Emergency Contraception FSRH Dec 2017

Question 1

When is emergency contraception (EC) indicated?

Answer 1

• do not wish to conceive: offer EC after UPSI (happened on any day of natural menstrual cycle).
• offer EC after:
  
  • • Day 21 after childbirth (unless criteria for LAM met).
  • • From Day 5 after abortion, miscarriage, ectopic pregnancy or uterine evacuation for GTD.
  • • if their regular contraception compromised or used incorrectly.

Question 2

Provision of EC

What are the responsibilities of EC providers?

Answer 2

• HCP inform: all methods and signpost them to services provider.
• If referred on for Cu-IUD, oral EC should be given at time of referral in case Cu-IUD cannot be inserted or the woman changes her mind.
• advise: oral EC methods not provide contraceptive cover for subsequent UPSI and need to use contraception or abstain to avoid further risk.
• inform: all methods of ongoing contraception and how to access these.

Question 3

How effective are the different methods of EC?

Answer 3

• Cu-IUD is the most effective.
• UPA-EC effective for EC up to 120 hours after UPSI.
• LNG-EC is licensed for EC up to 72 hours after UPSI. ineffective after 96 hours after UPSI.
• UPA-EC more effective than LNG-EC.
• Oral EC administered after ovulation is ineffective.

Question 4

What is the effect of weight/body mass index (BMI) on the effectiveness of EC?

Answer 4

• effectiveness Cu-IUD is not affected by weight/ BMI.

- higher weight or BMI could reduce effectiveness of oral EC, particularly LNG-EC.

Question 5

What drug interactions are relevant to use of EC?

Answer 5

• enzyme-inducing drugs, effectiveness of UPA-EC and LNG-EC could be reduced.
• using enzyme-inducing drugs should be offered a
  
  • • Cu-IUD if appropriate.
  • • 3 mg dose of LNG (effectiveness unknown).
  • • double-dose UPA-EC not recommended.
• effectiveness of UPA-EC could be reduced
  
  • • if takes progestogen in 5 days after taking UPA-EC.
  • • taken progestogen, 7 days prior to UPAEC. (theoretically)

Question 6

Are there any contraindications/restrictions to use of EC?

Answer 6

• contraindications to insertion of a Cu-IUD for EC are same as routine IUD insertion.
• UPA-EC is not suitable, severe asthma controlled by oral glucocorticoids.

Question 7

Are there any specific considerations for women who are breastfeeding and require EC?

Answer 7

• higher relative risk of uterine perforation during insertion of IUC than non-breastfeeding. absolute risk of perforation is low.
• not to breastfeed and to express and discard milk for a week after UPA-EC.
• LNG-EC has no adverse effects on breastfeeding or on their infants. limited evidence

Question 8

What methods of EC should be offered to a woman
who has had UPSI and wishes to avoid pregnancy?


Answer 8

• offer: a Cu-IUD if appropriate, most effective EC.
• Cu-IUD, up to 5 days after first UPSI in a natural menstrual cycle, or up to 5 days after the earliest likely date of ovulation (whichever is later).
• If a Cu-IUD is not appropriate or not acceptable, advise oral EC as soon as possible if UPSI withinlast 5 days.
• consider UPA-EC as first-line oral EC, for UPSI 96–120 hours ago (even if she has also had UPSI within the last 96 hours).
• UPA-EC as first-line oral EC for UPSI within last 5 days if UPSI is likely to have taken place, during 5 days prior to estimated day of ovulation.
• oral EC administered after ovulation is ineffective.
• Adolescents & after sexual assault should be offered all methods of EC including the Cu-IUD.

Question 9

Can oral EC be used if she had UPSI earlier in same cycle as well as within last 5 days,

Answer 9

• offer: UPA-EC or LNG-EC

evidence, UPA-EC and LNG-EC not disrupt existing pregnancy & not associated with fetal abnormality

Question 10

Can oral EC be used more than once in a cycle?

Answer 10

• If already taken UPA-EC once or more in a cycle, can offer her UPA-EC again after further UPSI in same cycle.
• If already taken LNG-EC once or more in a cycle, can offer her LNG-EC again after further UPSI in same cycle.
• if has already taken UPA-EC, LNG-EC should not be taken in following 5 days.
• if has already taken LNG-EC, UPA-EC could theoretically be less effective if taken in following 7 days.

Question 11

EC

What should women be advised regarding future contraception?

Answer 11

• Cu-IUD provides effective ongoing contraception.
• oral EC methods not provide ongoing contraception.
• after oral EC, pregnancy risk if further UPSI and ovulation occurs later in same cycle.
• After taking LNG-EC, start hormonal contraception immediately. must use condoms or abstain from sex until contraception becomes effective.
• after taking UPA-EC, wait 5 days before starting hormonal contraception. must use condoms or abstain from sex during 5 days waiting and then until their contraceptive method is effective.
• If UPSI is unlikely during fertile period, consider LNG-EC with immediate start of hormonal contraception rather than UPA-EC with delayed start.