Emergency Contraception

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Emergency Contraception A Well Kept Secret Tony Ogburn, MD University of New Mexico Health Sciences Center

Objectives : 

Objectives Understand the need for EC Review the current methods of EC available in the U.S. Understand the barriers to use that exist for EC. Be familiar with approaches to improve EC utilization.

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The few things I really want you to know! What form of EC is most effective Talk to every reproductive age woman at risk for pregnancy about EC Provide EC in advance Support EC to be available over the counter.

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A 27 yo G3 P3, married patient calls your office saying she and her husband noted the condom was broken after sex the night before. What should she do??

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The Setting ~3.0 million unintended pregnancies annually half (48%) of all pregnancies Half (48%) of women aged 15-44 have had an unintended pregnancy Unintended pregnancy is a major public health problem that affects individuals and society Emergency contraception has the potential to reduce unintended pregnancy significantly Source: Henshaw 1998, Trussell et al. 1997

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3 Million Unintended Pregnancies ONE HALF . . . couples using no method of contraception 3 million couples ONE HALF . . . couples using a reversible method imperfectly, or experiencing a method failure24 million couples Source: Henshaw 1998; Abma et al. 1997

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EC: Potential Impact Reduce unintendedpregnancies by 1.5 million Reduce abortions 0.7 million Source: Trussell et al. 1992; Henshaw 1998

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Emergency Options in theUnited States Oral contraceptive pills containing only progestin Oral contraceptive pills containing estrogen and progestin Emergency Copper-T IUD insertion

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Emergency Contraceptive Pills: Combined Regular birth control pills- Yuzpe method Contain estrogen and progestin- at least 1mg of LNG and 200mcg of ethinyl estradiol 2 doses of 2, 4, or 5 pills, depending on brand First dose within 72(120) hours Second dose 12 hours later(or maybe not!) Side effects: nausea (50%) and vomiting (20%) Trussell et al. Women’s Health Prim Care 1998;1:55

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(No longer available) Preven Emergency Contraceptive Pills: Combined

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Emergency Contraceptive Pills: Progestin-only Birth control pills containing only progestin 2 doses of 1 Plan B tablet or 20 Ovrette tablets First dose within 72(120) hours after intercourse Second dose 12 hours later(or maybe not!) Less nausea/vomiting than combined ECPs Task Force. Lancet 1998;352:428

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Emergency Contraceptive Pills: Progestin-only Plan B

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Emergency Copper IUD Insertion Copper-T IUD (ParaGard) Insertion within 5 days after unprotected intercourse 10 more years of highly effective contraception Much more effective than ECPs Not recommended for women at risk of sexually transmitted infections (STIs)

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Copper-T IUD Ortho

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Combined ECP Effectiveness: Single Use 100 women have unprotected sex in the 2nd or 3rd week of their cycle 8 will become pregnant without emergency contraception 2 will become pregnant using combined ECPs (75% reduction) Source: Trussell, Rodríguez and Ellertson 1998

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Progestin-only ECP Effectiveness: Single Use 100 women have unprotected sex in the 2nd or 3rd week of their cycle 8 will become pregnant without emergency contraception 1 will become pregnant using progestin ECPs (88% reduction) Source: WHO 1998

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IUD Effectiveness - Single Use 1000 women have unprotected sex in the 2nd or 3rd week of their cycle 80 will become pregnant without emergency contraception 1 will become pregnant after IUD insertion (99% reduction) Source: Trussell and Ellertson 1995

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Emergency Contraceptive Effectiveness If 1000 women have unprotected sex once in the second or third week of their cycle

Concerns about EC : 

Concerns about EC It’s an abortion pill It will keep woman from using more effective means of contraception and have “risky sex” It’s not safe and can cause serious side effects

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Definition of Pregnancy NIH/FDA Pregnancy encompasses the period of time from confirmation of implantation until expulsion or extraction of the fetus. ACOG Pregnancy is the state of a female after conception and until termination of the gestation. Conception is the implantation of the blastocyst. It is not synonymous with fertilization; it is synonymous with implantation. Source: US Government 1983; Hughes 1972

Mechanisms of Action : 

Mechanisms of Action Inhibit ovulation Trap sperm in thickened cervical mucus Inhibit tubal transport of egg or sperm Interfere with fertilization, early cell division, or transport of embryo Prevent implantation by disrupting the uterine lining

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Does Providing ECPs Increase Risk-Taking? Three randomized trials comparing advance provision vs. education only Use was appropriate Patients did not abandon or decrease the use of their regular contraceptives Decrease in unintended pregnancies

Safety : 

Safety No evidence based contraindications to progestin only ECP or IUDs Four case reports of cerebrovascular accidents with combined ECP

Other issues : 

Other issues How long after is too long? One dose or two? Nausea/vomiting Spotting Starting contraception Menses

How Long After the Morning After? : 

von Hertzen et al, Lancet, 2002, Ellertson et al, Obstet Gynecol, 2003 How Long After the Morning After? Initial recommendations were to administer first dose within 72 hours Several trials have found no decrease in efficacy if given within 120 hours

One dose or two? : 

von Hertzen et al, Lancet, 2002, Ellertson et al, Obstet Gynecol, 2003 One dose or two? Recommendations call for two doses 12 hours apart Studies indicate that giving the same total as one dose is as effective

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Reducing the Risk of Nausea Meclizine significantly reduces the risk of nausea and vomiting associated with the Yuzpe regimen of emergency contraception. Significantly increases the risk of drowsiness. Raymond et al. Obstet Gynecol 2000;95:271

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Spotting Ellertson et al. Obstet Gynecol 6/2003

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Number of Days of Spotting Ellertson et al. Obstet Gynecol 6/2003

Starting contraception after EC : 

Starting contraception after EC Oral contraceptives, patches, and vaginal rings Regular start: use backup until next period, then begin pills/patches/rings according to regular patient instructions Jump start: take 2 ECP doses. Start a new pack of OCs, or use a patch/ring the next day (use backup for first 7 days)

Starting contraception after EC : 

Starting contraception after EC Depo-Provera® Regular start: use backup until next period, then start Depo-Provera according to regular patient instructions Jump start: take 2 ECP doses. Start Depo-Provera the next day (use backup for first seven days)

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Menses after ECP Use Similar for combined and progestin-only regimens Relative to anticipated onset of next menses 13% have a delay of 8+ days 15% have a delay of 4-7 days 61% have menses within ? 3 days 11% have early onset (>3 days early) A follow-up visit is warranted if menses do not return within three weeks following treatment Source: WHO 1998