emergency hormonal contraception

Question 1

define emergency contraception

Answer 1

Intervention aimed at preventing unintended
pregnancy after unprotected sexual intercourse
or potential contraceptive failure

Question 2

what are the two main indications for EC?

Answer 2

When the patient has a natural cycle and no contraception has been used
When there is Incorrect use or potential failure of hormonal contraception

Question 3

how does oral EC work?

Answer 3

• Oral EC works by delaying ovulation
• EC administered after ovulation is ineffective.
• Ovulation occurs about 14 days before menstruation starts

Question 4

how do you calculate a patients estimated ovulation date?

Answer 4

• We work out the patients predicted ovulation by determining
the length of their cycle and subtracting 14.
• If irregular cycle, calculate earliest likely ovulation date
using the shortest cycle in past 12 months

Question 5

when is the fertile period?

Answer 5

• Theoretically, there’s only a short time when women can get
pregnant.
• This is the time around ovulation.
• Oral EC works by delaying ovulation
• Oral EC administered after ovulation is ineffective and wont
prevent pregnancy.
• The woman is said to be most fertile the 5 days leading up to and
including the estimated ovulation day (6 days)

Question 6

what drugs can you use before ovulation?

Answer 6

levonoregestrel
ulipristal acetate
intrauterine device - before and after

Question 7

how long can sperm survive in the female genital tract?

Answer 7

about 5

days after unprotected sexual intercourse (UPSI)

Question 8

when should EC be considered?

Answer 8

• On any day of a natural menstrual cycle.
• Particularly in the fertile window
• After regular hormonal contraception has been
compromised or used incorrectly.
• From day 21 after childbirth, unless all the lactational
amenorrhea method (LAM) criteria are met.
• From day 5 after miscarriage, abortion, ectopic pregnancy, or
uterine evacuation for gestational trophoblastic disease

Question 9

how can you obtain ulipristal- ellaone?

Answer 9

Pharmacy 
• Purchased OTC 
(charge)
• Supplied via a PGD 
(Free)
Other
• GP, SRH or GUM 
clinic (free)

Question 10

how can you obtain lebonogestrel-levonelle?

Answer 10

Pharmacy 
• Purchased OTC 
(charge)
• Supplied via a 
PGD (Free)
Other
• GP, SRH or GUM 
clinic (free)

Question 11

how can you obtain copper IUD?

Answer 11

GP or GUM clinic 
• Can only Inserted 
by a specially 
trained 
practitioner at a 
GP practice, SRH 
GUM clinic

Question 12

what is the most effective method of EC and how does it work?

Answer 12

copper IUD
Spermicidal/toxic to ovum – prevents fertilisation
• Can be fitted up to 120hrs (5 days) after UPSI or within 5 days of the earliest predicted date of ovulation
effective before and after ovulation

Question 13

what is c/i for cu-iud?

Answer 13

• Pregnancy
• >48 hours or <4 weeks post-partum
• Undiagnosed vaginal bleeding
• Gynaecological cancers – Cervical, Endometrial, 
Ovarian
• Acute Pelvic infection

Question 14

when is levonelle licensed for? what are its indications?

Answer 14

Licensed for use for up to 72hrs after UPSI
• Had UPSI or sex with compromised contraception within the
previous 72 hrs, or
• Have had levonorgestrel but vomited within THREE hours of
administration and are still within 72 hrs of UPSI.

Question 15

what happens if you take Levonelle prior to the lh surge?

Answer 15

If taken prior to the LH surge can result in ovulatory dysfunction
in the subsequent 5 days

Question 16

when do you use ulipristal?

Answer 16

UPSI up to 120 hours ago.
• First choice if UPSI during the fertile period
• Can prevent ovulation after the LH surge has started,
delaying follicular rupture for up to 5 days

Question 17

what influences your choice of oral EC?

Answer 17

• The age of the patient
• The time has elapsed since unprotected intercourse.
• Note what contraception was used at the time of intercourse, if any
• If no contraception has been used conduct a menstrual history.
• If there has been any other UPSI in this cycle = pregnancy risk
• Establish whether there has been any previous use of EC.
• Whether the woman is breast-feeding.
• Any medications
• Medical conditions- eg, liver disease, porphyria.
• Weight of the patient
• Need for ongoing contraception
• Whether they have recently used a progestogen

Question 18

how much does otc lebonelle cost?

Answer 18

25 pound- must be over 16

Question 19

how much does ulipristal cost otc?

Answer 19

35

Question 20

what should you consider when supplying patients u16?

Answer 20

non-consensual intercourse, child protection, vulnerable

adults, consent and confidentiality

Question 21

what do the fraser guidelines say relating to contraception?

Answer 21

1. The young person understands the advice being given.
2. The young person cannot be convinced to involve parents/carers or
   allow the medical practitioner to do so on their behalf.
3. It is likely that the young person will begin or continue having
   intercourse with or without treatment/contraception.
4. Unless he or she receives treatment/contraception their physical or
   mental health (or both) is likely to suffer.
5. The young person’s best interests require contraceptive advice,
   treatment or supplies to be given without parental consent

Question 22

how does the effectiveness of oral EH vary with time?

Answer 22

The efficacy of Levonogestrel declines with time.
– Up to 12 hours: 95%, 25-48 hours 85% effectiveness and 49-72
hours 58% effectiveness

Ulipristal remains 95% effective up to 120 hours after UPSI

Question 23

what is the natrual menstrual cycle?

Answer 23

• This is where the person is not using contraception and no
contraception has been used in the cycle

Question 24

what is the missed pill rule for COC?

Answer 24

first week pill-EC may be required if UPSI occurred in the pillfree interval or in the first week of pill-taking
second week-EC is not required if the pills in the preceding
7 days have been taken correctly. Advise the
woman to finish the pack and have the usual
7–day break.
3rd week-Omit the pill-free interval by finishing the pills
in the current pack and starting a new pack
the next day.
Emergency contraception is not required if
the pill-free interval is omitted.

Question 25

what happens if more than 7 active COC pills have been missed?

Answer 25

Advise to restart the COC as though she has

never used it before (as a new user)

Question 26

what will EH should be given if suspected pregnant?

Answer 26

• Levonogestrel will not harm the foetus if the woman is already
pregnant.
• Pregnancy or suspected pregnancy should be excluded before
ulipristal is given

Question 27

can you used ec more than once in the cycle?

Answer 27

Repeated use of both levonogestrel and ulipristal the same cycle is
acceptable

Question 28

what is recommended if the patient is breast feeding?

Answer 28

• Levonogestrel has no adverse effects on breastfeeding or on
their infants
You could advise the patient to take oral EC immediately after a
breast feed and avoids nursing at least 8 hours after- thus
reducing the amount of levonorgestrel the baby may take in the
next feed
• For Ulipristal, the advice is not to breastfeed and to express
and discard milk for 7 days after they have taken ulipristal.

Question 29

how does a persons BMI affect levonorgestrel?

Answer 29

The effectiveness of Levonorgestrel can be reduced in women who
weigh over 70kg (or BMI>26kg/m2)

Question 30

what is levonogestrel not recommended with?

Answer 30

severe liver dysfunction,
acute porphyria, patients at risk of ectopic pregnancy or who
have suffered inflammation of the fallopian tubes. There is also a
risk of reduced efficacy in patients with severe malabsorption
syndrome

Question 31

what is c/i in ulipristal?

Answer 31

Ulipristal is not recommended in patients with severe liver
impairment and in patients with severe asthma who are on oral
glucocorticoid treatment

Question 32

what other medication should you be aware of for interactions?

Answer 32

• Enzyme inducing drugs can effect the efficacy of EC
• The effectiveness of both ulipristal and levonogestrel are
affected by enzyme inducers.
• The guidance for women who have used enzyme-inducing drugs
in the past 4 weeks and need emergency contraception is to use
a Cu-IU

Question 33

what is recommended if takng enzyme inducers

Answer 33

A double dose (3000mcg) of levonogestrel can be used if they are
unable or unwilling to use a Cu-IUD

Question 34

how would recent use of progestoge affect EC?

Answer 34

The effectiveness of ulipristal could theoretically be reduced if
a woman has recently taken a progestogen. i.e if they have
missed pills
• FSRH advise not to use ulipristal if the patient has taken a
progestogen in the 7 days prior.
- levo consider

Question 35

what are the side effects from Ec?

Answer 35

vomiting- 3 hours- take another
cycle disruption- early/lateperiod
if later than 7 days take pregnancy test

Question 36

what are the key points for EC consultation?

Answer 36

• Assessing the risk of pregnancy
• Discuss the EC options appropriate for the circumstances
• Cu IUD is the most effective and should always be offered
• STI risk assessment
• Any other issues to consider?
• e.g. Fraser competent, Safeguarding. Was sex consensual?
• Drugs / alcohol involved?
• Ongoing contraception
• Arrange follow up for further STI screening and Pregnancy Testing