Emergency Contraception

Question 1

When is emergency contraception used?

Answer 1

• used after episodes of UPSI
• this includes damaged condoms / missed pills

Question 2

What is meant by “established pregnancy”?

How do EC methods interfere with this?

Answer 2

• established pregnancy is defined at implantation
• this occurs between day 6 and 12 post-fertilisation
• EC methods are NOT abortifacient as they work prior to implantation

Question 3

What is the definition of post-coital contraception?

Answer 3

an intervention to stop pregnancy within 120 hours of fertilisation (5 days)

this is before implantation has occurred and pregnancy is “established”

Question 3

What is the definition of post-coital contraception?

Answer 3

an intervention to stop pregnancy within 120 hours of fertilisation (5 days)

this is before implantation has occurred and pregnancy is “established”

Question 4

How can the menstrual cycle be divided into 2 halves?

Answer 4

proliferative / follicular phase:

• this is the first half of the cycle that is oestrogen driven
• it can vary in length

luteal / secretory phase:

• this is the second half that is progesterone driven
• it is ALWAYS 14 days in length

Question 5

How can the timing of ovulation be calculated?

How long does the ovum survive for?

Answer 5

• the timing of ovulation is cycle length minus 14 days
• the ovum survives for 12-24 hours

Question 6

What is the survival of sperm like?

Answer 6

• the survival of sperm is 7 days
• traditional / conservative views stated 1-2 days
• it is more likely to be around 5 days

Question 7

Why is a pregnancy test not always relevant when considering EC?

Answer 7

• a pregnancy test is not reliable until after 3 weeks
• patients may be advised to re-perform one in 3 weeks despite EC

Question 8

What are the 3 most important areas to cover in an EC history?

Answer 8

LMP / cycle length:

• to calculate date of ovulation

(if someone has irregular cycles, minus 14 from the shortest cycle they have had)

timing of UPSI:

• the most recent and all UPSI in this cycle

potential contraceptive failure:

• e.g. missed pills / condom accident
• potential medication interactions
  • antituberculosis
  • antiretroviral
  • antiepileptic
  • St John’s Wort

Question 9

What are the 4 indications for EC?

Answer 9

• UPSI on any day of a natural menstrual cycle
• UPSI from day 21 post childbirth
• UPSI from day 5 after abortion, miscarriage or ectopic pregnancy
• regular contraception has been compromised / used incorrectly

Question 10

At what points in the cycle is someone most fertile?

Answer 10

• most fertile at / around the time of ovulation
• the pregnancy risk is negligible on day 1-3
• and the risk is very low 48 hours after ovulation due to demise of the ovary

Question 11

What are the 3 options for emergency contraception?

Answer 11

levonorgestrel 1500mcg:

• must be taken within 72 hours of UPSI
• e.g. Levonelle / Upostelle

ulipristal acetate 30mg:

• must be taken within 120 hours of UPSI
• e.g. EllaOne

copper coil:

• can be inserted within 5 days of UPSI

Question 12

When must levonorgestrel be taken to be effective?

Answer 12

within 72 hours of UPSI

Question 13

When must ulipristal acetate be taken to be effective?

Answer 13

within 120 hours of UPSI

• this is more powerful / effective than levonorgestrel

Question 14

What is the most effective method of EC?

Answer 14

copper IUD

• this is not affected by BMI, enzyme-inducing drugs or malabsorption
• it also provides ongoing contraception

Question 15

At what points during the menstrual cycle is EC offered?

Answer 15

• it is offered at ANY time during the cycle
• it is unlikely to be effective if ovulation has already occurred
• the woman should be advised to take a pregnancy test in 3 weeks / if her period is delayed

Question 16

What is levonorgestrel and how does it work?

Answer 16

• it is a progestogen
• it works by preventing / delaying ovulation by suppressing the LH surge for up to 5 days

(it is not effective if the LH surge has already occurred, but fertility is reduced after demise of the ovum anyway)

• it is not harmful in pregnancy if this does occur

Question 17

When can contraception be started following levonorgestrel?

Answer 17

• COCP or POP can be started immediately
• condoms should be used for 7 days after starting COCP
• condoms should be used for 2 days after starting POP

Question 18

What is the dose of levonorgestrel that is given?

Answer 18

• 1.5mg as a single dose
• 3mg as a single dose if BMI > 26** or **> 70kg

(double dose is also given with enzyme-inducing drugs but this is off licence)

Question 19

What is done if vomiting occurs after levonorgestrel?

Answer 19

• the dose must be repeated if vomiting occurs within 3 hours
• nausea & vomiting are common side effects

Question 20

What are the other side effects associated with levonorgestrel?

Answer 20

• spotting / changes to next menstrual period
• diarrhoea
• breast tenderness
• dizziness
• depressed mood

Question 21

How does levonorgestrel affect breast feeding?

Answer 21

• it is NOT harmful in breastfeeding, so this can continue
• it is advised to avoid breast feeding for 8 hours after taking the dose

Question 22

How does ulipristal work?

Answer 22

• it is a selective progesterone receptor modulator (SPRM)
• it suppresses the LH surge, but more powerfully than levonorgestrel
• it prevents / delays ovulation

Question 23

What advice is given around starting contraception after ulipristal?

Answer 23

!! WAIT 5 DAYS !!

• when starting COCP, use condoms for initial 7 days
• when starting POP, use condoms for initial 2 days

Question 24

What dose of ulipristal is given?

Answer 24

* a single dose of **_30mg_** * unlike levonorgestrel, this dose ***CANNOT be doubled***

Question 25

What are the limitations to the use of ulipristal?

Answer 25

* as the dose cannot be doubled, it **_cannot_** be used with **enzyme-inducers** * it is not known whether UPA or LNG is more effective when **_BMI \> 30**_ or _**weight \> 85kg_** * **breast-feeding** must be **_avoided for 1 week_** after use

Question 26

What are the contraindications to ulipristal?

Answer 26

severe asthma

Question 27

What should happen if vomiting occurs after taking ulipristal?

Answer 27

if vomiting occurs ***_within 3 hours_*****,** the dose must be repeated

Question 28

What are the other side effects associated with ulipristal?

Answer 28

* breast tenderness * N&V * back pain * mood changes * spotting / changes to next menstrual period * headache / dizziness * abdominal / pelvic pain

Question 29

What are the significant drug interactions associated with ulipristal?

Answer 29

**_UPA is less effective if:_** * **progestogens** have been taken in the ***_7 days prior_*** * progestogens are taken in the ***_5 days following_*** * enzyme inducers

Question 30

When is UPA used?

Answer 30

if patient presents **_72-120 hours post-UPSI_** and does not want an IUD

Question 31

When is the IUD used as emergency contraception?

Answer 31

* it can be fitted up to **_5 days after UPSI_** OR * within **5 days** of **_earliest calculated day of ovulation_** * *this is 14 days before the cycle ends* * *e.g. day 12 for a 26 day cycle* * it is recommended when there have been **multiple episodes of UPSI** within the last few days

Question 32

Why is the copper IUD the first line for EC?

Answer 32

* it is 99% effective * it can be used for ongoing contraception * it is **toxic to the ovum + sperm** and **inhibits implantation**

Question 33

How long should the copper IUD be kept in for if it is not wanted for contraception?

Answer 33

* it needs to be kept in until at least the **_next period_** * after this, it can be removed

Question 34

What is the major side effect associated with the copper IUD?

Answer 34

* insertion can lead to **pelvic inflammatory disease** * this is more likely in women who are high risk for STIs

Question 35

What are the disadvantages to copper-IUD fitting?

Answer 35

* periods can become **longer, heavier + painful** * there is a risk of **perforation** * there is a risk of **expulsion** * there is an increased risk of **ectopic pregnancy**

Question 36

When is insertion of a Cu-IUD strongly encouraged?

Answer 36

* around the **time of ovulation**, the chance of pregnancy from a single act of UPSI is 30% * after ovulation has occurred, **levonorgestrel + ulipristal are less likely to be effective** * the IUD will still work to be toxic to the sperm / ovum

Question 37

Why can the Cu-IUD only be inserted up to 5 days after UPSI?

Answer 37

* the earliest date of **implantation** is **_6 days after ovulation_** * the IUD must be inserted **prior to implantation** occurring