dr lynda turner june 2015. honorarium from hra pharma
TRANSCRIPT
By the end of the session you will be able to:
1. Describe the methods and effectiveness of all methods of
emergency contraception.
2. Recognise where there is a risk of pregnancy and advise
appropriately
3. Specify key points in history taking, counselling and follow up
for safe and effective use of EC.
4. Identify needs for future contraception and when this can be
started as well as any risk of STI and advise appropriately
Learning objectives.
Use of any drug or device after unprotected sexual intercourse to prevent an unintended pregnancy
Acts prior to implantation – pregnancy begins at implantation, therefore EC is not an abortifacient
Implantation is assumed to occur no sooner than 6 days after ovulation
What is emergency contraception?
Ovum survives 24-36 hour. Sperm can survive up to 7 days (in the uterus) Where in cycle sex occurs from 8% risk early in
cycle to 36% on day of ovulation. Drops rapidly following ovulation
Fertility of both partners (unknown)
There is no time in the cycle when you can withhold emergency contraception on physiological
grounds
Factors Influencing Risk of Pregnancy following unprotected sex
What is currently available? How do they work? How effective are the methods?
Emergency contraception
Copper IUD
Levonelle (Levonorgestrel 1.5mg)
ellaOne (Ulipristal acetate 30mg)
What is currently available?
Best method of EC - more than 99% effective Spermicidal/toxic to ovum – prevents
fertilisation Also has some anti-implantation effect Can be fitted up to 120hrs (5 days) after UPSI
or within 5 days of the earliest predicted date of ovulation.
Offer all eligible women IUD as most effective EC Method
Copper IUD
Selective progesterone receptor modulator
Primary mode of action –inhibition or delay of ovulation
Can prevent ovulation after the LH surge has started, delaying follicular rupture for up to 5 days
Licensed for up to 120hrs after UPSI
ellaOne
Progestogen Thought to delay or inhibit ovulation If taken prior to the LH surge can result in
ovulatory dysfunction in the subsequent 5 days NO better at suppressing ovulation than placebo
when given immediately prior to ovulation Licensed for use for 72hrs after UPSI Shown to be effective up to 96hrs after UPSI
Levonorgestrel 1.5mg
How do EHCs work?Both Ulipristal acetate and levonorgestrel act by delaying
ovulation:1
Ulipristal is effective even after onset of the LH surge2
• levonorgestrel has been shown to be no better than placebo at inhibiting ovulation when given immediately prior to ovulation1
• Ulipristal is effective right up to the point of ovulation, even if lutenising hormone (LH) levels have already begun to rise1,2
References: 1. Emergency Contraception. Clinical Effectiveness Unit. Faculty of Sexual & Reproductive Healthcare Clinical Guidance. Available at fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf. Last accessed January 2012. 2. Brache V et al., Hum Reprod 2010; 25: 2256–63.
⌂Ulipristal
Fig 1 Window of action of different emergency contraceptive methods in relation to ovulation.
Prabakar I , Webb A BMJ 2012;344:bmj.e1492
©2012 by British Medical Journal Publishing Group
Pregnancy Less than 4 weeks postpartum Undiagnosed vaginal bleeding Gynae cancers – Cervical, Endometrial, Ovarian Acute Pelvic infection Any congenital or acquired uterine abnormality
causing distortion of the uterine cavity eg fibroids
Contraindications to Cu IUD
FSRH Clinical Guidelines on EC does not identify any medical condition that limits the use of Levonorgestrel 1.5mg
Levonorgestrel 1.5mg
Precautions◦Use in women with severe asthma treated by
oral glucocorticoids is not recommended
◦Breast feeding women must not breast feed for 1 week after taking ellaOne 30mg
ellaOne 30mg
Discuss fitting procedure Discuss possible side effects Can be removed AFTER next period if preferred Can continue with IUD for 5 -10yrs STI screen and prophylactic antibiotics will be
offered Give EHC even if IUD going to be fitted by GP or
other service
Cu IUD – information to client
Safety profile of oral EC
References: 1. Glasier AF et al., Lancet 2010; 375: 555–62. 2. HRA Pharma UK Ltd. ellaOne® 30 mg tablet Summary of Product Characteristics.
Prescribing information is available on slide 19.
Ulipristal
Nausea Vomiting 1% - if within 2hrs of taking LNG or 3hrs
of taking ellaOne further dose required Headache Both can affect timing of next menstrual period Do pregnancy test if not had a normal menstrual
period 3 weeks after UPSI
Adverse effects of ellaOne and Levonelle
Liver enzyme inducing medications used currently or up to 28 days previously◦ e.g. rifampicin, phenytoin, phenobarbital, carbamazepine, St John’s wort
(Hypericum perforatum)
Products that increase gastric pH taken in the preceding 24hours◦ e.g. proton pump inhibitors, antacids, H2-receptor antagonists
Use in women with severe asthma treated by oral glucocorticoids is not recommended
ellaOne may interfere with oestrogen and progestogen methods of contraception including Levonelle
Potential drug interactions for ellaOne
Liver enzyme inducing medications used currently or up to 28 days previously◦ e.g. some antiepileptic drugs, some treatments for TB and HIV
and some herbal remedies eg St John’s wort
For this group, the best choice EC is Copper IUD
If declined or contraindicated, you can use double dose Levonelle (off licence)
Potential drug interactions for Levonelle
Has no effect on future fertility Does not interrupt an established pregnancy If mistakenly given in early pregnancy, does not
harm a developing foetus Does not protect against STIs Does not provide contraception for further UPSI in
the days after EHC has been taken
Facts about Emergency Hormonal Contraception
When no contraceptive method used When failure or potential contraceptive failure of
method used – e.g.◦Split or slipped condom◦ Forgotten progestogen only pills◦ Forgotten combined pills or patch or ring◦When Depo-provera late◦ IUD/IUS expelled or expired◦Nexplanon expired
When should EC be used?
Was any method of contraception used? If yes, reason for failure/potential failure of method? First day of LMP Cycle length (if variable, shortest and longest) When did they last have UPSI? Were there any other episodes of UPSI in current
cycle? EC previously used this cycle? Medical history Drug history including any OTC Allergies
What EC options are suitable for this client?
POP◦ >27 hours since last POP (Micronor, Noriday, Norgeston)
and UPSI in next 48 hours◦ >36 hours since last desogestrel only pill (Cerelle and
Cerazette) and UPSI in next 48 hours Depo-provera◦ Late injection (>14 weeks) and UPSI after this time.
Indications for EC
FSRH Clinical guidance on missed pills 1 pill can be missed anywhere in the pill pack with
no need for extra protection or EC If 2 pills or more are missed, then extra protection
should be used for 7 days and EC may be required
Missed COC Pills
Need to think hard about pills missed in week 1 and week 3◦Pills 1-7 Consider EC if UPSI (including in PFI) if 2 pills
missed.After EC continue pills and use condoms for 7 days if LNG taken and 14 days if UPA taken
◦Pills 8-14 No need for EC if UPSIContinue pills and use condoms for 7 days
◦Pills 15-21 No need for EC if UPSI but continue pills, avoid PFI and use condoms for 7 days
Missed COC pills – minimising the risk of pregnancy
EC Option COCP POP QLAIRA
LNG 7 days 2 days 9 days
UPA 14 days 9 days 16 days
Quick starting hormonal contraception after oral EC – how long is barrier contraception needed?
FSRH Quick starting contraception 2010
ellaOne SmPC instructions"If a woman wishes to start or continue using hormonal contraception, she can do so after using ellaOne, however, she should be advised to use a reliable barrier method until the next menstrual period".
Assessing the risk of pregnancy Discuss the EC options appropriate for the
circumstances STI risk assessment Any other issues to consider? e.g. Fraser competent, Safeguarding. Was sex consensual? Drugs / alcohol involved? Ongoing contraception Arrange follow up for further STI screening and
Pregnancy Testing
Key points for EC Consultation
3 methods of EC – Levonelle, ellaOne and Cu IUD. Cu IUD is the most effective Always check medical eligibility for EC Always ask about medications taken including OTC,
which may make oral EHC less effective. Always address ongoing contraception STI risk assessment is an essential part of EC
consultation. Use this opportunity to explore any issues relating to non-
consensual sex, sexual assault or abuse and domestic violence
Session Key Points