Reni A. Soon and Tod C. Aeby
History of present illness
A 25-year-old gravida 0 woman presents to the urgent care clinic requesting emergency contraception (EC). She and her boyfriend had intercourse four days prior using a condom, which reportedly“broke.”She states her last menstrual period (LMP) started approximately two weeks prior to today’s visit.
A friend told her about EC and so she came to the clinic as soon as possible. Her medical history is only significant for migraine headaches with aura. She denies any surgical history.
She is on no medications. She smokes socially and drinks one or two alcoholic drinks per week. She is very stressed out about the possibility of getting pregnant.
Physical examination
General appearance:Normal, healthy woman who appears anxious
Vital signs:All within normal limits (BMI: 31 kg/m2) Laboratory studies:Urine pregnancy test: Negative
How would you manage this patient?
A copper intrauterine device (IUD) was recommended to her as the most effective method of EC. Since she declined this method [or if it had been unavailable], the next most effective method of EC was ulipristal acetate (UPA). She should be given a prescription or administered the 30 mg pill in the clinic and advised to either abstain from intercourse or to use condoms for the next 14 days (or until she gets her next menses, whichever comesfirst). She should also be counseled about the importance of initiating additional/alternative contraceptive methods as soon as possible.
Emergency contraception (Table 6.1)
Emergency contraception (EC) is available in four forms: the copper IUD, levonorgestrel emergency contraceptive pills (ECPs), UPA ECPs, and combination estrogen–progestin pills.
There are almost no contraindications to EC, and EC should be considered for any woman presenting with a recent act of unprotected intercourse, or like in this case, a failed form of contraception.
ECPs are pills formulated specifically for use as EC and include UPA and levonorgestrel. UPA is a progesterone receptor modulator that has been shown to reduce the risk of pregnancy up to five days after unprotected intercourse. The mechanism of action of both UPA and levonorgestrel is the
inhibition or delay of ovulation by interfering with the release of luteinizing hormone (LH) from the pituitary. The LH surge is required for ovulation to occur. While levonorgestrel cannot prevent ovulation once the preovulatory LH surge has begun [1], UPA has the additional benefit of preventing follicular rupture even after initiation of the LH surge [1]. This is believed to be the explanation for UPA’s higher efficacy at preventing pregnancy, when compared to levonorgestrel, if the drug is given midcycle during ovulation, when a woman is most fertile.
If ECPs are obtained during the three- to five-day time period after unprotected (or underprotected) intercourse, UPA has again been shown to be more efficacious when compared to levonorgestrel [2]. Furthermore, data from two randomized trials of levonorgestrel and UPA suggest higher failure rates in obese women (BMI>30 kg/m2) for both medications, but the risk of failure is greater with levonorgestrel, when compared to UPA [3]. Overall, it appears that UPA is more effective at preventing pregnancies, especially if the patient is obese or is in her midcycle. Both ECPs, levonorgestrel and UPA, are asso- ciated with slightly higher failure rates than the copper IUD [4].
UPA is available only by prescription in the United States (marketed under the brand name Ella®), and is available as a single 30 mg oral dose. Levonorgestrel can be taken as either two 0.75 mg oral doses (marketed as Plan B®) or one 1.5 mg dose (marketed as Plan B One-Step®). Generic equivalents for both are available. The label on the two-dose levonorgestrel formulations states to take the 0.75 mg tablets 12 hours apart.
Research has shown, however, that the regimen is just as effective if taken as a single dose simultaneously [5], which eliminates the risk of noncompliance with the second dose.
Plan B One-Step is available over-the-counter, and as of June 2013, there are no age restrictions to accessing this medication.
The other formulations of levonorgestrel ECPs are“behind the counter,”available without prescription to anyone aged 17 or older. A single treatment costs between $35 and $60, with generics being only slightly cheaper.
The combined estrogen–progestin (Yuzpe) [6] regimen can be created using conventional combination oral contraceptive pills and is taken in two doses. Each dose must contain at least 100 μg of ethinyl estradiol and 0.5 mg of levonorgestrel; therefore, depending on the pill formulation, each dose would consist of two to six pills. Like with other forms of EC, thefirst dose should be taken as soon as possible but within 120 hours of unprotected intercourse. The second dose is taken 12 hours later [5].
Although the combined estrogen–progestin regimen has not been compared to UPA specifically, it is considered to be Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
less effective than both levonorgestrel (and thus UPA) in preventing pregnancy. It is also associated with more side effects such as nausea and emesis [5], and, for these reasons, the Yuzpe method should be a second-line choice for EC.
Routine use of anti-emetics before taking ECPs is not recommended; however, these medications may be considered, based on clinical judgment. If vomiting occurs within three hours of taking ECPs, another dose of ECPs should be taken and an anti-emetic should be added [7].
The US Medical Eligibility Criteria for Contraceptive Use (USMEC) does not list any medical conditions for which ECPs should be avoided [8], although it does not specifically address UPA as this medication was approved the same year the USMEC was released. Even medical conditions that may preclude the use of combined hormonal contraceptive methods for regular con- traception (migraines with aura–as in our patient–cardiovas- cular disease, liver disease) are not contraindications for ECPs.
The duration of use for the combined estrogen–progestin regi- men as an EC is believed to be too short to incur a negative clinical impact despite a patient’s medical comorbidities [8].
ECPs should, therefore, be offered to any woman who has had unprotected intercourse and does not desire pregnancy [5].
No clinical exams or testing need to be done prior to administration of ECPs [7]. However, because there is some evidence that BMI may affect the efficacy of levonorgestrel more so than UPA, the patient’s weight may be an important consideration. Pregnancy testing is not necessary, as ECPs do not affect a pregnancy once implantation has occurred, and even high-dose oral contraceptives have not been shown to cause birth defects [7].
Because ECPs work by inhibiting or delaying ovulation, patients may be at risk for pregnancy later in the same cycle, and so regular contraception should be encouraged immedi- ately. There is a theoretical concern that hormonal contracep- tives could be affected by the antiprogestin activity of UPA.
Therefore, in addition to advising regular contraceptive initi- ation, it is recommended that patients who take UPA abstain from intercourse or use condoms for 14 days after taking the pill [7]. For patients who take levonorgestrel-based EC, it is
recommended that they abstain from intercourse or use condoms for seven days following EC use. They should also be encouraged to start a regular, reliable contraceptive method as quickly as possible [7].
Though our patient declined this option, the copper IUD is the most effective form of EC [4], and it can be inserted up tofive days after thefirst act of unprotected intercourse that follows the onset of a woman’s normal menstrual flow unless there is concern for pelvic inflammatory disease (PID) and/or purulent cervicitis [8]. If ovulation can be reasonably estimated (certain LMP and regular cycles), the copper IUD could be inserted more thanfive days after unprotected intercourse as long as it has not been more thanfive days after ovulation [7]. A recent systematic review of studies published over 35 years included over 7000 post-coital IUD insertions and found only 10 pregnancies, for a failure rate of 0.14% [4]. Not only is the copper IUD a highly effective form of EC, it has the added advantage of continuing to provide very reliable contraception for up to 10 years.
Because the mechanism of action of UPA is to inhibit or delay ovulation, our patient was counseled about the possibil- ity that she may ovulate later in the cycle and that immediately starting an effective regular method of contraception is critical to preventing an unintended pregnancy. In addition to abstaining for the next 14 days, she decided that she would schedule an appointment with her gynecologist to obtain a contraceptive implant later in the week.
Key teaching points
The copper intrauterine device (IUD) is the most effective method of emergency contraception (EC) and allows a woman to maintain long-acting reversible contraception.
Emergency contraceptive pill (ECP) regimens include levonorgestrel pills, ulipristal acetate (UPA), and combined estrogen–progestin regimens.
All EC can reduce the risk of pregnancy up to 5 days (120 hours) after unprotected or underprotected intercourse. BMI and ovulation timing should be taken into consideration when choosing an ECP
Table 6.1 A suggested approach to women requesting EC
What to assess? Best choices for EC Why?
Time sincefirst act of unprotected or
underprotected intercourse
If occurred between 3 and 5 days ago, consider copper IUD or UPA as best choices
Copper IUD and UPA are more effective than levonorgestrel, particularly if intercourse occurred>72 hours and<120 hours before administration of EC
Where in her menstrual cycle did the unprotected intercourse occur?
If occurred during most fertile time (near ovulation), consider copper IUD or UPA as best choices
Copper IUD and UPA are more effective than levonorgestrel, particularly when sex occurs during the most fertile time in the menstrual cycle
What is her BMI? If she is obese (BMI30 kg/m2), consider
copper IUD or UPA as best choices Effectiveness of copper IUD is not affected by BMI.
Effectiveness of UPA superior to levonorgestrel in obese patients
Can the patient access a
prescription? Yes: UPA
No: Levonorgestrel regimens Levonorgestrel regimens are available for“over-the-counter”
access BMI, body mass index; EC, emergency contraception; IUD, intrauterine device; UPA, ulipristal acetate.
regimen as UPA (which requires a prescription) will be the more effective option.
There are no contraindications to ECPs.
The mechanism of action for ECPs is the delay of ovulation. Patients need to be advised that when using ECPs, regular contraception should also be initiated.
References
1. Gemzell-Danielsson K, Berger C, Lalitkumar PGL. Emergency
contraception–mechanisms of action.
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2. Glasier A, Cameron ST, Fine PM, et al.
Ulipristal acetate versus levonorgestrel for emergency contraception: a randomized non-inferiority trial and meta-analysis.Lancet2010;375:555–62.
3. Glasier A, Cameron ST, 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.Contraception 2011;84:363–7.
4. Cleland K, Zhu H, Goldstuck N, Cheng L, Trussel J. The efficacy of intrauterine devices for emergency contraception:
a systematic review of 35 years of experience.Hum Reprod2012;27(7):
1994–2000.
5. American College of Obstetricians and Gynecologists. Emergency contraception. Practice Bulletin No. 112.Obstet Gynecol2010;115(5):
1100–9.
6. Yuzpe AA, Percival Smith R,
Rademaker AW. A multicenter clinical investigation employing ethenyl estradiol combined with dl-norgestrel as a postcoital contraceptive agent.
Fertil Steril1982;37:508–13.
7. Centers for Disease Control and Prevention. US selected practice recommendations for contraception use, 2013.MMWR2013;62:1–60.
8. Centers for Disease Control and Prevention. US medical eligibility criteria for contraceptive use, 2010.
MMWR2010;59:1–86.
Case 6: A 25-year-old woman requesting emergency contraception