emergency contraception Flashcards
menstrual cycle definition
time from the first day of menstruation up to the day before the next menstruation
How does oral EC work?
by delaying ovulation
When does ovulation occur?
14 days before menstruation starts
How to calculate estimated ovulation date?
determining the length of the patients cycle and subtracting 14
How to calculate expected ovulation from an irregular cycle?
calculate the earliest likely ovulation date using the shortest cycle in the past 12 months
When is the fertile peroid?
5 days leading up to and including the estimated ovulation day - 6 days
How long are sperm viable in the genital tract for?
5 days after UPSI
How long does an egg survive for?
12 - 24hrs
What is the pregnancy risk from 1 UPSI during 6 fertile days?
30%
drug in EllaOne?
Ulipristal
Where can you get EllaOne?
in a pharmacy
- OTC (charged)
- supplied by PGD (free)
drug in Levonelle
levonogestrel
Where can you get Levonelle?
in a pharmacy
- OTC (charged)
- PGD (free)
Where can you get a copper IUD?
GP or GUM clinic
inserted by a specially trained practitioner
effectiveness of copper IUD
> 99%
How does copper IUD work?
spermicidal and toxic to ovum
prevents fertilisation
When can Cu-IUD be fitted after UPSI?
120hrs (5 days) after
Is Cu-IUD effective after ovulation?
yes
When can Cu-IUD be inserted after earliest estimated ovulation?
up to 5 days of estimated ovulation
c/i for Cu-IUD
pregnancy > 48hrs or < 4 weeks postpartum undiagnosed vaginal bleeding gynaecological cancers (cervical, endometrial, ovarian) acute pelvic infection
When can Levonelle be taken after UPSI?
up to 72 hrs after
Levonelle and the LH surge
If taken before the LH surge can result in ovulatory dysfunction in the subsequent 5 days
it’s less effective if taken once LH has started to rise
What to give if LH has risen and can’t take Levonelle?
ulipristal
indications for Levonelle
- had UPSI/compromised contraception within last 72hrs
2. has levonogestrel but vomited within 3hrs of taking it and still within 72hrs of UPSI
What is ulipristal?
selective progesterone receptor modulator
indications of ulipristal
UPSI up to 120hrs ago
What is 1st choice EC?
Cu-IUD
ulipristal and LH surge
ulipristal can prevent ovulation after the LH surge has started
it delays folicular rupture for up to 5 days
When can you start hormonal contrapeption after taking ulipristal?
5 days after
When may ulipristal be less effective?
if the patient had progestogen in the previous 7 days
if they’re on oral contraceptives
What’s the only method of EC that is effective after ovulation?
copper IUD
Is copper IUD affected by BMI/weight/other drugs?
no
age of Levonelle on PGD
from 13 years provided they are Fraser competent
age and cost of Ulipristal OTC
no minimum age for supply
cost £35
age for ulipristal on PGD
from 13 years provided thay are Fraser competent
What must be assessed when supplying to U16? (OTC & PGD)
Fraser competency
Efficacy of levonogestrel over time
up to 12hrs - 95%
25-48hrs - 85%
49-72hrs - 58%
effectiveness of ulipristal over time
95% effective up to 120 hours
questions to consider when suppling EC with natural menstrual cycle (3)
- date of last menstrual period
- usual cycle length
- is ovulation likely to have taken place yet this cycle
When to use EC after POP late (traditional and desogestrel)?
traditional POP - > 3hrs late (last pill > 27hrs ago)
desogestrel POP - > 12hrs late (last pill > 36hrs ago)
When is EC needed while getting the depo injection?
> 14 weeks ago
When to get EC while using the transdermal patch?
off for 48hrs of unknown length of time
When to get EC while on CHC? (general)
2 or more pills missed
Taking COC and missed 2 or more pills in the first week. Is EC required? (pills 1-7)
EC required if UPSI occurred in HFI or 1st week
Taking COC and 2 or more pills missed in the 2nd week (days 8-14)
EC not required if pills taken correctly in past 7 days
advise to finish the pack and take the usual 7 day break
Taking COC and missed 2 or more pills in the 3rd week (days 15-21)
omit pill free interval by finishing current pack and starting next pack the next day
EC not required if HFI omitted
What to do if >7 active pills were missed?
restart COC like they’ve never used it before
pregnancy/suspected pregnancy and EC
- levongestrel won’t harm the foetus if already pregnant
- ulipristal - pregnancy/suspected should be excluded before giving ulipristal
Can you take EC if already taken in the same cycle?
yes for levonogestrel and ulipristal
breastfeeding and levongestrel
levongestrel has no adverse effects on breastfeeding or infant
avoid nursing at least 8hrs after to reduce amount of levongestrel the baby will take in
ulipristal and breast feeding
don’t breastfeed
express and discard milk for 7 days after taking ulipristal
BMI and levonogestrel
effectiveness of levonogestrel can be reduced in women who weigh > 70kg (BMI > 26)
can take a double dose of levonorgestrel (3mg) - off licence
or take ulipristal
BMI and ulipristal
unaffected by BMI
What to do if giving levonorgestrel and patient overweight?
give a double dose (3mg) of levonorgestrel
problem with giving a double dose of Levonelle?
it is off label - refer
most PGDs allow supply of 2 pills for these cases
What conditions is levonogestrel not recommended in?
severe liver dysfunction acute porphyria patients at risk of ectopic pregnancy suffered inflammation of the fallopian tubes severe malabsorption syndrome
What medical conditions is ulipristal not recommended in?
- severe liver impairement
- severe asthma who are on oral glucocorticoid treatment
What drugs can effect the efficacy of EC?
enzyme inducing drugs
What is the guidance for EC and taking enzyme inducing drugs?
use a Cu-IUD
If unable to give Cu-IUD and taking enzyme inducers and need EC, what can be given?
a double dose (300mcg) of levonogestrel can be used
ulipristal and enzyme inducing drugs
ulipristal not recommended for those who have taken enzme inducing drugs in the past 4 weeks
What can reduce the ability of ulipristal to delay ovulation?
if progestogen is taken in the following 120hrs
When to continue hormonal contraception after taking ulipristal?
don’t start until 5 days after taking ulipristal
How long after taking ulipristal will COC work?
12 days
When will hormonal contraception work after taking levonogestrel?
immediately
ulipristal and have taken progestogen recently, how long?
don’t give ulipristal if they have taken progestogen in the last 7 days
dosage of Levonelle
1.5 mg tab
antibiotics that are potent enzyme inducers
rifabutin
rifampicin
dosage of Ulipristal (EllaOne)
30mg tab
Can EllaOne be given more than once in the same menstrual cycle?
yes
vomiting after taking EC
vomiting within 3hrs another EC should be taken asap
Do EC need to be taken with food?
no
cycle disruption after taking EC
menstrual cycle may be altered
next period may be early/late esp. if > 1 dose given
pregnancy test recommended if peroid if delayed by >7 days after EC
