Emergency Hormonal Contraception

Emergency contraception

There are two methods currently available in the UK:

Emergency hormonal contraception

There are now two methods of emergency hormonal contraception (’emergency pill’, ‘morning-after pill’); levonorgestrel and ulipristal, a progesterone receptor modulator.

Levonorgestrel

  • should be taken as soon as possible – efficacy decreases with time
  • must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
  • single dose of levonorgestrel 1.5mg (a progesterone)
  • mode of action not fully understood – acts both to stop ovulation and inhibit implantation
  • 84% effective is used within 72 hours of UPSI
  • levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
  • if vomiting occurs within 2 hours then the dose should be repeated
  • can be used more than once in a menstrual cycle if clinically indicated
  • Double the dose for women on liver-enzyme inducing drugs
  • Adverse effects include nausea and vomiting (see below); menstrual irregularities; dizziness; diarrhoea; breast tenderness; ectopic pregnancy (rare)

Ulipristal

  • a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
  • 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
  • concomitant use with levonorgestrel is not recommended
  • may reduce the effectiveness of combined oral contraceptive pills and progesterone only pills
  • caution should be exercised in patients with severe asthma
  • repeated dosing within the same menstrual cycle is not recommended
  • breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
  • Not recommended for women also taking liver-enzyme inducing drugs
  • Vomiting (see below); Mood disorders; Dizziness; Nausea; Abdominal Pain/discomfort; Myalgia/back pain; Breast tenderness; Pelvic pain/Period pain; Fatigue; Ectopic pregnancy (rare)

Problems that may occur include vomiting.  In the case of early (< 3 hours) vomiting, a second dose of hormonal contraception should be given.  Women with persistent vomiting should be offered the IUD copper implant and/or an antiemetic (domperidone).
Intrauterine device (IUD)

  • must be inserted within 5 days of UPSI, or
  • if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
  • may inhibit fertilisation or implantation
  • prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
  • is 99% effective regardless of where it is used in the cycle
  • may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
  • Small risk of pelvic infection, uterine perforation; expulsion of the IUD more common; bleeding (spotting) is very common (usually improves with time); pain is also common (control with simple analgesia/NSAID)

*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication

Other issues to consider when offering emergency contraception

  • Offer STI screen (including HIV)
    • Offer Chlamydia test prior to insertion of IUCD
  • Continuing hormonal contraception
    • Levonorgestrel
      • 7 days for OCP/implant/patch/injection; 2 days for POP
    • Ullipristal
      • 14 days for OCP/implants/patch/injection; 9 days for POP
    • IUCD
      • Not required

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