Emergency Contraception N I C E / F S R H G U I D E L I N E S C L I N I C A L K N O W L E D G E S U M M A R Y

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1 Emergency Contraception N I C E / F S R H G U I D E L I N E S C L I N I C A L K N O W L E D G E S U M M A R Y

2 Contraception Contraception11pdf Medical Eligibility Criteria Decision aid / risk discussion (NICE) ption/resources/pda_contraceptionpdf Decision aid (patientcouk)

3 Three Recommended Forms Levonorgestrel (Levonelle 1500) Oral progesterone only Uliprostal Acetate (EllaOne) Selective Progesterone Receptor Modulator Copper IUCD These methods have replaced combined pills

4 Important Points to Consider 1 There is no point in the cycle when it is completely safe to have unprotected intercourse, especially if cycle is irregular Conception is however very unlikely on the first 3 days of the cycle 2 Emergency contraception is not legally considered to be causing abortion 3 Cu-IUD is the most effective form of contraception and should be offered to all women presenting <72 hours

5 Indications When no contraception has been used Following consensual sexual intercourse Following rape or sexual assault When there is contraceptive failure or incorrect use Incorrect use or failure of barrier methods such as the condom, diaphragm or cap Failed coitus interruptus (ejaculation into vagina or on to external genitalia) Miscalculation of the periodic abstinence method or failure to abstain during the fertile period IUCD/intrauterine system (IUS) expulsion (if complete or partial expulsion has occurred or if it is necessary to remove the device mid-cycle and there has been unprotected sexual intercourse (UPSI) within the previous seven days) [5] Whilst using any form of hormonal contraception if intercourse has occurred whilst taking, or within 28 days after taking, enzyme-inducing agents, eg rifampicin, and if no additional barrier methods have been used Following incorrect use or potential failure of hormonal method of contraception

6 Failure of Combined Oral Contraceptive If 2 or more pills have been missed in the first 7 days of the packet and unprotected sexual intercourse (UPSI) has taken place in these 7 days or in the 7-day pill-free interval If 4 or more pills have been missed from the middle of the packet and UPSI has taken place within 7 days of the last missed pill If UPSI takes place without the use of an additional barrier method of contraception within 7 days of an episode of vomiting or severe diarrhoea In all cases, additional barrier methods are needed for 7 days if progestogen-only emergency contraception (POEC) is used, whilst continuing normal pill taking If these 7 days run beyond the end of the packet, the next packet should be started immediately without a break If >2 pills are missed during the last 7 days of the packet, the next packet should be started immediately without a 7-day pill-free interval The pillfree interval will be shorter and the woman will be more protected than usual Emergency contraception is very rarely indicated for pills missed days 15-21

7 Failure of POP If one or more pill has been missed or taken >3 hours late (>12 hours late for Cerazette), and UPSI has occured before 2 further tablets have been correctly taken Additional barrier methods are required for a further 2 days whilst continuing the normal progestogenonly pill regime

8 Failure of Depoprovera UPSI has taken place >14 weeks after the last injection

9 Take a Full History Elapsed time since unprotected intercourse What contraception was used at the time of intercourse, if any Menstrual history: Any other unprotected intercourse this cycle? Could the woman already be pregnant? Any previous use of EC? Gynaecological history (with particular attention to history of pelvic inflammatory disease (PID), current vaginal discharge, ectopic pregnancy) Medications used, eg enzyme-inducing agents such as phenytoin (don't forget over-the-counter enzyme inducers such as StJohn's wort) General health, looking for any contra-indications, eg liver disease, porphyria Sexual history - consider the risk of sexually transmitted infection (STI)

10 Levonelle 1500 Available OTC for >16 year olds Licensed <72 hours Can be used more than once per cycle Safe if patient thinks she may already be pregnant 84% efficacy (<72 hours) 63% efficacy hours recommend IUD Double dose if taking C-P450 inducing meds recommend IUD Side effects: nausea and vomiting repeat dose needed if vomits within 2 hours Resume normal pill within 12 hours and ensure contraception used for remainder of cycle Do not double dose for obese patients

11 Ullipristal Acetate (EllaOne) Inhibits ovulation and affects changes in endometrium to prevent implantation Licensed up to 120 hours 98% efficacy More expensive but the only PO alternative for hours Common side effects similar to LNG plus irregular bleeding and cramps Exclude pregnancy prior to use CI: severe liver disease, severe asthma

12 Copper IUD Inhibits fertilisation and implantation Can be used up to 5 days post UPSI or even 5 days post-ovulation following the episode of UPSI 99% efficacy offer as first alternative to ALL Can be removed after subsequent period if required CI: allergy, Wilsons, distorted uterine cavity Consider Abx prophylaxis and STI screening if possible STI/PID May need to offer oral EC while referral is arranged Best option if taking CP450 inducing drugs

13 Other Considerations Discuss failure rate, and document Give a written advice sheet Explain that their next period unpredictable Explain that they should return for a pregnancy test if they have not had a normal period within seven days of their expected next period or if they have irregular bleeding Should see a doctor immediately if they develop lower abdominal pain (consider the possibility of ectopic pregnancy) More definitive method of contraception for the future Discuss the risk of sexually transmitted infection (STI) Examine and document Fraser-ruling competence if appropriate

14 Fraser Competence Understands Cannot be persuaded to talk to parents Treatment in best interests Would continue having intercourse without Patient s physical / mental health would suffer w/o Consider safeguarding

15 Question 1 A 25-year-old female presents to her GP as she has missed two consecutive Microgynon 30 pills She has taken the Microgynon for the past 5 years and is currently 11 days into a packet of pills Last night she had sexual intercourse with a new partner but unfortunately the condom split What is the correct management? A B C D E Perform a pregnancy test No action needed Advise condom use for next 7 days Emergency contraception should be offered Omit pill break at end of pack

16 Question 1 A 25-year-old female presents to her GP as she has missed two consecutive Microgynon 30 pills She has taken the Microgynon for the past 5 years and is currently 11 days into a packet of pills Last night she had sexual intercourse with a new partner but unfortunately the condom split What is the correct management? A B C D E Perform a pregnancy test No action needed Advise condom use for next 7 days Emergency contraception should be offered Omit pill break at end of pack

17 Pill rules - Combined If one pill is missed, anywhere in the pack The last pill missed should be taken now, even if it means taking two pills in one day The rest of the pack should be taken as usual No additional contraception is needed The 7-day break is taken as normal

18 Pill rules - combined If 2 or more pills missed Take a pill as soon as possible and then continue taking pills daily, one each day The women should use condoms or abstain from sex until she has taken pills for 7 days in a row FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed If pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1 If pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception If pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

19 Pill rules progesterone only When a woman realises she has missed a pill: She should take the missed pill as soon as she remembers and resume her usual pill-taking schedule - even if this means taking two pills on the same day, ie one when she remembers and the next pill on time In addition, if the pill is more than 3 hours late (12 hours with Cerazette) an alternative back-up method is required, eg a condom should be used (or abstinence) for the next 2 days, and consider the need for emergency contraception if there was unprotected sexual intercourse 2-3 days prior to the missed pills, or there has been intercourse since the missed pill(s)

20 Question 2 You are considering prescribing ulipristal (EllaOne) for a woman who has presented requesting emergency contraception How long after unprotected sexual intercourse may ulipristal be used? A B C D E 72 hours 96 hours 120 hours (5 days) 144 hours (6 days) 168 hours (7 days)

21 Question 2 You are considering prescribing ulipristal (EllaOne) for a woman who has presented requesting emergency contraception How long after unprotected sexual intercourse may ulipristal be used? A B C D E 72 hours 96 hours 120 hours (5 days) 144 hours (6 days) 168 hours (7 days)

22 Question 3 A 19-year-old woman presents requesting emergency contraception Last night the condom split She does not use regular contraception and is on day 20 of a 28 day cycle You discuss the intrauterine device but she declines Of the available options, what is the most appropriate action? A B C D E Stat dose of levonorgestrel 750mg + repeat dose levonorgestrel 750mg 12 hours later Stat dose of levonorgestrel 15mg + repeat dose levonorgestrel 15mg 12 hours later Explain she is outside the emergency contraception window and advise her take a pregnancy test if her period is late Reassure her she does not require emergency contraception at this point in her cycle Stat dose of levonorgestrel 15mg

23 Question 3 A 19-year-old woman presents requesting emergency contraception Last night the condom split She does not use regular contraception and is on day 20 of a 28 day cycle You discuss the intrauterine device but she declines Of the available options, what is the most appropriate action? A B C D E Stat dose of levonorgestrel 750mg + repeat dose levonorgestrel 750mg 12 hours later Stat dose of levonorgestrel 15mg + repeat dose levonorgestrel 15mg 12 hours later Explain she is outside the emergency contraception window and advise her take a pregnancy test if her period is late Reassure her she does not require emergency contraception at this point in her cycle Stat dose of levonorgestrel 15mg

24 Question 4 A 23-year-old female has a Nexplanon inserted on day 18 of her 28 day cycle At what point can the Nexplanon be relied upon to provide contraception? A B C D E After 2 days At the end of the next menstrual period Immediately After 7 days At the start of the next menstrual period

25 Question 4 A 23-year-old female has a Nexplanon inserted on day 18 of her 28 day cycle At what point can the Nexplanon be relied upon to provide contraception? A B C D E After 2 days At the end of the next menstrual period Immediately After 7 days At the start of the next menstrual period

26 Time to effectiveness instant: IUD 2 days: POP 7 days: COC, injection, implant, IUS

27 Question 5 You have a telephone consultation at the end of morning surgery A 24-year-old woman has missed her last three Microgynon 30 pills as she went away for the weekend She last had unprotected intercourse around 36 hours ago She is on day 19 of her pack and has otherwise taken Microgynon 30 as prescribed for the past six months What is the most appropriate advice? A B C D E Omit pill-free interval Offer emergency contraception + omit pill-free interval No action needed Use condoms/abstain for 7 days Omit pill-free interval + use condoms/abstain for 7 days

28 Question 5 You have a telephone consultation at the end of morning surgery A 24-year-old woman has missed her last three Microgynon 30 pills as she went away for the weekend She last had unprotected intercourse around 36 hours ago She is on day 19 of her pack and has otherwise taken Microgynon 30 as prescribed for the past six months What is the most appropriate advice? A B C D E Omit pill-free interval Offer emergency contraception + omit pill-free interval No action needed Use condoms/abstain for 7 days Omit pill-free interval + use condoms/abstain for 7 days

29 Pill rules - combined If 2 or more pills missed Take a pill as soon as possible and then continue taking pills daily, one each day The women should use condoms or abstain from sex until she has taken pills for 7 days in a row FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed If pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1 If pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception If pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

30 Question 6 Which one of the following is an absolute contraindication to combined oral contraceptive pill use? A B C D E Concurrent use of St John's Wort Family history of thromboembolic disease in first degree relatives < 45 years Immobility (eg wheelchair use) Migraine with aura Diabetes mellitus (diagnosed 11 years ago)

31 Combined oral contraceptive - contraindications UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method UKMEC 2: advantages generally outweigh the disadvantages UKMEC 3: disadvantages generally outweigh the advantages UKMEC 4: represents an unacceptable health risk

32 Question 7 Which one of the following is an absolute contraindication to combined oral contraceptive pill use? A B C D E 37-year-old woman smoking 10 cigarettes/day 4 weeks post-partum and breast feeding Being a wheelchair user BMI of 43 kg / m^2 Family history of thromboembolic disease in first degree relatives < 45 years

33 Question 7 Which one of the following is an absolute contraindication to combined oral contraceptive pill use? A B C D E 37-year-old woman smoking 10 cigarettes/day 4 weeks post-partum and breast feeding Being a wheelchair user BMI of 43 kg / m^2 Family history of thromboembolic disease in first degree relatives < 45 years

34 Combined Oral Contraceptives Examples of UKMEC 4 conditions include: more than 35 years old and smoking more than 15 cigarettes/day migraine with aura history of thromboembolic disease or thrombogenic mutation history of stroke or ischaemic heart disease breast feeding < 6 weeks post-partum uncontrolled hypertension breast cancer major surgery with prolonged immobilisation

35 UK MEC Guidelines (FSRH 2009) 09pdf Examined repeatedly in AKT

36 Question 8 A 16-year-old female with a history of acne requests to start a combined oral contraceptive pill (COC) She has been taking oxytetracycline for the past 2 months What is the most appropriate advice? A B C D E A double-dose COC should be used Condoms should be used for the first 14 days of COC use She can start using a COC with usual advice A COC is inappropriate and an alternative method of contraception should be considered Condoms should be used for the first 21 days of COC use

37 Question 8 A 16-year-old female with a history of acne requests to start a combined oral contraceptive pill (COC) She has been taking oxytetracycline for the past 2 months What is the most appropriate advice? A B C D E A double-dose COC should be used Condoms should be used for the first 14 days of COC use She can start using a COC with usual advice A COC is inappropriate and an alternative method of contraception should be considered Condoms should be used for the first 21 days of COC use

38 Question 9 Which one of the following is less common in women who take the combined oral contraceptive pill? A B C D E Stroke Endometrial cancer Pulmonary embolism Cervical cancer Ischaemic heart disease

39 Question 9 Which one of the following is less common in women who take the combined oral contraceptive pill? A B C D E Stroke Endometrial cancer Pulmonary embolism Cervical cancer Ischaemic heart disease

40 Advantages of combined oral contraceptive pill highly effective (failure rate < 1 per 100 woman years) doesn't interfere with sex contraceptive effects reversible upon stopping usually makes periods regular, lighter and less painful reduced risk of ovarian, endometrial and colorectal cancer may protect against pelvic inflammatory disease may reduce ovarian cysts, benign breast disease, acne vulgaris (not Dianette increased risk of DVT)

41 Disadvantages of COCP people may forget to take it offers no protection against sexually transmitted infections increased risk of venous thromboembolic disease increased risk of breast and cervical cancer increased risk of stroke and ischaemic heart disease (especially in smokers) temporary side-effects such as headache, nausea, breast tenderness may be seen