Emergency Contraception (EC)

1. Emergency Contraception (EC)

2. Emergency Contraception Clinical Effectiveness Unit August 2011 http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf

3. Emergency contraception (EC) is a method of preventing pregnancy following unprotected sexual intercourse (UPSI) or potential contraceptive failure.

4. Minimum history required • Pharmacists can do this so……..

5. Minimum history required • LMP • Cycle length (shortest) • When did they have sex? Including prior episodes in current cycle and any EC? • Drug history • Allergies • Would a pregnancy be disasterous?

6. 3 options • Copper Intrauterine device (IUD) • Levonorgestrel 1.5mg (Levonelle One Step or Levonelle 1500) LNG • Ulipristal Acetate 30mg (ellaOne) UPA

8. Timing and efficacy Copper IUD Failure rate considerably lower than 1% and not affected by timing (1963 women and no pregnancies in first month) Can be fitted up to120 hours after first episode of UPSI or up to 120 hours from the earliest estimated date of ovulation A Cu-IUD can be fitted in good faith, providing appropriate steps have been taken to try and establish earliest estimated date of ovulation

9. Timing and efficacy LNG Incompletely understood action ?inhibits ovulation May delay ovulation by 5 days No better than placebo at suppressing ovulation when given immediately prior to ovulation Licensed for 72 hours. May be effective up to 96 hours. Quicker the better. Cycle timing probably alters efficacy. Can be used more than once in cycle (If more than 3 weeks - pregnancy test first)

11. Timing and efficacy UPA Licensed up to 120 hours after UPSI Thought to inhibit or delay ovulation No apparent decline within that time period Glasier study 2010 randomised, non-inferiority trials showing UPA no less effective and non-significant trend towards lower pregnancy rates with UPA Should not be used more than once in cycle or if there has been another episode of UPSI outside 120 hr window

13. Copper IUD Can be fitted up to 120 hours after first episode of UPSI Can be fitted up to 120 hours after earliest estimated date of ovulation

15. Intrauterine device (IUD) Not suitable for? Acute PID Patients who would not tolerate speculum examination or fitting procedure Risks Failed fitting Uncomfortable to fit Perforation 1-2 in 1000 Expulsion 1 in 20 Ectopic pregnancy Infection (increased risk in first 20 days) Periods may be heavier or longer in first 3 months

17. Cu IUD A Cu IUD should be offered to all women requesting EC if timing is appropriate If it is not possible to insert Cu IUD at first presentation oral EC should be given in the interim in case she changes her mind or it is not possible to fit the IUD.

18. LNG Liver–enzyme inducing drugs Outside product licence give double dose 3mg UPA Liver-enzyme inducing drugs Drugs that increase gastric pH Severe asthma controlled by oral glucocorticoids Hepatic dysfunction Breastfeeding (36 hours) Restrictions for oral EC

19. Investigations? STI screen including HIV Window period Consider antibiotics for emergency IUD eg.azithromycin 1g PO ceftriaxone 500mg IM dissolved in 2mls 1% lidocaine Hepatitis B vaccinations

20. Additional Contraceptive Precautions Required

22. The Qlaira pill pack

23. When should EC be used? • When no contraceptive method used • Following sexual assault • Split or slipped condom • Forgotten progestogen only pills • Forgotten combined pills or patch or ring • When depo provera late

24. Indications for EC POP >27 hours since last POP and UPSI in next 48 hours >36 hours since last desogestrel only pill and UPSI in next 48 hours Depo-provera Late injection (>14 weeks) and UPSI after this time.

25. Indications for EC COC Missed two or more active pills AND these are in the first week of packet AND UPSI in the first week of taking pills or pill free interval

26. Menopause If under 50 years – need 2 years of contraception from LMP If over 50 years – need 1 year of contraception from LMP …….. If amenorrhoeic due to POP or Mirena use FSH levels to determine “LMP”