Emergency contraception

• Faculty of Sexual & Reproductive Healthcare •

Summary of key recommendations

What methods should be offered to women requesting emergency contraception?

• Health professionals should discuss individual need for emergency contraception (EC) and inform women about the different methods with regard to efficacy, adverse effects, interactions, medical eligibility and need for additional contraceptive precautions
• The copper-bearing intrauterine device (Cu-IUD) can be inserted up to 120 hours after the first episode of unprotected sexual intercourse (UPSI) or within 5 days of the earliest expected date of ovulation
• The efficacy of ulipristal acetate (UPA) has been demonstrated up to 120 hours and can be offered to all eligible women requesting EC during this time period. It is the only oral EC licensed for use between 72 and 120 hours
  
• The efficacy of levonorgestrel (LNG) has been demonstrated up to 96 hours; between 96 and 120 hours efficacy is unknown. Use of LNG beyond 72 hours is outside the product licence
  
• If a service or health professional is unable to provide a method of EC, local referral mechanisms should facilitate timely access to a service that can provide the woman's preferred method
  
• Ideally an emergency intrauterine device (IUD) should be inserted at first presentation, but where this is not possible oral EC can be given in the interim, and the woman advised to return at the earliest appropriate time

Future/ongoing contraception

• Women should be advised that oral EC methods do not provide contraceptive cover for subsequent UPSI and that they will need to use contraception or refrain from sex to avoid further risk of pregnancy
  
• If a woman is likely to continue to be at risk of pregnancy or has expressed a preference to start contraception immediately after EC, a health professional may 'quick start' combined hormonal contraception (excluding co-cyprindiol), the progestogen-only pill (POP) or implant, providing the woman has been appropriately informed and advised to have a pregnancy test in ≥3 weeks
  
• Women requesting the progestogen-only injectable after EC should ideally be offered an alternative method until pregnancy can be excluded. The injectable should be started immediately only if other methods are not appropriate or acceptable and the woman has been appropriately informed and advised to have a pregnancy test in ≥3 weeks
  
• Following administration of LNG, women continuing to use a hormonal method of contraception should be advised to use additional contraceptive precautions for 7 days (2 days for POP, 9 days for estradiol valerate with dienogest)
  
• Following administration of UPA, women continuing to use a hormonal method of contraception should be advised to use additional contraceptive precautions for 14 days (9 days for POP, 16 days for estradiol valerate with dienogest)

Drug interactions

• Women taking liver enzyme-inducing drugs (or who have stopped taking this medication within the last 28 days) should be advised that a copper-bearing intrauterine device (Cu-IUD) is the only method of EC not affected by these drugs
• Women taking liver enzyme-inducing drugs, including post-exposure HIV prophylaxis after sexual exposure (or who have stopped within the last 28 days), and who decline or are not eligible for a Cu-IUD, should be advised to take a dose of 3 mg LNG as soon as possible within 120 hours of UPSI (outside the product licence). The efficacy of LNG after 96 hours is uncertain
  
• Women taking liver enzyme-inducing drugs should be advised not to use UPA during or within 28 days of stopping taking this medication
  
• Women should be advised not to use UPA if they are currently taking drugs that increase gastric pH (e.g. antacids, histamine H2 antagonists and proton pump inhibitors)

Side effects

• Women should be advised to seek medical advice if they vomit within 2 hours of taking LNG or 3 hours of UPA administration. A repeat dose of the same method or a Cu-IUD may be offered if appropriate
  
• Women should be advised about menstrual disturbances after oral EC use. If there is any doubt about whether menstruation has occurred, a pregnancy test should be performed ≥3 weeks after UPSI has occurred

Multiple use in the same cycle

• LNG can be used more than once in a cycle or for a recent indication even if there has been an earlier episode of UPSI outside the treatment window (>120 hours)
• The CEU does not currently support use of UPA more than once per cycle or if there has been another episode of UPSI outside the treatment window (>120 hours)

Clinical examinations and investigations

• Women attending for EC should be offered the opportunity to undergo testing for sexually transmitted infections (STIs) including HIV
• For women at risk of STIs, if test results are unavailable before IUD insertion, health professionals should consider prophylactic antibiotics at least to cover Chlamydia trachomatis

Advance provision

• Health professionals should inform women about availability of EC and when it can be used. Advance supply may be considered but there is no evidence to support routine provision

full guidelines available from…
Faculty of Sexual & Reproductive Healthcare
http://www.fsrh.org

Faculty of Sexual & Reproductive Healthcare Clinical Guidance: Emergency contraception (August 2011)