Emergency Contraception

Question 1

What is the timeframe when you can use EC?

Answer 1

within 72 hours and up to 120 hours

Question 2

Are there any options for EC beyond 120 hours?

Answer 2

You can use the copper intrauterine device for up to seven days.

Question 3

What are the options for oral EC?

Answer 3

There are two options available in Canada:

1. Plan B - levonorgestrel
2. Yuzpe regimen - combined hormonal method

Not available in Canada:
Mifepristone - fist-generation progesterone receptor modulator
Ulipristal aceate - second-generation progesterone receotpr modulator. A recent study found it to be highly effective and well tolerated

Question 4

What is the MOA of oral EC?

Answer 4

Still somewhat unknown. This is what we know:

1. suppressing or delaying the LH peak
2. delaying or inhibiting ovulation
3. disrupting follicular development
4. interfering with the maturation of the corpus luteum

NB they do not affect pregnancy once it has already implanted in the uterine lining

Question 5

How effective are oral EC?

Answer 5

if you have sex mid cycle (during the middle two weeks of the menstrual cycle):

• no protection –> 8% women will get pregnant
• no protection + Plan B –> 1-3% women will get pregnant
• no protection + Yuzpe –> 3-7% women will get pregnant

Question 6

Are there any contraindication to obtaining oral EC?

Answer 6

anyone who has attained menarche and had unprotected sexual intercourse. The only contraindications are known pregnancy and known allergy to one of the components of the products.

Question 7

What are the situations in which you would consider one EC over the other?

Answer 7

In the following situations you would choose PLan B > Yuzpe:

• VTE (DVT, PE, stroke)
• known thrombophilia
• migraines with neurological component

Question 8

In the context of unprotected sex for someone on the OCP, what are the missed pill guidelines regarding when you should use EC?

Answer 8

For combined OCP

• 1 pill in the 1st week
• 2 pills in the 2nd and 3rd week
• the start of a cycle’s pills is delayed by 24 hours

For progesterone OCP
- 1 or more pills missed or 3 hours late

Question 9

In the context of unprotected sex for someone on DEPOT, what are the guidelines regarding when you should use EC?

Answer 9

• if the shot is 2 weeks late

Question 10

In the context of unprotected sex for someone using transdermal patch, what are the guidelines regarding when you should use EC?

Answer 10

• if the patch was detached for 24 hours in the 1st week or 72 hours in the 2nd or 3rd week

Question 11

In the context of unprotected sex for someone using vaginal contraceptive ring, what are the guidelines regarding when you should use EC?

Answer 11

if the ring is expelled for 3 hours in the 1st week, or 72 hours in the 2nd or 3rd week
if the ring is left in for more than 5 weeks

Question 12

Do you have to ensure anything prior to prescribing the EC?

Answer 12

No.
Health care providers should provide C without requiring female adolescents to receive a pregnancy test, pelvic examination, PAP smear or STI testing

Question 13

Do you need a doctors prescription for the EC?

Answer 13

No

Plan B can be obtained from pharmacist as OTC

Question 14

How do you give Plan B and what kind of SE can you anticipate?

Answer 14

Levongestrel 0.75 mg pills: 2 pills at once (previously thought you had to give the pills 12 hours apart)

SE: nausea (38-50%), headache (50%), fatigue (21%), dizziness (27%)

Question 15

How do you give Yuzpe and what kind of SE can you anticipate?

Answer 15

norgestrel (250ug) -ethinyl estradiol (50 ug) - 2 pills repeated 12 hours later

SE nausea an vomiting

Question 16

What do you do if the second dose of Yuzpe is missed?

Answer 16

If the second set is missed or late, you have to repeat the entire course

For this regimen, the timing of the second dose is important.

Question 17

What can you advise if the EC is not available

Answer 17

4-5 low dose OCP pills Q12H

Question 18

Which form of EC is better tolerated

Answer 18

Plan B is better tolerated and easier to take (no second dose)

Question 19

What do you do if the patient vomits after taking the EC?

Answer 19

If you vomit less than 1 h after taking the EC - you need to repeat the dose
If you vomit over 1 hour after taking the EC - you do not need to repeat it.

NB you can take gravol 1 hour before.

Question 20

Are there any teratogenic effects of EC?

Answer 20

No teragotenic effects as well as no pregnancy complications or adverse outcomes

Question 21

Is there anything that decreases the efficacy of EC?

Answer 21

yes. For the combined method (Yuzpe):
- AED
- St John’s Wort
- HIV meds
- rifampin
- Griseofulvin

NB not for Plan B

Question 22

Which women would a copper IUD be appropriate?

Answer 22

later presentation (can use for up to 7 days)
Women who are in a stable, monogamous relationship, and at low risk for STI

Question 23

Is there anything you should do before using a Copper IUS

Answer 23

Urine pregnancy test
Endocervical swabs for chlamydia and gonorrhoea
You can consider prophylactic ABx

Question 24

Does awareness and use of EC affect sexual activity?

Answer 24

No.

No increased risk of unprotected sexual intercourse

Question 25

After giving the EC, what should you tell the teenager?

Answer 25

It might still fail
period may be early, on time or late
Use a barrier method until the next period (may be at increased risk for pregnancy after the EC, because it works by delaying the ovulation)
If she wants to use OCP, she can start immediately after finishing EC
Return if the next period is > 7 days late or unusual.
Return if pain or heavy bleeding.