EHC & Progesterone Pill Flashcards
What are some examples of issues that you could suspect when supplying an emergency contraceptive?
- Non-consensual intercourse
- Child protection
- Vulnerable adults
- Consent/confidentiality
Which 2 drugs are currently used as emergency contraceptives (give their doses too)?
- Levonorgestrel 1500mcg (1.5mg) tablets
2. Ulipristal acetate 30mg tablet
Can you provide contraception/sexual health advice to a child <16 years old?
Yes, as it may be consensual in their case.
Use your judgement and assess the situation.
How long after unprotected sexual intercourse can levonorgestrel be given, & at what age is it licensed as a P medicine?
It must be taken within 72h (3 days) after unprotected sexual intercourse.
It is licensed as a P medicine >16years old.
How is levonorgestrel given to <16 year olds?
As a POM under a PGD
How long after unprotected sexual intercourse can ulipristal acetate be given?
It must be taken within 120h (5 days) after unprotected sexual intercourse.
What brand contains ulipristal acetate?
ellaOne.
What is the mechanism of action of ulipristal acetate?
It is a selective progesterone receptor modulator (SPRM) & inhibits/delays ovulation of the female.
This hence alters the endometrial environment and inhibiting implantation from occurring.
When should an intra-uterine device (IUD) be fitted after unprotected sexual intercourse?
An IUD should be fitted 5 days after unprotected sex (or within 5 days of expected ovulation).
What information should you need before supplying EHC?
- When the sexual intercourse happened.
- Age
______________________
3 days: Levonorgestrel 1500mcg
5 days: ellaOne (ulipristal acetate) 30mg, or IUD
When should you refer a patient who wishes to purchase an EHC?
- If her last period was late
- If her last period was lighter/shorter than normal
- If her last period was unusual in any way
What class of drugs reduce the efficacy of levonorgestrel?
Anti-epileptic drugs, e.g. phenytoin, carbamazapine.
They are enzyme inducers.
- Others can include rifampicin, ritonavir, St. johns wort, and rifabutin.
Why do EHC’s have a long half life?
Because it gets circulated in the portal vein, which constantly gets reabsorbed & circulated in the body.
Which immunosuppressive drug can increase in toxicity when given with levonorgestrel?
Ciclosporin - its metabolism is inhibited.
What are some examples of some drugs that interact with ulipristal acetate, & should be avoided?
- Carbamazepine
- Phenobarbital
- St. johns wort
- Rifampicin
- Nevirapine
What should you offer to women who plan on purchasing an EHC, but are taking enzyme-inducing drugs?
Either:
1. Encourage to fit a copper IUD (Cu-IUD)
OR
- Consider double dose of levonorgestrel (3mg), although may be ineffective
- Do not give double dose of ulipristal acetate
How could the effectiveness of ulipristal acetate be reduced?
If she has taken progesterone-only pills 7 days before, or 5 days after taking ulipristal acetate.
- E.G. she is on regular progesterone-only contraceptives, but has missed a dose & needs EHC.
Which EHC is given if the patient has a BMI >26Kg/m^2, (or weighing >70kg)?
Ulipristal acetate
- Double dose of levonorgestrel can alternatively be given (3mg)
What are the benefits of fitting a copper IUD?
- Provides immediate effective ongoing contraception
2. Does not affect BMI/weight or with other drugs
Which bodily system does EHC increase the risk of?
Blood clotting - consultation is needed if the person is overweight.
Which EHC should asthmatic women taking glucocorticoids NOT be given?
Ulipristal acetate
Which medical conditions should levonorgestrel be avoided in?
- Severe liver dysfunction
- Crohns disease
- Inflammation of fallopian tubes
What should the patient do if she vomits 2h after taking levonorgestrel?
She must take another dose of 1.5mg levonorgestrel immediately.
What should the patient do if she vomits 3h after taking ulipristal acetate?
Another 30mg tablet should be taken immediately.
What are some common side effects of EHC?
- Headache
- Nausea
- Altered bleeding patterns (next period being late/early)
What could lower abdominal pain after taking EHC signify?
It could signify an ectopic pregnancy & she must be referred immediately.
What should the patient do if her next period is light/heavy/unusual in any way after taking EHC?
She should do a pregnancy test 3 weeks after unprotected sex
What is contained in a combined oral contraceptive pill (COC)?
Progesterone & oestrogen.
How many COC pills can be missed for it to be considered missed pills?
2 pills or more
How many days does it take for COCs to reach maximum efficacy?
7 days (due to hepatic metabolism)
After week 1 of taking COCs, the pill is at its max. efficacy
If a woman is taking COC pills, and they miss 2 or more pills in their first week (or barrier failure/unprotected sex), what is given?
EHC, as the pill hasn’t reached its max. efficacy within the 1st week.
Why is the last week of the contraceptive pack considered a placebo week?
The last 7 days contain placebo pills which are there to help the woman make a habit of taking the pill regularly, until she starts a new pack the next month.
- This week is also known as the ‘pill-free’ week.
This is why some packs contain 21, or 28 tablets.
If a woman is taking COCs, when will EHC be needed?
- If her ‘pill-free’ week (placebo week) is extended
- If >2 pills are missed in the 1st week - reduced efficacy
- If >7 pills are missed in any week during contraceptive therapy
What precautions must be taken if a woman is on COCs, and has taken either levonorgestrel or uripristal (and for how long)?
- Use barrier methods/refrain from sex
1. For levonorgestrel: 7 days (to reach efficacy) - restart COC immediately
2. For uripristal: 12 days - restart COC 5 days after taking uriprisal
When is EHC not given to a woman who is taking COCs?
- If she has only missed 1 pill during the 1st week
2. 2-7 pills are missed 2-3 weeks during contraceptive therapy
What is considered a late/missed pill if the woman is taking progesterone only pills (POP)?
If she has taken her next dose >12h from her previous dose.
This is why POPs should be taken at the same time everyday.
How many days do POPs reach max. efficacy?
2 days.
When is EHC given if the woman uses POP?
- If she has taken her pill late or missed a pill
2. She has had unprotected sex/failed barrier method before max. efficacy of the POP has been established (2 days)
What precautions must be taken if a woman is on POPs, and has taken either levonorgestrel, or uripristal (and for how long)?
- Use barrier methods/refrain from sex
1. For levonorgestrel: 2 days (to react efficacy) - restart POP immediately
- For uripristal: 7 days - restart POP 5 days after uripristal given
Which EHC is given if a woman has missed her POP for >12h?
Levonorgestrel.
If a woman is breastfeeding, when should she take levonorgestrel?
After breastfeeding, to avoid the amount of levonorgestrel in breast milk in the next feed.
When can you not breast feed after taking ulipristal acetate?
After using uripristal, you cannot breast feed for 1 week because it would be present in breast milk.
What is the mini pill?
It is a POP licensed as P in pharmacies, so women can buy them.
What are the 2 mini-pills available in pharmacies to buy (including doses)?
- Lovima 75mcg tablets
2. Hana 75mcg tablets
What type of progesterone is present in the mini pill?
Desogestrel.
How does desogestrel prevent pregnancy?
It inhibits ovulation by thinning the lining of the uterus & preventing implantation of the fertilised egg.
Cervical mucus also thickens & prevents the sperm from penetrating the egg.
How are mini pills usually taken (remember they are POPs)?
One tablet at the same time everyday.
You must start it on day 1 of period.
What conditions contraindicate the use of the mini pill?
- Active thrombosis - blood clotting
- Active/history of liver disease/cancer
- Active/suspected sex-steroid sensitive cancer - breast/uterine/ovarian
- Undiagnosed vaginal bleeding
- Hypertension/uncontrolled diabetes
What happens if a woman has missed her mini pill for >12h?
She should take the pill as soon as she remembers, & carry on with the next pill at the right time.
Since she is now unprotected, she should also use a barrier method for the next 2 days.
If she had unprotected sex after her missed pill, give EHC.
If a woman is on enzyme-inducing drugs (e.g. phenytoin/rifampicin/St. johns wort/carbamazepine), what extra precaution should she do if she is already taking mini pills?
She should use a temporary barrier method during the time she is taking the enzyme inducing drugs.
Which specific anti-epileptic drug should not be given with Lovima & why?
Lamotrigine.
The mini pill reduces lamotrigine’s efficacy.
What are some side effects of the mini pill?
- Acne
- Mood changes
- Breast pain
- Weight gain
- Nausea
What should happen if a woman vomits 3-4h after taking her mini pill?
Follow the missed pill rule.
- Take pill, and next dose as normal
- Protection for 2 days
