Emergency contraception

1. Emergency contraception

2. Emergency Contraception “Post exposure methods which prevent fertilisation and possibly implantation and hence the establishment of pregnancy.”

3. Usual scenario.... • 20 yr old woman requests the “morning after pill” for upsi 36 hours ago. • When you offer her a copper intrauterine device, ulipristal acetate or levornogestrel she looks surprised and says “can’t I just have the pill I had last time”

4. 3 methods • Copper IUD; can be used up to 5 days following first UPSI in cycle or within 5 days from the earliest estimated day of ovulation. • Effectiveness >99% at any time of cycle.

5. Oral emergency contraception

6. Levonorgestrel, LNG • Levonelle 1500; prescribed £5.20 • Levonelle one step; otc £25 cost to patient • A progesterone; single 1.5mg dose • Use 12-13 years • Licensed for use up to 72 hours after UPSI or contraceptive failure; may be used up to 120 hours ( off licence)

7. Ulipristal/UPA “ellaOne” • A selective progesterone receptor modulator; single dose 30 mg. • Licensed for use up to 120 hours after UPSI or contraceptive failure. • Cost £16.95

8. When is EC needed? • Missed cocp • Late POP ( >27 hrs for conventional POP,>36 hours for cerazette) • Condom not used/ condom accident • Late depo >14w since last injection • IUD removal, expulsion, lost threads • Enzyme inducing drugs and failure to use extra precautions

9. How does it work? • IUD; copper toxic to sperm and ovum; primarily inhibits fertilisation (and implantation) • LNG; interferes with ovulation by inhibiting LH surge • ellaOne; delays LH surge and has effect on follicular rupture; additional action

10. Levonorgestrel, levonelle • Inhibits ovulation only if given before the LH surge. • It has no effect if given after ovulation.

11. Ulipristal, EllaOne • Suppresses lead follicles when given just before ovulation, including during the LH surge. • It is unclear if it has any effect after ovulation

12. Actions different EC methods

13. How effective is it? • IUD >99% effective • LNG up to 95% within 24 hrs • up to 85% within 25-48 hrs • up to 58% within 49-72 hrs • UPA at least as effective as LNG up to 120 hours

15. Evidence LNG v UPA • Glasier; meta-analysis ( Lancet 2010) • Looked at 2 randomised controlled trials • Authors concluded that the pregnancy rate with UPA was significantly lower at all time periods analysed up to 120 hours.

16. Case one • 22 year old Elaine has just started a new job. She attends your surgery on Tues am after bank holiday weekend. She got drunk at a party on the Thursday night and cannot remember using condom. She is requesting a “morning after pill” • What other information do you need?

17. Case one • She has a predictable 28 day cycle and her last period started 9 days ago. She has not had any other acts of upsi this cycle. • What treatment would you offer her?

18. Date of LMP; Time since UPSI Previous UPSI this cycle? EC used this cycle? Duration shortest "usual" cycle; Discussed oral method v IUD? Ongoing contraception discussed? Condoms offered if needed? Given leaflets for EC and larc's. Need STI screen? Advised PT in 3weeks if no period;

19. Risk of pregnancy • Risk is highest mid cycle( 5 days before and 1 day after ovulation) Risk is 20-30% • Rest of cycle; risk is around 10% but due to unpredictable nature of ovulation there is no point at which one could guarantee that pregnancy won’t occur. • Implantation is always at least 5 days after ovulation.

20. Case two • 18 year old girl, no regular contraception. Sunday pm, on call centre. Had sex last night, condom came off. LMP started 10 days ago. She has a regular cycle, but can be up to 3 days early. She is very keen to avoid pregnancy as she is going to university after her gap year and is going on a college field trip tomorrow. • What method do you feel would be most suitable for her?

21. Case two • This is a mid cycle event; most risky time but she is only 24 hours after the event. • In theory; LNG or UPA can be used • UPA may offer a slight advantage due to its additonal effect on ovulation.

22. What are the side effects of EC? • IUD; pain • LNG and UPA; nausea, headache, altered bleeding pattern • Vomiting in approx 1%( suggest repeat dose if vomit within 2 hrs LNG or 3 hours UPA) Repeat dose/offer IUD • Next menses; on average 1.2 days earlier with LNG, 2 days later with UPA

23. When to do pregnancy test? • If no period, pregnancy test should be positive 3 weeks after event of upsi.

24. Case three • 16 year old Mary has a chaotic cycle. She had sex with her new boyfriend last night and he did not have a condom. On further questioning she took LNG 3 weeks ago after having sex with someone else and has not had a period since. • What should you consider and how would you proceed?

25. Can the method be used again in the same cycle? • IUD can be used for multiple events in same cycle if fitted within 5 days earliest calculated date of ovulation • LNG can be used more than once in same cycle; even if the earlier episode of upsi was outside the treatment window( outside product licence)

26. Can the method be used more than once in same cycle? • UPA can not be used more than once in same cycle and cannot be used if LNG has been given earlier in the cycle. • UPA cannot be used if there has been an earlier UPSI event earlier in the cycle outside the treatment window of 120 hours.

27. Case four • Lorraine is 16. You saw her a week ago and provided LNG for her for upsi the night before. It is now 13 days since her last period which occur every 4 weeks. She admits when you ask that she also had sex 4 days ago but was afraid to mention it. Again she had not used a condom. • What is her EC method of choice?

28. Case four • Copper IUD deals with both episodes and is her best choice. • LNG can be used but is only 50% effective. • You have until day 19 in a 28 day cycle to fit IUD; ie you have 6 days to organise this. • If you arrange for her to have IUD fitted in 2 days time what else would you do?

29. What methods can be used together? • LNG>1 per cycle • LNG and IUD( recommended if considering IUD) • UPA and IUD • But not; LNG and UPA in same cycle • Or…….UPA>1 per cycle

30. Drug interactions with EC • LNG; reduced efficacy with liver enzyme inducers and for 28 days after. Offer copper IUD or if this is unacceptable a single 3mg dose LNG( outside product licence) • Eg St John’s Wort; use double dose • Concomitant use cyclosporin; increases toxicity; IUD preferred

31. Drug interactions with EC • UPA ; cannot be used if on liver enzyme inducers or for 28 days after this. • UPA; requires acidic pH in stomach; cannot be used if on antacids, PPI, H2 blocker • Also ;avoid UPA if severe asthma uncontrolled with oral steroids.

32. Investigations? • STI testing including HIV • Retest after appropriate window; 2 weeks for chlamydia • Consider prophylactic antibiotics with emergency IUD; stat dose azithromycin to cover chlamydia.

33. Future contraception • Oral EC does not provide contraceptive cover for further UPSi in same cycle. • Consider “quick start”;cocp, pop or implant with extra precautions. • IUD; can leave for future contraception/ remove when pregnancy excluded. If removing ensure adequate method/no sex for 7 days before removal.

34. Continuing current method • After LNG; condoms for 7d on cocp • for 2 days if on pop • for 9 days if on Qlaira • After UPA; condoms for 14 days on cocp • for 9 days if on pop • for 16 days Qlaira

35. What method should be offered? • Copper IUD should be offered to ALL WOMEN and DOCUMENT this. • Use of LNG > 72 hours would be unlicensed but supported by Clinical Effectiveness Unit for up to 96 hours • UPA is the only oral method licensed for 72 to 120 hours and is the preferred method if elligible.

36. Cost effectiveness? • Ulipristal is a cost effective alternative to levornogestrel for all women requesting EC. • Provision of EC however has not been shown to reduce the rate of unintended pregnancy or abortions.

37. Information required; summary • Medical eligibility • Efficacy of method • LMP and cycle length • Number episodes UPSI in cycle and when • Previous use EC in same cycle • Drug interactions • Need for additional precautions/ ongoing contraception

38. QOF target • Document “larc advice given” at the time of provision of oral EC ( or within next month)