Emergency Contraception Update

Emergency Contraception Update

Emergency Contraception Update Dr Lynda Turner June 2015 Disclosure Honorarium from HRA Pharma Learning objectives. By the end of the session you will be able to:

1. Describe the methods and effectiveness of all methods of emergency contraception. 2. Recognise where there is a risk of pregnancy and advise appropriately 3.

Specify key points in history taking, counselling and follow up for safe and effective use of EC. 4. Identify needs for future contraception and when this can be started as well as any risk of STI and advise appropriately Plan for session Presentation: Emergency Contraception update Case studies: Small group work

What is emergency contraception? Use of any drug or device after unprotected sexual intercourse to prevent an unintended pregnancy Acts prior to implantation pregnancy begins at implantation, therefore EC is not an abortifacient

Implantation is assumed to occur no sooner than 6 days after ovulation Reasons for requesting emergency contraception Menstrual Cycle Factors Influencing Risk of Pregnancy following unprotected sex

Ovum survives 24-36 hour. Sperm can survive up to 7 days (in the uterus) Where in cycle sex occurs from 8% risk early in cycle to 36% on day of ovulation. Drops rapidly

following ovulation Fertility of both partners (unknown) There is no time in the cycle when you can withhold emergency contraception on physiological grounds From ovulation, to fertilisation, to pregnancy

Emergency contraception What is currently available? How do they work? How effective are the methods? What is currently available? Copper IUD

Levonelle (Levonorgestrel 1.5mg) ellaOne (Ulipristal acetate 30mg) Copper IUD Best method of EC - more than 99% effective Spermicidal/toxic to ovum prevents fertilisation Also has some anti-implantation effect

Can be fitted up to 120hrs (5 days) after UPSI or within 5 days of the earliest predicted date of ovulation. Offer all eligible women IUD as most effective EC Method Calculating ovulation date ellaOne

Selective progesterone receptor modulator Primary mode of action inhibition or delay of ovulation Can prevent ovulation after the LH surge has started, delaying follicular

rupture for up to 5 days Licensed for up to 120hrs after UPSI Levonorgestrel 1.5mg Progestogen Thought to delay or inhibit ovulation If taken prior to the LH surge can result in ovulatory dysfunction in the subsequent 5 days NO better at suppressing ovulation than placebo when given immediately prior to ovulation Licensed for use for 72hrs after UPSI Shown to be effective up to 96hrs after UPSI

How do EHCs work? Both Ulipristal acetate and levonorgestrel act by delaying ovulation:1 levonorgestrel has been shown to be no better than placebo at inhibiting ovulation when given

immediately prior to ovulation1 Ulipristal Ulipristal is effective even after onset of the LH surge2 References: 1. Emergency Contraception. Clinical Effectiveness Unit. Faculty of Sexual & Reproductive Healthcare Clinical Guidance. Available at fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf. Last accessed January 2012. 2. Brache V et al., Hum Reprod 2010; 25: 225663.

Ulipristal is effective right up to the point of ovulation, even if lutenising hormone (LH) levels have already begun to rise1,2 Fig 1 Window of action of different emergency contraceptive methods in relation to ovulation. Prabakar I , Webb A BMJ 2012;344:bmj.e1492

2012 by British Medical Journal Publishing Group Contraindications to Cu IUD Pregnancy Less than 4 weeks postpartum Undiagnosed vaginal bleeding Gynae cancers Cervical, Endometrial, Ovarian Acute Pelvic infection Any congenital or acquired uterine abnormality causing distortion of the uterine cavity eg fibroids

Levonorgestrel 1.5mg FSRH Clinical Guidelines on EC does not identify any medical condition that limits the use of Levonorgestrel 1.5mg ellaOne 30mg Precautions Use in women with severe asthma treated by

oral glucocorticoids is not recommended Breast feeding women must not breast feed for 1 week after taking ellaOne 30mg Cu IUD information to client

Discuss fitting procedure Discuss possible side effects Can be removed AFTER next period if preferred Can continue with IUD for 5 -10yrs STI screen and prophylactic antibiotics will be offered Give EHC even if IUD going to be fitted by GP or other service Safety profile of oral EC Uliprist al

References: 1. Glasier AF et al., Lancet 2010; 375: 55562. 2. HRA Pharma UK Ltd. ellaOne 30 mg tablet Summary of Product Characteristics. Prescribing information is available on slide 19. Adverse effects of ellaOne and Levonelle Nausea Vomiting 1% - if within 2hrs of taking LNG or 3hrs of taking ellaOne further dose required Headache Both can affect timing of next menstrual period Do pregnancy test if not had a normal menstrual

period 3 weeks after UPSI Potential drug interactions for ellaOne Liver enzyme inducing medications used currently or up to 28 days previously e.g. rifampicin, phenytoin, phenobarbital, carbamazepine, St Johns wort (Hypericum perforatum)

Products that increase gastric pH taken in the preceding 24hours e.g. proton pump inhibitors, antacids, H2-receptor antagonists Use in women with severe asthma treated by oral glucocorticoids is not recommended ellaOne may interfere with oestrogen and progestogen methods of

contraception including Levonelle Potential drug interactions for Levonelle Liver enzyme inducing medications used currently or up to 28 days previously e.g. some antiepileptic drugs, some treatments for TB and HIV and some herbal remedies eg St Johns wort

For this group, the best choice EC is Copper IUD If declined or contraindicated, you can use double dose Levonelle (off licence) Facts about Emergency Hormonal Contraception Has no effect on future fertility

Does not interrupt an established pregnancy If mistakenly given in early pregnancy, does not harm a developing foetus Does not protect against STIs Does not provide contraception for further UPSI in the days after EHC has been taken When should EC be used? When no contraceptive method used When failure or potential contraceptive failure of method used e.g.

Split or slipped condom Forgotten progestogen only pills Forgotten combined pills or patch or ring When Depo-provera late IUD/IUS expelled or expired Nexplanon expired What EC options are suitable for this client? Was any method of contraception used?

If yes, reason for failure/potential failure of method? First day of LMP Cycle length (if variable, shortest and longest) When did they last have UPSI? Were there any other episodes of UPSI in current cycle? EC previously used this cycle? Medical history Drug history including any OTC Allergies Indications for EC

POP >27 hours since last POP (Micronor, Noriday, Norgeston) and UPSI in next 48 hours >36 hours since last desogestrel only pill (Cerelle and Cerazette) and UPSI in next 48 hours Depo-provera Late injection (>14 weeks) and UPSI after this time.

Missed COC Pills FSRH Clinical guidance on missed pills 1 pill can be missed anywhere in the pill pack with no need for extra protection or EC If 2 pills or more are missed, then extra protection should be used for 7 days and EC may be required Missed COC pills minimising the risk of pregnancy

Need to think hard about pills missed in week 1 and week 3 Pills 1-7 Consider EC if UPSI (including in PFI) if 2 pills missed. After EC continue pills and use condoms for 7 days if LNG taken and 14 days if UPA taken Pills 8-14 No need for EC if UPSI Continue pills and use condoms for 7 days Pills 15-21 No need for EC if UPSI but continue pills, avoid PFI and use condoms for 7 days

Quick starting hormonal contraception after oral EC how long is barrier contraception needed? EC Option COCP POP QLAIRA LNG

7 days 2 days 9 days UPA 14 days 9 days

16 days FSRH Quick starting contraception 2010 ellaOne SmPC instructions "If a woman wishes to start or continue using hormonal contraception, she can do so after using ellaOne, however, she should be advised to use a reliable barrier method until the next menstrual period". Key points for EC Consultation

Assessing the risk of pregnancy Discuss the EC options appropriate for the circumstances 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 Session Key Points

3 methods of EC Levonelle, ellaOne and Cu IUD. Cu IUD is the most effective Always check medical eligibility for EC Always ask about medications taken including OTC, which may make oral EHC less effective. Always address ongoing contraception STI risk assessment is an essential part of EC consultation.

Use this opportunity to explore any issues relating to nonconsensual sex, sexual assault or abuse and domestic violence

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