EMERGENCY CONTRACEPTION (EC) - SOM - State of Michigan



EMERGENCY CONTRACEPTION (EC)DEFINITIONEmergency contraception (EC) refers to the contraceptive options that can decrease the risk of pregnancy after intercourse but before the establishment of a pregnancy. These methods can be used after intercourse when no contraception was employed (i.e., unprotected intercourse [UPI]), a method was used imperfectly (i.e., a condom slipped or broke, pills or injection was missed), or sex was forced without use of contraception. Options include the copper IUD, with a pregnancy rate of 0.1% if placed within 5 days of unprotected intercourse. It prevents fertilization and may prevent some pregnancies after fertilization. Hormonal methods of EC include ulipristal acetate (UPA) (Ella?) and levonorgestrel (LNG) EC (Plan B One Step? and several generic versions such as Econtra EZ and Next Choice?). These medications prevent or delay ovulation. They do not cause abortion, harm an established pregnancy, or increase the risk for ectopic pregnancy. UPA is the most effective, with a pregnancy rate of 1.3% if taken within 5 days (120 hours). LNG, if taken within 72 hours, has a pregnancy rate of 2.2%. ECPs may be less effective among women with a body mass index (BMI) ≥30 kg/m2 than among women with a BMI <25 kg/m2. The Cu-IUD or theUPA regimen is recommended for obese women however women should never be denied access to ECPs due to higher weights or BMI. (Note: the probability of clinical pregnancy after unprotected intercourse ranges from 0% to 9.7%, based on the time of intercourse relative to the day of the menstrual cycle.) SUBJECTIVEMust include:Reproductive Life PlanIf acute need for EC:LNMP and menstrual history.History of any unprotected acts of intercourse since LNMP.Including time of last unprotected intercourseLactation statusCalculation of BMI, as indicated, LNG ECPs might be less effective among women with BMI≥26 kg/m2 than among women with BMI ≤25kg/m2 UPA ECPs might be less effective among women with BME≥35If prescription is being given in advance of need:Couple with using a method which might not be correctly and consistently usedClient interested in having EC available in case of needZika Risk Assessment- As per current CDC guideline- and partner(s)Past travel – where and whenPlans for future travel –where and whenAssessment of contraindications:PregnancySymptoms of pregnancy, unless pregnancy test negativeIf considering copper IUD, any US MEC category 4 condition for IUD placement (See IUD Protocol)OBJECTIVEMust include:Assessment of contraindications:PregnancyUSMEC category 4 condition for method of EC being consideredLABORATORYMust include:For acute need:Using copper IUD or UPA (Ella): Negative sensitive urine pregnancy test.Using LNG-EC: Negative sensitive urine pregnancy test needed only for women with:Signs or symptoms of pregnancy Delayed menses Earlier episodes of unprotected intercourse which could have resulted in established pregnancyFor advance prescriptions of EC:LNG-EC: No pregnancy test neededUPA (Ella): Client must be able to perform home pregnancy test or come to clinic for testingASSESSMENTClient at risk for unwanted pregnancy who is a candidate for EC.PLANAcute need for EC. Try to establish why the client’s method did not work and attempt to prevent repetition.Copper T-380A IUD is the preferred method for all women without US MEC category 3 or 4 conditions to its use. Use of the copper IUD as EC is off-label. A pregnancy test should be performed prior to placement for documentation. No back-up method is needed after IUD placement. If the client is interested in using the copper IUD for EC, follow steps outlined in the protocol Identification of Intrauterine Device (IUD) Candidate.Note: The copper T380A IUD has many important features for EC:can be placed up to 120 hours after coitus.is the most effective method of EC especially for client’s who are obese. (failure rate of about 0.1 – 0.7%)is immediately effective as an ongoing method.no back-up method is needed. Hormonal EC. For women who do not choose the copper IUD for EC, recommendation for EC should be based on client preference, client BMI and time since intercourse. There are 3 options available for hormonal EC:Ulipristal acetate (UPA)(Ella) 30mg tablet taken orally once. A pregnancy test should be performed prior to use for documentation. Allow at least 5 days before initiating CHCs, POPs, Implants, DMPA, or LNG IUC after UPA (Ella) has been taken. Advise abstinence or back up method for 14 days.Note: UPA (Ella) has many important features for EC:Can be taken up to 120 hours after coitus on labelIs more effective than LNG EC; may be more effective than LNG EC for women with BMI>26 kg/m2 Efficacy does not diminish with time since coitus within 120 hours Works by inhibiting ovulation up to the time of follicle rupture. It has no impact on implantation.LNG EC (1.5 mg) taken as one dose orally (preferred dosing), or as 2 tablets LNG EC (0.75 mg) taken one tablet orally 12 hours apart. LNG-EC can be taken on label up to 72 hours after intercourse and off-label up to 120 hours following intercourse. Pregnancy testing is not necessary unless symptoms or history suggest the need. Note: LNG EC is not as effective as UPAEspecially in overweight and obese women Especially if taken more than 12 hours after intercourse Its efficacy diminishes rapidly with time since intercourse, so advance prescription for future use is helpful.LNG-EC works by ovulation suppression up to the beginning of the LH surge.LNG-EC is available both by prescription and over the counter for women of all ages. Clients should understand that insurance will not cover the cost without a prescription. Men can also purchase LNG-EC over the counter without age restriction.Refer to Contraceptive Technology, 21st edition (page 331) if combined oral contraceptive pills are used for emergency contraception.If a woman does become pregnant despite use of EC, the risk of ectopic pregnancy is slightly higher than background rates. Advance prescription of EC.In general, the LNG-EC products are best for this application. Provide client with product or give her a prescription that she should fill at once to have on hand. Insurance will probably cover at least part of the cost if she has a prescription. If possible, write for several refills.Advise her to keep her EC in a readily accessible site.Remind her to use EC as soon as possible following unprotected or inadequately protected sex.Ask her to request new prescription whenever she runs out or if the product expires.Let client know that LNG-EC products are available at pharmacies without a prescription, but she will have to pay full price to purchase the product if she does not have a prescription.UPA (Ella) may be provided by prescription in advance of need, but make sure client understands she should do a home pregnancy test before she starts UPA (Ella), to document that she is not pregnant. Because there are no adequately and well controlled studies in pregnant women, it is not clear if UPA (Ella) could have an adverse impact on an established pregnancy. UPA (Ella) –breastfeeding is not recommended for 24 hours after taking UPA because it is excreted in breast milk, with highest concentrations in the first 24 hours, and maximum maternal serum levels are reached 1-3 hours after administration. Mean UPA concentration in breast milk decreases markedly from 0 to 24-48 hours and then slowly decrease over 5 days. Breast milk should be expressed and discarded for 24 hours after taking UPA. Repeated use of ECIf using UPA (Ella), it is advised not to repeat use within the same menstrual cycle as safety and efficacy of repeat use within the same cycle has not been evaluated.If using LNG EC, there is no restriction on repeated use, however, client needs to be advised that EC is not a highly effective form of ongoing contraception. UPA (Ella) and LNG EC should not be taken within 5 days of one another.CLIENT EDUCATIONIf client uses copper IUD, provide client education from protocol Identification of Intrauterine Contraceptive (IUC) Candidate and Placement of Intrauterine Contraceptive.If she uses any hormonal EC, reinforce that hormonal EC works best if taken as soon as possible after unprotected or inadequately protected intercourseIf she uses ulipristal acetate: UPA (Ella)Advise that this is the most effective hormonal EC.Women starting hormonal birth control method (CHC, POP, Implant, DMPA, LNG IUC) should wait at least 5 days after UPA (Ella) to start methoduse back up method for 14 daysFor women who do not use LARC or hormonal methods advise using a back-up method for 14 days.Advise client of the possible risk of very early pregnancy and recommend repeating urine pregnancy test in 3 weeks.If she uses LNG-EC, advise her thatLNG EC works best if taken within 12 hours of intercourse.LNG EC may be used for up to 120 hours after exposure, but pregnancy rates are much higher when it is used that late.Advise her to resume use of her primary method of contraception immediately and to use backup method for 7 days following EC.Caution her that the LNG-EC may not work as well in overweight women and may not be effective for obese women.Advise her to return for pregnancy testing if her menses does not start within 2 weeks or if symptoms of pregnancy develop.Tell her that all hormonal methods of EC work only to block ovulation. They are not anything like an abortion. They are contraceptives.Advise client that hormonal EC will not work if she is already pregnant. Inform her that if she has conceived less than 10 days ago, the pregnancy test may not be able to detect that pregnancy at this time.Review mechanisms of action. Hormonal EC does not cause abortion but suppresses ovulation. It is a contraceptive. LNG EC will not harm a fetus if the woman uses it while she is pregnant.Describe temporary common side effects with hormonal EC:Irregular bleeding or spotting.Change in onset of next menses.Short term headache, bloating, breast tenderness and other hormonal side effects.Nausea and/or vomiting. Tell client that nausea may occur, especially with estrogen- containing pills; incidence significantly lower with levonorgestrel EC than with conventional pills. Nausea may be reduced if pills are taken with food. If vomiting occurs within 2 hours of taking hormonal EC, consider an additional dose. Reinforce concept that hormonal EC is for emergency use only and should not be considered a primary method of contraception.Advise that hormonal EC will not protect her from any future acts of unprotected intercourse. She should resume an ongoing method as instructed.Reinforce with client that hormonal EC is not perfect. Remind client to get pregnancy testing if she has had no menses in 3 weeks after using hormonal EC.For client getting EC ahead of time (advanced prescription):Advise her that some pharmacies may not rapidly fill prescription.Recommend she have prescription filled soon and keep EC readily available.Instruct client to check for expiration date and to review instructions on how to use.Remind client that EC is not effective if she is already pregnant.Reinforce need to promptly resume ongoing method after using LNG-EC and to use backup methods. EC will not protect her from additional acts of unprotected intercourse.Remind women planning to get Ella in advance of need that they should have a pregnancy test before they start Ella. Instruct client that EC will not protect against STDs and Zika Virus transmission.Zika virus education and prevention strategies Avoid traveling to impacted areasAvoiding mosquito bites if traveling to impacted areasUsing condoms to prevent transmission of virusAvoiding pregnancy if infected or partner infectedRisk to unborn fetus REFER TO MD/ERNoneREFERENCESACOG Practice Bulletin No. 152: Emergency contraception. Obstet Gynecol. 2015; 126: e1-11.Centers for Disease Control and Prevention. U.S. medical eligibility criteria for contraceptive use, 2016. Available at for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. Available at RA, et al (editors). Contraceptive Technology, 21th Ed. New York: Ayer Company Publishers, Inc. 2018; 329-365Centers for Disease Control and Prevention (CDC). Zika Virus Homepage-: 2020 ................
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