Emergency Contraception!

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! 


FURTHER READING! 


*Blog post based on Med-Peds Forum talk by Suzanne McLaughlin, MP Core Faculty