You are on clinic call. A 19yo woman calls asking for advice. She finished her last pack of birth control pills two weeks ago and did not pick up a refill. Last night she had sex with her boyfriend without using contraception. She does not wish to be pregnant. What can you recommend to reduce her risk of pregnancy?
| options | ulipristal acetate | levonorgestrel | ethinyl estradiol | copper IUD |
| aka | Ella | Plan B, Take Action, Next Choice, My Way | Yuzpe method | Paragard |
| MOA | progesterone receptor agonist/antagonist (delays ovulation) | progestin (delays ovulation) | combined estrogen/progestin (delays ovulation) | copper-eluting (spermicidal) |
| how to get it | Rx or clinic visit; $50 | Rx or OTC; $15-50 | Rx; $10-20 | clinic visit; >$900 |
| efficacy | <2% within 120 hr | 2-2.5% within 72-120 hr | – | 0.09% within 120 hr |
| ADE | HA (18%), nausea (12%), dysmenorrhea (12%), menstrual disturbances (>24%) | nausea (25%), vomiting (10%), dysmenorrhea (12%), menstrual disturbances (>24%) | nausea (50%), vomiting (20%) | menorrhagia (12%), expulsion <1yr (6%) |
WHAT ELSE SHOULD WE CONSIDER?
- There are VERY FEW limiting conditions–check the CDC’s guidance through the MEC app–but there are definitely points to consider!
- For instance, according to the CDC, “frequent repeated use of emergency contraception pills (ECPs) might be harmful for women with conditions classified as 2, 3, or 4 for combined hormonal contraceptive or progestin-only contraceptive use.”
- Also, “ECPs might be less effective among women with BMI ≥30 than among women with BMI <25. Despite this, no safety concerns exist.”
- Other important issues include your patient’s insurance and pharmacy access. For instance, availability of ulipristal varies greatly by location!
WHAT ELSE NEEDS TO BE DONE?
- Repeat dosing? → If you vomit within 3 hours of dosing, then repeat the dose.
- Pregnancy test? → If you go >3wk without your period, then check a pregnancy test.
- Safety?
- STI screening/prevention?
- Follow-up care?
INITIATING CONTRACEPTION AFTER EC
- Levonorgestrel or combined EC:
- Any regular contraceptive method can be started immediately
- Abstain from intercourse or use backup contraception for 7 days
- Next menses may come somewhat sooner
- UPA EC:
- Resume or start hormonal contraception no sooner than 5 days after UPA (or start of next menses, whichever comes first)
- Non-hormonal contraception can be started immediately
- Abstain or use backup contraception for 7 days
- Next menses may come somewhat later
- Advise the woman to have a pregnancy test if she does not have a withdrawal bleed within 3wk
BE THE INFO SOURCE… AND BE A GOOD ONE!
- There are many great sources online: the Center for Young Women’s Health, Planned Parenthood, Bedsider.org, etc
- Studies show that adolescents are more likely to use EC when they have been supplied or prescribed EC in advance of need!
FURTHER READING!
- Raymond EG, Cleland K. Clinical practice. Emergency contraception. N Engl J Med. 2015 Apr 2;372(14):1342-8. doi: 10.1056/NEJMcp1406328. PMID: 25830424.
- Upadhya KK. AAP Committee on Adolescence Policy Statement on Emergency Contraception. Pediatrics;2019;144(6):e20193149
- Cheng L, Che Y, Gülmezoglu AM. Interventions for emergency contraception. Cochrane Database Syst Rev. 2012 Aug 15;(8):CD001324. doi: 10.1002/14651858.CD001324.pub4. Update in: Cochrane Database Syst Rev. 2017 Aug 02;8:CD001324. PMID: 22895920.
- Glasier A, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011 Oct;84(4):363-7. doi: 10.1016/j.contraception.2011.02.009. Epub 2011 Apr 2. PMID: 21920190.
- Cleland K, et al. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod. 2012 Jul;27(7):1994-2000. doi: 10.1093/humrep/des140. Epub 2012 May 8. PMID: 22570193; PMCID: PMC3619968.
- Meyer JL, et al. Advance provision of emergency contraception among adolescent and young adult women: a systematic review of literature. J Pediatr Adolesc Gynecol. 2011 Feb;24(1):2-9. doi: 10.1016/j.jpag.2010.06.002. Epub 2010 Sep 24. PMID: 20869281.
*Blog post based on Med-Peds Forum talk by Suzanne McLaughlin, MP Core Faculty