13 - Emergency Contraception Flashcards
How does Emergency Contraception Work?
- *Pregnancy/Fertilization** is
- NOT instantaneous*
Sperm can survive for several days
awaiting for fertilization
Ovulation takes time
Types of EMERGENCY CONTRACEPTIVES
Pharmacological Agents
ECPs = Combined emergency contraception pills
Progestrin-ONLY ECP’s
ECP + Ulipristal Acetate
- NON-pharmacological*
- *IUD** = Copper T Intrauterine Device
Combined ECPs
Contain WHAT?
ESTROGEN + PROGESTRIN
Estrogen = Ethinyl Estradiol
Progestrin = Levonogestrel or Norgestrel
Combined ECP’s
Use / Products
RARELY USED
Estrogen + Progestrin
Progestin-ONLY ECP’s are more effective w/ less ADRs
Contain Levonorgestrel at VARIED doses
19 products
Cryselle / Aviane / Low-Ogestrel / Ogestrel
Lo/Ovral / Sronyx
Combined ECP’s
MECHANISM OF ACTION
Estrogen + Progestrin
- **INHIBIT or DELAY —>* OVULATION
- NOT an abortifacient // disrupts follicular development***
- BLOCKS* Luteinizing Hormone (LH) SERGE
- disrupts luteal phase*
Progestin causes thinning of endometrium
preventing implantation
Progestin also thickens the mucus in the cervix
PREVENTING sperm from reaching eggs
- *Combined ECPs**
- *Estrogen + Progestin**
Timing / ADR / CIs
<120 hours
RX Only / 74% effective / 0-30$
- *N/V** + Headache/Dizziness
- *Breast tenderness** + Irregular Bleeding
Contraindications:
pregnancy / breast cancer (or history)
hepatic disease / abnormal uterine bleeding
risk for venous/arterial disease / hypersensitivity
Combined ECPs
COUNSELING POINTS
Use BACK-UP contraception methed for 7 DAYS
Restart hormonal contraception
AFTER next menses or day after ECPs
Take with food
Vomiting within 3 HOURS of dose
may require an _additional dose_ due to insufficient absorption
can PREVENT w/ DPH or Meclizine
1hr b4 ECP
Pregnancy Test
>21 days since menstrual cycle
DOES NOT PROTECT AGAINST STDS
Progestin-only ECPs
Levonorgestrel 1.5mg
Next Choice / Plan B / Take Action / My Way
2 tablet formulation discontinued
2x 0.75-mg doses 12 hours apart
Preferred over Yuzpe Method (Combined ECPs)
Progestin-Only ECPs
MOA
Inhibit / Delay of ovulation
- NOT an abortifacient*
- not a lot of info on endometrium / cervical mucus*
< 72 hours post-coital
NO NEED FOR RX ALL AGES
89% effective , 0-45$
Progestin-Only ECPs
ADR’s + CI’s
Changes in your menstrual periods
- *Nausea + Vomiting** within 2 hours
- may REPEAT dose if LESS THAN 2 HOURS*
Stomach/Ab Pain + Diarrhea
Fatigue / Headache / Dizziness / Breast Pain/tender
CONTRAINDICATIONS:
pregnancy / HYPERsensitivity
Progestin-Only ECPs
COUNSELING
no RX required / OTC
DO NOT USE IF ALREADY PREGNANT
use backup for 7 days
may start hormonal contraception after:
start of next menses /// day after ECPs
If taken too close to ovulation = may be INNEFECTIVE
>21 days since menstrual cycle –> recommend pregnancy test
- *FDA Approved 72 hours** /// Reasonably effective <120 hours
- efficacy declines as time elapses*
UPA ECP
ELLA = Ulipristal Acetate
30mg Tablet
Pharmacist prescribing = State specific
Effectiveness does NOT decline with delay in treatment
UPA ECP
MoA
ELLA = Ulipristal Acetate 30mg
- *Selective Progestrone-Receptor Modulator**
- inhibition or delay of* ovulation
- prevents implantation ?*
- *<120 hours after intercourse**,
- does NOT decrease in efficacy over time*
More effective > progestin ECPs = 98%
10-70$, RX ONLY
UPA ECP
Ella = Ulipristal
ADR / CI’s
HA / Nausea / Dizziness / Tiredness
Stomach pain / Menstrual Pain
CONTRAINDICATIONS:
- *pregnancy / breastfeeding**
- *same menstrual cycle use** / hypersensitivity
UPA ECP = ELLA
COUNSELING
Requires Prescription
do not use if PREGNANT / not a regular birth control
if you vomit <3 hours –> contact MD
use back up barrier contraception method 7 days
effective for up to 120 hours
>21 days since menstrual cycle –> rec. pregnancy test
wait at least 5 days to restart hormonal contraception after ELLA
do not use ELLA > 1 time in the same menstrual cycle
Copper T IUD
Paragard = Hormone-Free
Mostly implanted WITHIN 5-7 DAYS
- after unprotected intercourse* (unknown ovulation)
- *does NOT decrease in effectiveness during the 5 days**
can be implanted <8 days after intercourse
if ovulation occured >72 hours post intercourse
effective ongoing conraception for 10-12 years
Copper T IUD
MOA
ENHANCE Inflammatory response
Copper diminishes sperm motility / viability
Copper alters the metabolism of the endometrial cells
massive decidual changes
trophic glands / atrophy of entire functional layer
Copper T IUD
Paraguard
Timing / Facts
<120 hours
Prescription / Procedure
99% within 5 days
0-1000$
RARELY used for emergency contraception
insertion requires proper training / scheduling issue
cost prohibitive w/o insurance
Copper T IUD
ADR / CI’s
- *Heavier / Longer periods** + spotting between periods
- *Pelvic inflammatory disease**
difficult removals / perforation / expulsion / anemia
backache / pain during intercourse / menstrual cramps
allergic reaction / vaginal infection+discharge / faintness
CONTRAINDICATIONS:
pelvic infections / frequent infections / cancer
Copper T IUD
Counseling
- do NOT use if you have a:*
- *pelvic infection** / get infections easily / certain cancers
persistant pelvic pain / stomach pain
if IUD comes out –> tell MD & use backup birth control
- *bleeding / spotting** may INCREASE at FIRST
- but should DECREASE in* 2-3 months
- *IUD migration –> surgically removed**
- *PREGNANCY w/ IUD can be LIFE threatening
- > loss of fertility or pregnancy**
ECP
SAFETY
if breastfeeding, may safely use progestin-only ECPs
may experience transient change in milk suppl
ECP’s can be safely used in women with contraindications to ROUTINE use of combo hormonal contraception:
past ectopic pregnancy / CV disease / Migraines
thromboembolic risk / liver disease
pregnancy > risk for thromboembolic & liver disease
than 1 day course of estrogen / progestin
Barriers to EC Use
UNDERESTIMATE RISK of Pregnancy
Belief that OTC EC is behind the counter
timeliness / POLITICS
lack of awareness / clinical discussion
Emergency department access is limite
lack of marketing / COST
Patient Assessment
ECPs
Last time since unprotected intercourse
RISK for unprotected intercourse
Patient appropriateness EC use
Using intermediate / high failure rate forms of contraception
encourage to keep advanced supply of ECPs
