Emergency contraception (EC) is used when a woman’s normal contraceptive fails due to missed or late method use, concurrent use of enzyme-inducing drugs, acute diarrhoea, or unprotected sexual intercourse (UPSI). There are three emergency contraception options: Cu-IUD, Levonorgestrel (LNG), and Ulipristal acetate (UPA).
Choosing emergency contraception relies on:
- Pregnancy risk
- Contraindications
- Patient preferences
Chance of Pregnancy
Sperm can exist in the upper reproductive tract for 5 days (maximum of 7 days), while unfertilized ovum can survive for 24 hours. The biggest chance of pregnancy from a single act of UPSI occurs 24 hours before or on the day of ovulation. Pregnancy risk is lowest during the first and last days of the menstrual cycle (days 1-9 and 18-28 of a 28-day cycle).
If there is a possibility of pregnancy, there may also be a risk of STI exposure from current or earlier episodes of UPSI. It is recommended to do a STI risk assessment and consider screening for STIs.
A pregnancy test may be indicated, especially if there was a risk earlier in the cycle. Pregnancy cannot be ruled out until three weeks following an occurrence of UPSI.
Cu-IUD
The Cu-IUD is the most effective emergency contraception and should be available to all eligible women. Copper is harmful to both sperm and ovum, which impairs fertilization. It isn’t an abortion pill. Using the shortest cycle length, determine the earliest date of ovulation for Cu-IUD insertion. Age, nulliparity, risk of sexually transmitted infections, and previous ectopic pregnancy are not grounds against use. Cu-IUD is quickly effective, hence using it for EC doesn’t need any further safety measures.
The LNG-IUS should be avoided because it is useless for emergency contraception.
Levonorgestrel
Levonorgestrel is extensively licenced worldwide for use as progestogen-only emergency contraception (POEC). It is marketed as Plan B OneStep® (USA, Canada), Levonelle® (UK, Australia, and New Zealand), and Norlevo® (Asia, Africa, Western Europe). Levonelle One Step® can be bought in UK pharmacies without a prescription.
Ulipristal acetate
Introduced in 2009, the oral EC method is known as ellaOne® in Europe and Ella® in the US.
Selective progesterone receptor modulator (SPRM) UPA. A lady should inform the manufacturer if she wants to carry on with a pregnancy after a failed UPA, so they can monitor the pregnancy’s effects.
Which option to choose?
All eligible women should have access to the Cu-IUD, the most effective emergency contraception. Though it costs more than LNG, UPA may be advised for women who are at high risk of becoming pregnant, including those who have had a mid-cycle UPSI or who have been without one for more than 72 to 120 hours.
Vomiting after oral emergency contraception
A second dose is advised if, within two hours after therapy, vomiting occurs.
UPA: It is advised to take a second dose if vomiting happens within three hours of treatment.
Repeat use of oral emergency contraception in a cycle
No chance of unfavorable pregnancy results or congenital problems exists if LNG does not prevent pregnancy. An abortion cannot be brought on by LNG. Should more UPSI episodes arise during the same cycle, a repeat LNG dosage (with product licence) may be given. Following an LNG dosage, no further EC treatment is required for the next twelve hours.
Given the paucity of evidence on the safety of UPA during pregnancy, it should not be taken more than once every cycle. Give UPA not at the same time as LNG. LNG can be provided after UPA, nevertheless, to handle extra risk after UPSI in the same cycle.
Follow-up
A woman should get tested for pregnancy if, three weeks after EC, her menstrual cycle does not start. Following Cu-IUD insertion, follow-up is recommended within three weeks or after the first menstrual cycle. Once pregnancy has been ruled out, requests for removal are accepted if no UPSI occurs within seven days. Follow-up may reveal the need for further STI testing. You should look at continuing contraception.
Meeting ongoing contraceptive needs
UPA and LNG do not provide contraception for additional UPSI episodes within the same cycle.
Continuous contraception can be achieved with the Cu-IUD.
‘Quick starting’ contraception
Women can choose to “quick start” or resume their current method of contraception or wait until pregnancy is ruled out before using a hormonal approach. This means starting contraception right now at your request, without waiting for the next menstrual cycle. Though recommended by national guidelines, this is not covered by the product licensing for hormonal procedures, LNG-IUS, and some Cu-IUDs.
If the woman consents and understands the need of follow-up to rule out pregnancy (e.g., a pregnancy test within ≥3 weeks), the COC, POP, or PO implant can be started right away after EC. A confirmed pregnancy cannot be stopped or eliminated using DMPA. It should therefore only be started if there are no workable or acceptable alternatives. An LNG-IUS should never be implanted to prevent pregnancy; a Cu-IUD should only be used as an EC when specific requirements are fulfilled. Should a pregnancy be discovered following an early start and the woman wants to carry on, the treatment should be stopped. Use of a hormonal contraceptive requires additional precautions. Advanced oral EC may be given consideration individually even if it has not been shown to lower conception rates.
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