Emergency Contraception - Curbside
Emergency Contraception
Editors: Dan Imler, MD, Sujatha Seetharaman, Paula Hillard, & 1 more...
Inclusion Criteria  (All criteria are present)
  • Female
  • Sexually active, plans to become sexually active, rape or contraception failure
Exclusion Criteria
  • Known or suspected pregnancy

Consider adolecent medicine or OBGYN consultation

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Evidence
Total Notes: 10
Evidence

1 Emergency contraception with a copper IUD

The copper IUD is the most efficacious method of emergency contraception. It also allows for ongoing contraception after the initial event. In studies looking at its effectiveness, the likelihood of preventing a pregnancy is 96-100% up to 5 days after the sexual encounter. In addition, it is even more effective, as compared to oral medications, in overweight/obese women.

Placement of the copper IUD should be avoided if the woman has known, active gonorrhea or chlamydial infection because of the increased risk of pelvic inflammatory disease. However, the copper IUD has been shown safe to insert on the same day as the women presents for emergency contraception, even if STI status is unknown.

Although efficacious, the IUD does need to be inserted by a trained provider within 5 days. However, this option should be presented to women and many family planning and GYN clinics offer same day visits for placements.



References:
  1. Copper T380A intrauterine device for emergency contraception: a prospective, multicentre, cohort clinical trial.
    Wu S, Godfrey EM, Wojdyla D, Dong J, Cong J, Wang C, von Hertzen H,
    BJOG 2010 Sep;117(10):1205-10.
  2. Interventions for emergency contraception.
    Cheng L, Che Y, Glmezoglu AM,
    Cochrane Database Syst Rev 2012;8:CD001324.
  3. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel.
    Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, Gainer E, Ulmann A,
    Contraception 2011 Oct;84(4):363-7.
  4. Emergency contraception with Multiload Cu-375 SL IUD: a multicenter clinical trial.
    Zhou L, Xiao B,
    Contraception 2001 Aug;64(2):107-12.
  5. Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers.
    Harper CC, Speidel JJ, Drey EA, Trussell J, Blum M, Darney PD,
    Obstet Gynecol 2012 Feb;119(2 Pt 1):220-6.
  6. Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing.
    Schwarz EB, Kavanaugh M, Douglas E, Dubowitz T, Creinin MD,
    Obstet Gynecol 2009 Apr;113(4):833-9.
  7. Routine counseling about intrauterine contraception for women seeking emergency contraception.
    Schwarz EB, Papic M, Parisi SM, Baldauf E, Rapkin R, Updike G,
    Contraception 2014 Jul;90(1):66-71.
  8. Emergency Contraception for Adolescents and Young Adults: Guidance for Health Care Professionals
    Society for Adolescent Health and Medicine
    Journal of Adolescent Health, 2016-02-01, Volume 58, Issue 2, Pages 245-248,

2 Levonorgestrel

Levonorgestrel, a progestin, is the most widely available form of EC worldwide and is available over-the-counter (OTC) in many countries. The recommended dose is 1.5 mg ingested as soon as possible after UPIC. Although levonorgestrel is clinically useful up to 5 days (120 hours) after UPIC, its efficacy may decline over this time. Levonorgestrel works by preventing or delaying ovulation and works only up until the luteinizing hormone surge.

Levonorgestrel was more effective than the Yuzpe regimen in preventing pregnancy nd was associated with a lower rate of side effects such as nausea, vomiting, headache and breast tenderness.                                                            

Although efficacy of all types of oral EC medications is reduced in obese women. obesity is not a contraindication for use of oral EC medications. The failure rate for levonorgestrel (5.8%) is greater than for UPA (2.6%) in obese women . Data suggest that levonorgestrel becomes less effective for women with body mass indexes (BMIs) > 25 and ineffective for women with BMIs > 30, whereas UPA becomes less effective for women with BMIs > 30 and ineffective for women with BMIs > 35.

Although the Centers for Disease Control and Prevention (CDC) and the World Health Organization's (WHO) Medical Eligibility Criteria for Contraceptive Use applies contraindications to daily use of hormonal contraceptives in some women based on their medical history, these contraindications do not apply to women seeking emergency contraception.

In particular, cardiovascular disease, thrombophilic disorders, migraine, liver disease, and breastfeeding are considered conditions where the advantages of using the method generally outweigh the theoretical or proven risks.



References:
  1. Emergency Contraception for Adolescents and Young Adults: Guidance for Health Care Professionals
    Society for adolescent health medicine
    Journal of Adolescent Health, , 2016-02-01, Volume 58, Issue 2, Pages 245-248
  2. Mechanisms of action of oral emergency contraception.
    Gemzell-Danielsson K., Berger C., and Lalitkumar P.G.
    Gynecol Endocrinol 2014; 30: pp. 685-687
  3. Glasier A., Cameron S.T., Blithe D., et al: Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel.
    Glasier A., Cameron S.T., Blithe D., et al
    Contraception 2011; 84: pp. 363-367
  4. Interventions for emergency contraception
    AU Cheng L, Che Y, Gülmezoglu AM SO
    Cochrane Database Syst Rev. 2012;8:CD001324.
  5. Emergency contraception
    World Health Organization
    February 2016
  6. Sexual and reproductive health
    WHO publications
    (Accessed on May 30th 2016)
  7. U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Classification for emergency contraception.
    CDC
    (Accessed on May 30th 2016)

3 Ulipristal

UPA, a selective progesterone receptor modulator, is the newest and most effective oral EC product that is currently available in 79 countries. The recommended dose is 30 mg ingested orally as soon as possible after UPIC. UPA is effective up to 5 days after UPIC and does not decline in efficacy over time. UPA works by preventing or delaying ovulation and only works up until ovulation.

Data suggest that levonorgestrel becomes less effective for women with body mass indexes (BMIs) > 25 and ineffective for women with BMIs > 30, whereas UPA becomes less effective for women with BMIs > 30 and ineffective for women with BMIs > 35 . In contrast, the efficacy of the copper IUD for EC is not affected by weight. Nevertheless, if a copper IUD is not available or acceptable to a woman needing EC, UPA is a better option than levonorgestrel for overweight and obese women. There are no data on the variability of mifepristone efficacy by weight.



References:
  1. Emergency contraceptive pills: Medical and service delivery guidelines.

  2. Emergency contraception (Fact sheet no 244). Geneva: World Health Organization, 2012.

  3. Glasier A., Cameron S.T., Blithe D., et al: Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel.
    Glasier A., Cameron S.T., Blithe D., et al:
    Contraception 2011; 84: pp. 363-367
  4. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis.
    AU Glasier AF, Cameron ST, Fine PM, Logan SJ, Casale W, Van Horn J, Sogor L, Blithe DL, Scherrer B, Mathe H, Jaspart A, Ulmann A, Gainer E
    Lancet. 2010;375(9714):555.

4 Pregnancy testing

The rate of ectopic pregnancy when treatment with emergency contraceptive pills does not exceed the rate observed in the general population. Since emergency contraceptive pills are effective in lowering the risk of pregnancy, their use should reduce the chance that an act of intercourse will result in ectopic pregnancy.

A history of ectopic pregnancy is not a contraindication for use of emergency contraception.



References:
  1. Ectopic pregnancy and emergency contraceptive pills: a systematic review.
    Cleland K, Raymond E, Trussell J, et al.
    Obstet Gynecol 2010; 115:1263.

5 Contraindications to copper IUD

Contraindications to copper IUD use include severe uterine distortion, active pelvic infection, copper allergy, and suspected pregnancy. A current history of dysmenorrhea or menorrhagia is a relative contraindication to use of the TCu380A IUD, as the device can worsen these symptoms.



References:
  1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report (MMWR). U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition. Early release - May 28, 2010. (Accessed on May 28, 2016).

  2. Intrauterine device use among women with uterine fibroids: a systematic review.
    Zapata LB, Whiteman MK, Tepper NK, et al.
    Contraception 2010; 82:41.
  3. Contraindications to IUD and IUS use
    Nelson AL.
    Contraception 2007; 75:S76.

6 Emergency contraception

Emergency contraception is the use of medications or devices to avoid pregnancy after coitus and before implantation. It is not developed as a primary or back-up contraception method. In the US between 2006-10 1/9 reproductive aged women used emergency contraception.

Oral EC acts by delaying implantation while IUDs inhibit fertilization by affecting sperm viability and function.



References:
  1. Use of emergency contraception among women agged 15-44: United States, 2006-2010
    Daniels K, Jones J, Abma J
    NCHS Data Brief No. 112.. 2013;
  2. Talking straight about emergency contraception.
    Trussell J, Guthrie KA,
    J Fam Plann Reprod Health Care 2007 Jul;33(3):139-42.
  3. Mechanism of action of emergency contraception.
    Gemzell-Danielsson K,
    Contraception 2010 Nov;82(5):404-9.
  4. Contraceptive efficacy of emergency contraception with levonorgestrel given before or after ovulation.
    No G, Croxatto HB, Salvatierra AM, Reyes V, Villarroel C, Muoz C, Morales G, Retamales A,
    Contraception 2011 Nov;84(5):486-92.
  5. Immediate pre-ovulatory administration of 30 mg ulipristal acetate significantly delays follicular rupture.
    Brache V, Cochon L, Jesam C, Maldonado R, Salvatierra AM, Levy DP, Gainer E, Croxatto HB,
    Hum. Reprod. 2010 Sep;25(9):2256-63.
  6. Effectiveness of levonorgestrel emergency contraception given before or after ovulation--a pilot study.
    Novikova N, Weisberg E, Stanczyk FZ, Croxatto HB, Fraser IS,
    Contraception 2007 Feb;75(2):112-8.
  7. Emergency contraception -- mechanisms of action.
    Gemzell-Danielsson K, Berger C, P G L L,
    Contraception 2013 Mar;87(3):300-8.
  8. Practice Bulletin No. 152: Emergency Contraception.

    Obstet Gynecol 2015 Sep;126(3):e1-11.

7 Starting therapy

There is no requirement for a physical exam or laboratory tests prior to starting oral therapy as emergency contraception. As the time to therapy is so important in emergency contraception and the side effects are so limited, aggressive management of these patients is indicated.



References:
  1. Practice Bulletin No. 152: Emergency Contraception.

    Obstet Gynecol 2015 Sep;126(3):e1-11.

8 Vomiting

Estrogen-progestin regimens have been shown to cause more nausea and vomiting than ulipristal (nausea: 12%) or levonorgestrel (nausea: 24%, vomiting: 9%). However, it is not routine recommended to prophylactically prescribe anti-emetics for ulipristal or levonogestrel. If vomiting occurs within 3 hours however, anti-emetics and repeat dosing is warranted.



References:
  1. Practice Bulletin No. 152: Emergency Contraception.

    Obstet Gynecol 2015 Sep;126(3):e1-11.
  2. Ulipristal acetate for emergency contraception: postmarketing experience after use by more than 1 million women.
    Levy DP, Jager M, Kapp N, Abitbol JL,
    Contraception 2014 May;89(5):431-3.
  3. Prevention and management of nausea and vomiting with emergency contraception: a systematic review.
    Rodriguez MI, Godfrey EM, Warden M, Curtis KM,
    Contraception 2013 May;87(5):583-9.
  4. Meclizine for prevention of nausea associated with use of emergency contraceptive pills: a randomized trial.
    Raymond EG, Creinin MD, Barnhart KT, Lovvorn AE, Rountree RW, Trussell J,
    Obstet Gynecol 2000 Feb;95(2):271-7.
  5. Metoclopramide pretreatment attenuates emergency contraceptive-associated nausea.
    Ragan RE, Rock RW, Buck HW,
    Am. J. Obstet. Gynecol. 2003 Feb;188(2):330-3.

9 Overweight and obese patients

Levonorgestrel and ulipristal emergency contraception may be less effective in overweight or obese women.

 

The data is more robust for decreased effectiveness with levonorgestrel.

for women with a BMI of 26 or over who used progestin-only EC, pregnancy rates were no different than would be expected if they hadn't used EC at all.

 

Ulipristal acetate (ella) appeared to lose effectiveness at a higher BMI threshold of 35.

IUD effectiveness does not appear to be affected.

 

Some new evidence is emerging that may support doubling the dose of progestin-only EC for obese women, but it's not certain whether it would be effective.



References:
  1. Effect of body weight and BMI on the efficacy of levonorgestrel emergency contraception.
    Kapp N, Abitbol JL, Math H, Scherrer B, Guillard H, Gainer E, Ulmann A,
    Contraception 2015 Feb;91(2):97-104.
  2. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel.
    Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, Gainer E, Ulmann A,
    Contraception 2011 Oct;84(4):363-7.


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