IMPERIAL YEAR 5 SPECIALTIES - O&G > Emergency_Contraception_Flashcards > Flashcards
Emergency_Contraception_Flashcards
What are the two methods of emergency contraception currently available in the UK?
Emergency hormonal contraception and intrauterine device (IUD).
What are the two methods of emergency hormonal contraception?
Levonorgestrel and ulipristal, a progesterone receptor modulator.
What is the mode of action of levonorgestrel?
Not fully understood - acts both to stop ovulation and inhibit implantation.
When should levonorgestrel be taken?
As soon as possible - efficacy decreases with time. Must be taken within 72 hours of unprotected sexual intercourse (UPSI).
What is the dosage for levonorgestrel?
Single dose of levonorgestrel 1.5mg (a progesterone). The dose should be doubled for those with a BMI >26 or weight over 70kg.
How effective is levonorgestrel when used within 72 hours of UPSI?
84% effective.
What are the side effects of levonorgestrel?
Disturbance of the current menstrual cycle in a significant minority of women. Vomiting occurs in around 1%. If vomiting occurs within 3 hours, the dose should be repeated.
Can levonorgestrel be used more than once in a menstrual cycle?
Yes, if clinically indicated.
When can hormonal contraception be started after using levonorgestrel?
Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception.
What is the primary mode of action of ulipristal?
Inhibition of ovulation.
What is the dosage for ulipristal?
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse.
Can ulipristal be used concomitantly with levonorgestrel?
No, concomitant use with levonorgestrel is not recommended.
How does ulipristal affect hormonal contraception?
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch, or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period.
What caution should be exercised with ulipristal?
Caution should be exercised in patients with severe asthma.
Can ulipristal be used more than once in the same menstrual cycle?
Yes, it can be used more than once in the same cycle.
What is the recommendation for breastfeeding after taking ulipristal?
Breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel.
What is the most effective method of emergency contraception?
A copper IUD.
When should a copper IUD be inserted?
Must be inserted within 5 days of UPSI, or if a woman presents after more than 5 days, an IUD may be fitted up to 5 days after the likely ovulation date.
What are the benefits of a copper IUD for emergency contraception?
It may inhibit fertilisation or implantation, is 99% effective regardless of where it is used in the cycle, and may be left in-situ to provide long-term contraception.
What should be done if the patient is considered at high risk of sexually transmitted infection when using a copper IUD?
Prophylactic antibiotics may be given.
summarise
Emergency contraception
There are two methods currently available in the UK:
Emergency hormonal contraception
There are now two methods of emergency hormonal contraception (‘emergency pill’, ‘morning-after pill’); levonorgestrel and ulipristal, a progesterone receptor modulator.
Levonorgestrel
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI >26 or weight over 70kg
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well-tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 3 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
Ulipristal
a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
caution should be exercised in patients with severe asthma
repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
Intrauterine device (IUD)
a copper IUD is the most effective method of emergency contraception and should be offered to all women if they meet the criteria
if the criteria for insertion of a copper IUD are not met or is not acceptable to the woman, oral emergency contraception should be considered
in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are
must be inserted within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
may inhibit fertilisation or implantation
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication
An 18-year-old attends her GP the morning after unprotected sexual intercourse (UPSI). She would like emergency contraception to ensure she is not pregnant. A pregnancy test is negative. Which is the most appropriate next step in management?
- Danazol
- Clomiphene
- Combined oral contraceptive pill
- Levonorgestrel
- Advise patient to return in one week to repeat pregnancy test, as it is too soon to see if she is pregnant at present
- Levonorgestrel
Levonorgestrel must be taken within 72 hours of UPSI
A copper intrauterine contraceptive device (copper coil), an oral progesterone-only contraceptive (levonorgestrel) or a selective progesterone receptor modulator (ulipristal acetate) could be offered in the above situation as emergency contraception. These both act to prevent a fertilised ovum being implanted.
Levonorgestrel is licensed for use up to 72 hours after UPSI. Although unlicensed, use between 72-120 hours after UPSI may be considered if other methods of emergency contraception are contraindicated. It can also be used more than once in the same cycle if indicated, although in such cases patients may require referral for education regarding safe sexual practices. 5-5.8% of women will become pregnant after a single UPSI episode if emergency contraception is not sought, compared with pregnancy rates of 1.1-2.6% in patients taking levonorgestrel within 72 hours.
Clomiphene is used to induce ovulation in patients with anovulatory infertility. It will not prevent implantation.
Danazol is a derivative of ethisterone. It can be used to treat endometriosis and fibrocystic breast disease. It will not prevent implantation and can cause virilisation of female fetuses, so is contraindicated in pregnancy.
The COCP prevents ovulation and is 99% effective at preventing pregnancy when taken correctly, but it will not prevent implantation if taken after an episode of UPSI.
A 22-year-old woman presents to her local sexual health clinic seeking emergency contraception after an episode of unprotected intercourse with a one-time male partner four days ago. She is on day 10 of her regular 30-day menstrual cycle, has no significant medical history, takes no medications, and reports no allergies. She expresses a preference for a non-invasive method of emergency contraception.
Following counselling about the need for sexually transmitted infection screening:
What is the most appropriate form of emergency contraception to prescribe?
Copper intrauterine device
Levonorgestrel
Levonorgestrel-releasing intrauterine system
No appropriate contraception is available
Ulipristal
Ulipristal
Ulipristal (EllaOne) - a type of emergency hormonal contraception, can be used up to 120 hours post UPSI
Ulipristal is the correct choice. This option, an oral hormonal emergency contraceptive, is minimally invasive and can be administered up to 120 hours following unprotected sexual intercourse. Therefore, the patient remains eligible for this form of contraception within the specified timeframe.
The copper intrauterine device is not the appropriate selection in this scenario. Despite being the most effective emergency contraceptive method and one that should always be considered, the patient’s preference for a non-invasive option must be respected. Given that ulipristal remains a viable alternative within her current window of opportunity, it represents a more suitable choice per her wishes.
Levonorgestrel does not represent a valid option here. Although levonorgestrel is another type of oral emergency hormonal contraceptive, its effectiveness extends only to within 72 hours (3 days) post-unprotected sexual intercourse; hence it would not serve this patient’s needs given the timing of her exposure.
The levonorgestrel-releasing intrauterine system (IUS) is also an incorrect choice. The IUS functions as a long-term hormonal contraceptive by thickening cervical mucus, impeding sperm mobility, and attenuating the endometrial lining to prevent fertilisation and implantation. However, due to inconclusive evidence regarding its use as an emergency contraceptive measure, it does not constitute an accepted practice for such purposes within the UK healthcare setting.
The option no appropriate contraception is available is incorrect. The patient engaged in unprotected sexual activity 4 days (96 hours) ago, which means she remains within the acceptable period for using both ulipristal and the copper intrauterine device as forms of emergency contraception. Ulipristal is likely to retain its efficacy at this stage since she is on day 10 of her typical 30-day menstrual cycle, indicating ovulation has probably not yet occurred; ovulation typically takes place around day 16.
A 22-year-old woman calls her GP surgery. The previous day she visited her pharmacist and was given the levonorgestrel emergency contraceptive pill following an episode of unprotected sexual intercourse. The patient explains to you that she wants a more reliable method of contraception.
You prescribe the combined oral contraceptive pill (COCP).
When can this patient start the COCP?
7 days after the emergency contraceptive pill
30 days after the emergency contraceptive pill
After she has had a negative pregnancy test
Immediately
The COCP is contraindicated
Immediately
Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception
Important for meLess important
After using the levonorgestrel emergency contraceptive pill, hormonal contraception can be started immediately.
Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch, or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during these 5 days.
7 days after the emergency contraceptive pill is incorrect. Levonorgestrel is not known to impact the efficacy of regular hormonal contraception. Therefore, there is no required time interval before restarting/starting hormonal contraception.
30 days after the emergency contraceptive pill is incorrect. Levonorgestrel is not known to impact the efficacy of regular hormonal contraception. Therefore, there is no required time interval before restarting/starting hormonal contraception.
After she has had a negative pregnancy test is incorrect. After taking levonorgestrel, a pregnancy test is not routinely recommended. According to NICE, a pregnancy test is only indicated if the patient’s next period is more than 5-7 days late or lighter than usual.
The COCP is contraindicated is incorrect. Using levonorgestrel is not a contraindication to the COCP. Contraindications of the COCP include current breast cancer, migraine with aura or, being aged over 35 years old and smoking more than 15 cigarettes per day.
A 23-year-old university student presents to her GP four days after having unprotected sexual intercourse with her new boyfriend. She does not intend to start a family in the next five years. She has a history of anxiety and asthma. She is not taking any medication, but she wishes to begin regular contraception.
What is the most appropriate emergency contraception for this patient?
Contraceptive implant
Copper intrauterine device
Oral levonorgestrel
Oral ulipristal (EllaOne)
Progesterone intrauterine system (Mirena)
The copper intrauterine device can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within 5 days of the earliest estimated date of ovulation, whichever is later
Important for meLess important
This patient does not wish to start a family in the next five years and, therefore, does not wish to become pregnant. She, thus, requires emergency contraception. There are two methods of emergency hormonal contraception: levonorgestrel and ulipristal, both of which are oral progesterone receptor modulators. The only non-hormonal option is copper intrauterine device (IUD), also referred to as the copper coil.
Copper intrauterine device is the correct answer. This is the most effective method of emergency contraception. It is recommended for women who can have it inserted within five days of unprotected sexual intercourse (UPSI) or up to five days after their estimated ovulation date, whichever comes later. In this scenario, the patient presents four days following UPSI, thus meeting the criteria for IUD insertion. Given that this woman does not wish to start a family in the next five years, it would be appropriate to discuss contraception methods. The IUD can be left in situ to provide long-term contraception following its use as an emergency contraception.
Contraceptive implant is incorrect. It is not indicated for use as an emergency contraceptive but rather serves as a long-term method of contraception. Therefore, it would not be useful for this patient who requires emergency contraception.
Oral levonorgestrel is incorrect. Ideally, it should be taken as soon as possible, as efficacy decreases with time. It can be taken up to 72 hours after UPSI. Therefore, too much time has lapsed since this patient had UPSI. Furthermore, it cannot be used as long-term contraception as it is a one-off tablet. Therefore, it is not the most appropriate option for this patient.
Oral ulipristal (EllaOne) is incorrect. It can be used within a five-day window following UPSI; however, caution must be exercised in patients with a history of asthma. Like levonorgestrel, ulipristal cannot provide sustained contraceptive coverage due to its single-use design. Therefore, it is not the most appropriate option for this patient, who would ideally like long-term contraception as well.
Progesterone intrauterine system (Mirena) is incorrect. It is not indicated for use as an emergency contraceptive but instead serves as a long-term method of contraception. Therefore, it would not be helpful for this patient who requires emergency contraception.
A 26-year-old woman presents to her GP, asking about emergency contraception. She had unprotected sexual intercourse with a male partner 7 days ago. She has a regular 28-day menstrual cycle and, based on her last period, estimates that today is day 17 of her current cycle.
What can be used as emergency contraception for this patient?
Copper intrauterine device
Levonorgestrel
Mirena intrauterine system
Norethisterone
Ulipristal
Copper intrauterine device
The copper intrauterine device can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within 5 days of the earliest estimated date of ovulation, whichever is later
Of the options listed here, the only suitable method for this patient is the copper intrauterine device (IUD). As well as being an effective form of regular contraception, it can be used as a form of emergency contraception if inserted within 5 days of unprotected sexual intercourse. Alternatively, if presenting after more than 5 days, it may be fitted up to 5 days after the likely ovulation date. As this patient has a regular 28-day cycle, her ovulation would be expected to occur at day 14. She is currently at day 17 and so within the 5-day window for fitting of the IUD.
Levonorgestrel is a tablet commonly used for emergency contraception. It must be taken within 72 hours of unprotected sexual intercourse, however, and so would not be suitable in this instance.
The Mirena intrauterine system is a hormonal device fitted in the uterus that acts as an extremely effective form of regular contraception. It is generally more popular than the copper device nowadays, due to generally reducing bleeding/stopping periods altogether, rather than increasing the heaviness of bleeding as the copper device does. However, unlike the copper device, it cannot be used as emergency contraception.
Norethisterone is a drug used to control dysfunctional uterine bleeding and also to delay periods. It is not used as emergency contraception.
Ulipristal is an alternative tablet to levonorgestrel and can be taken up to 5 days after unprotected sexual intercourse. Given that this patient is presenting 7 days later, this is not a suitable option.
A 19-year-old woman attends a walk-in sexual health clinic.
She had sexual intercourse with her boyfriend on Saturday. They usually use condoms as contraception, but they did not on this occasion as they had none available.
The patient has a history of severe asthma controlled with oral steroids, but is otherwise fit and well.
It is now Wednesday.
What is the most appropriate form of emergency contraception?
Combined oral contraceptive pill
Intrauterine device
Intrauterine system
Levonorgestrel
Ulipristal acetate
Intrauterine device
A copper IUD is the most effective method of emergency contraception and should be offered to all women
A copper intrauterine device (IUD) is the most effective method of emergency contraception, and should be offered first-line to all women who have experienced unprotected sexual intercourse (UPSI). The IUD can be offered for up to 5 days after the UPSI, or up to 5 days after the earliest estimated date of ovulation.
The combined oral contraceptive pill is incorrect. This cannot be used as emergency contraception.
The intrauterine system is incorrect. This cannot be used as emergency contraception.
Levonorgestrel is incorrect. Although levonorgestrel can be prescribed as emergency contraception, it must be offered within 72 hours of the UPSI. This patient has presented 4 days after the UPSI, so levonorgestrel is not an option. Regardless, the IUD is more effective than levonorgestrel and so should be offered first-line, even if presenting within 72 hours of the UPSI.
Ulipristal acetate is incorrect. This drug can be prescribed as emergency contraception within 5 days of the UPSI. However, the IUD is more effective and so should be offered first-line. Furthermore, caution should be used when prescribing ulipristal acetate to those with severe asthma.
An 18-year-old female presents to the local sexual health clinic following unprotected sexual intercourse. The intercourse happened four days ago. She is not on any form of contraception. The patient would rather have an oral form of contraception as opposed to an invasive form.
Which one of the following is the most appropriate management plan?
Insert an intrauterine device
Insert an intrauterine system
Prescribe levonorgestrel
Prescribe mifepristone
Prescribe ulipristal
Prescribe ulipristal
Levonorgestrel must be taken within 72 hours of UPSI
The correct answer is to prescribe ulipristal. This patient is inquiring about emergency contraception for unprotected sexual intercourse that happened 96 hours ago. Ulipristal (a selective progesterone receptor modulator) can be prescribed up to 120 hours following the intercourse. It is thought to work by inhibiting ovulation. This is the only option between the proposed one that can be administered in the current timeframe and does not involve the administration of invasive contraception.
Insertion of an intrauterine device is inappropriate as the patient declined an offer of invasive contraception. A copper device can be inserted to prevent pregnancy up to five days following unprotected intercourse, but it has to be left in situ at least until the next period. Since she has no contraindication for taking ulipristal, this option is inappropriate as it goes against the wish of the patient.
Insert of an intrauterine system is inappropriate as this option is not used for emergency contraception. Even if the medication contained in this option is levonorgestrel, it cannot be used as emergency contraception in this form.
Prescription of levonorgestrel is inappropriate as this medication is effective for emergency contraception only up to 72 hours following the unprotected intercourse. This patient reports the intercourse happening 96 hours ago making the option incorrect.
Prescription of mifepristone is inappropriate as this drug is not licensed for emergency contraception. This drug is a prostaglandin analogue that causes uterine contractions. It is used in combination with misoprostol to terminate pregnancies.
An 18-year-old woman presents to her general practitioner seeking emergency contraception for an episode of unprotected sex that occurred 80 hours ago. She is on day 20 of her menstrual cycle. The GP notes that ellaOne (ulipristal acetate) was prescribed to this patient 10 days ago for a similar episode. Which of the following is a suitable method of emergency contraception in this case?
Combined oral contraceptive pill
Mirena (levonorgestrel) device
Nexplanon (etonogestrel) implant
ellaOne (ulipristal acetate) pill
Levonelle (levonorgestrel) pill
ellaOne (ulipristal acetate) pill
The only two methods on this list that can be used as emergency contraception are ellaOne (ulipristal acetate 30mg) and Levonelle (levonorgestrel 1.5mg). The other three options can provide routine but not emergency contraception, so whilst they may be useful in the longer term they do not address the immediate problem.
Levonelle is most effective if taken within 72 hours of unprotected intercourse (it may be used until 96 hours but its effectiveness decreases over time) and can be used more than once during a menstrual cycle. ellaOne (ulipristal acetate) is effective if taken within 120 hours of unprotected intercourse. Previously it was advised that ulipristal could only be used once during a menstrual cycle. However, this guidance has now changed. Please see the link for more details.
The copper intrauterine device would be a viable alternative but did not appear on the list of options.
(BNF 2015)
A 25-year-old comes to see you on a Monday morning after an episode of unprotected intercourse the Friday before. She is concerned about an unwanted pregnancy and wishes to be prescribed the most effective option to prevent this. Her last menstrual period was two weeks ago.
What is the most appropriate action?
- Advise she has missed the window for emergency contraception
- Arrange for copper coil (IUD) insertion
- Prescribe levonorgestrel emergency contraception
- Prescribe ulipristal acetate emergency contraception
- Start the combined oral contraceptive pill
*
Arrange for copper coil (IUD) insertion
A copper IUD is the most effective method of emergency contraception and should be offered to all women
This patient is presenting approximately 72 hours following an episode of unprotected intercourse and would like the most effective form of contraception. The most appropriate action is to arrange for copper coil (IUD) insertion. The IUD is effective in preventing pregnancy for up to five days (120 hours) following unprotected intercourse (if not yet ovulated) or up to five days following ovulation and acts to prevent fertilisation or implantation respectively. If there are concerns about the presence of sexually transmitted diseases, antibiotics can be given concurrently.
Advise she has missed the window for emergency contraception is incorrect. Both the copper coil (first-line) and ulipristal acetate are licensed for emergency contraception up to five days (120 hours) following intercourse, whilst levonorgestrel emergency contraception can be taken up to 72 hours post-coitus.
Prescribe levonorgestrel emergency contraception is incorrect. Levonorgestrel efficacy is greatest when taken within 12 hours, and no later than 72 hours, post-intercourse. Efficacy decreases with time and is minimally effective if ovulation has occurred. This patient is presenting 72 hours following intercourse and with her last menstrual period 14 days ago it is possible that she has already ovulated. A copper coil (IUD) insertion would therefore be a more appropriate choice.
Prescribe ulipristal acetate emergency contraception is incorrect. Whilst ulipristal acetate may be taken up to 120 hours post-intercourse, its efficacy decreases with time. Additionally, the main mechanism of action is to prevent ovulation and therefore efficacy decreases if ovulation has occurred. In this case, a copper coil would be more appropriate.
Start the combined oral contraceptive pill is incorrect. Whilst the discussion of contraceptive choices going forward is appropriate in this consultation, this will not address the patient’s presenting concern.
