterone receptor modulator. By preventing progesterone from occupying its receptor, ulipristal is thought to inhibit or delay ovulation and possibly also suppress maturation of the endometrium necessary for implantation of the embryo.

1. Ellaone Summary of Product Characteristics, 2009. 2. CHMP Assessment Report for Ellaone. EMEA/261787/2009

The two emergency contraceptives work differently:• Plan B One-Step contains levonorgestrel, a progestin

hormone used in lower doses in many birth control pills.

• Ellaone contains ulipristal, a non-hormonal drug that blocks the effects of key hormones necessary for conception.

• Plan B should be taken as soon as possible after sex. It may work for up to 72 hours, but is ineffective once the hormonal surge that leads to ovulation occurs.

• Although emergency contraception should not be delayed, Ellaone's efficacy does not fade for 120 hours (five days) after sex, regardless of whether the hormonal surge has occurred.

The two emergency contraceptives

Difference Plan B One-Step Ellaone

Active ingredients Levonorgestrel ,a progestin hormone used in lower doses in many birth control pills.

ulipristal, a non-hormonal drug that blocks the effects of key hormones necessary for conception.

TIMING As soon as possible after sex. It may work for up to 72 hours, but is ineffective once the hormonal surge that leads to ovulation occurs.

As soon as possible after sex., Ella's efficacy does not fade for 120 hours (five days) after sex, regardless of whether the hormonal surge has occurred.

Drawbacks It ineffective once the hormonal surge that leads to ovulation occurs.

Ella may be less effective in obese women.

IUDs: Instructions for Use as Emergency Contraception• Step 1: Insert IUD within 5 days of

unprotected intercourse.

• Step 2: If no menses (vaginal bleeding) within 3 weeks, the client should consult the clinic or service provider to check for possible pregnancy.

• Step 3: If pregnancy not prevented, counsel client regarding options.

ANTIPROGESTINS

• Different action from its use in medical abortion, same dose

• A single 600mg dose of Mifepristone (RU-486) within 72 hrs after unprotected intercourse is highly effective

• Fewer side-effects than Yuzpe• 10mg dose may be equally effective

Emergency Contraception: Limitations• COCs are effective only if used within 72 hours of

unprotected intercourse.• COCs cause nausea and vomiting.• POPs must be used within 72 hours of

unprotected intercourse but cause much less nausea than COCs.

• IUDs are effective only if inserted within 5 days of unprotected intercourse.

• IUD insertion requires minor procedure performed by a trained provider.

• IUDs are not best choice for women at risk for STDs (e.g., HBV, HIV/AIDS).

Emergency contraception is using a drug or copper intrauterine device (Cu-IUD) to prevent pregnancy after unprotected sex. This is for backup, not regular contraception. Mifepristone and levonorgestrel are very effective with few adverse effects, and are preferred to oestrogen and progestogen combined. Levonorgestrel could be used in a single dose (1.5 mg) instead of two split doses (0.75 mg) 12 hours apart. Another effective method for emergency contraception is Cu-IUD and it can be kept for ongoing contraception.

FINAL WORDS….