Emergency contraception

Question 1

When should EC be considered in:
Normal cycle
After childbirth
After miscarriage/abortion/ectopic?

Answer 1

Normal cycle - any day
After childbirth - from day 21 unless LAM
After miscarriage/abortion/ectopic - after d5
Also after regular contraception has been used incorrectly

Question 2

When to consider Cu-IUD, what can it be inserted, what are its advantages, BMI/drug considerations

Answer 2

It’s the most effective method of EC and should be considered by ALL women. Only one that works after ovulation.

Can be inserted for EC:
- Within 5 days after first UPSI in a cycle or within 5 days of the earliest estimated date of ovulation - whichever is later

Has advantages of providing immediate effective ongoing contraception. It is not known to be affected by BMI or by other drugs.

Cycles must be regular if estimating ovulation, and always taken from their shortest cycle. If referring/booking into a later appt ensure EHC is administered for last UPSI (if last UPSI is within 5/7) just in case, it cannot be fitted, or they don’t attend.

Question 3

Why oral EC unlikely to be effective if taken >120 hours after UPSI

Answer 3

Viable sperm are present for about 5 days

Question 4

Choosing between UPA-EC and LNG-EC

Answer 4

Ulipristal acetate EC has been demonstrated to be more effective than levonorgestrel from 0-120 hours after UPSI.

NB- both ineffective after ovulation

LNG-EC ineffective if taken more than 96h after UPSI

Question 5

What considerations should we have between 0-96 hours after UPSI when considering oral EC?

Answer 5

1. Risk of preg - if close to ovulation, high risk of preg and UPA-EC should be considered first line
2. The risk of preg resulting from further UPSI if delay in commencing ongoing contraception - can start quicker if use LNG-EC
3. Recent use of progestogen - effectiveness of UPA-EC reduced *******
4. BMI / body weight - if BMI >26 or weight >70kg LNG-EC effect reduced. Use double dose (3mg) or use UPA-EC.****
5. Enzyme-inducers - both types of oral EC effect could be reduced if on. Not known if either method effective. Could do double dose LNG-EC.***

Question 6

Does oral EC cause damage to an early preg?

Answer 6

No

Question 7

Important additional parts of EC consultation

Answer 7

1. Ongoing contraception - importance of this and methods
2. Quick starting options
3. F/u PT
4. Assess STI risk and offer appropriate testing

Question 8

When for EC with contraceptive failure
How long can we offer cu-iud
Considerations re: oral EC

Answer 8

If 48h since last CHC taken (2 pills/ patch removed 48h) or since POP (12h or 3h), or >14w after last injection, and has been UPSI or barrier failure.
HFI extended past 7d and there has been UPSI during the HFI or week 1.
Can offer Cu-IUD up to 13d after HFI assuming perfect use prior

Not for UPA-EC if any CHC past 7d

Question 9

How long should additional protection be used if on liver enzyme inducers

Answer 9

during use, and 28d after use

• double dose LNG-EC or cu-iud. UPA EC not recommended.

Question 10

How does Cu-IUD work

Answer 10

inhibits fertilisation by toxic effect on sperm and ova - it adversely affects the motility and viablity of sperm and the viability and transport of ova. if fertilisation does occur, the local endometrial inflammatory reaction resulting from presence of cu-iud prevents implantation - so it has both pre and post fertilisation MOAs.

Question 11

when does implantation occur at its earliest after ovulation

Answer 11

6 days, and over 80% are believed to occur at days 8-10.

Question 12

how to calculate earliest ovulation

Answer 12

shortest cycle minus 14. lmp must be accurately known and cycles must be regular to make an estimation. a cU-IUD can be inserted up to 5d after this date.

Question 13

what is UPA EC and how does it work

Answer 13

• a selective progesterone receptor modulator
• delays ovulation for at least 5d, even after start of LH surge (whereas LNG-EC is no longer effective after start of LH surge)
• not effective after ovulation
• women will ovulate later so need ongoing contraception

Question 14

how does LNG-UC work

Answer 14

It is a progestogen

inhibits ovulation, delays or prevents follicular rupture and causes luteal dysfunction
if taken before lh surge prevents ovulation for 5d

Question 15

contraindications to oral ECs?

Answer 15

• UPA-EC is CI in women who have severe asthma controlled by steroids!!!!
• ella one contains lactose
• LNG-EC has no CI’s

Both suggest avoid in severe hepatic impairment but pregnancy poses a big risk in hepatic impairment too so we advise to give

Question 16

Advise for all EC methods in women breast feeding!!

Answer 16

• Cu-IUD- higher risk of uterine rupture however absolute risk still low (6 per 1000)
• UPA-EC - express and discard milk for 7 days
• LNG-EC - no evidence to suggest cant use - advise to take immediately after feeding and avoid nursing for 8 hours after.

Question 17

can repeated oral EC be used in same cycle

Answer 17

yes - no issues there
but should be aware that if woman has had upa-ec, lng-ec should be avoided in following 5d, and if lng-ec has been taken, upa-ec is less effective in next 7d

Question 18

Common SEs of EC

Answer 18

headache, nausea, dysmenorrhoea - 10% of users

Question 19

Advice around vomitting

Answer 19

if vomit within 3h, repeat dose