Appendix 7C - EMERGENCY CONTRACEPTION
Sexual Health Service
Patient requesting emergency contraception (EC)
• • • • •
Take full medical, contraceptive, sexual, menstrual, lifestyle / social history, incl. STI risk assessment Exclude existing pregnancy and medical contraindications to various EC methods Check whether current/recent use of enzyme inducing drugs Check whether client has used hormonal emergency contraception (HEC) in this cycle already Establish: o Number of episodes of unprotected sexual intercourse (UPSI) in this cycle o Timing of earliest & most recent UPSI in relation to last menstrual period (LMP) o Timing of intercourse in relation to incorrect contraception use, incl. sex in pill/patch/ring free week o Earliest possible date of ovulation (= 14 days before period, based on shortest possible cycle) o Timing of earliest & most recent UPSI in relation to earliest possible date of ovulation
Reassurance
EC not required
EC not suitable
EC required
PT in 3 weeks ←
Less than 5 days since earliest UPSI
More than 5 days since earliest UPSI
Discuss hormonal EC & Copper-IUD
Copper-IUD preferred / more suitable
Hormonal EC preferred option Up to 72 hours since earliest UPSI
72 - 120 hours since earliest UPSI
Levonorgestrel (Levonelle)
Ulipristal (EllaOne)
• Probably most effective EC method. • Also provides ongoing contraception. • Most suitable method if on enzyme inducers. • May be inserted:Up to 5 days (120 hours) after 1st UPSI. Up to 15 days after st 21 COC taken if prior correct COC use. If timing of ovulation can be estimated an IUD may be inserted more than 5 days after UPSI, if still within 5 days of earliest possible ovulation. • If separate appointment for insertion needed, give interim hormonal EC. • Consider prophylactic Azithromycin if STI risk. • If requested remove CuIUD with next period or when no pregnancy risk & start alternative method. •
• May use more than once in cycle*. • Efficacy demonstrated up to 96 hours (if >72 hours = off-label use). • Efficacy between 96 – 120 hours not known.
• More effective & expensive than Levonelle . • Should only be used once per cycle. • Based on clinical judgement consider use before 72 hours, eg midcycle, teenagers. • Do not use >120 hours after UPSI.
Other factors that may influence choice of hormonal EC method
* off-label use
If EC given because of UPSI:• Advise condom use for remainder of cycle. Discuss ongoing contraception & provide method. • Consider ‘quick-starting’* ongoing hormonal contraception (= starting method at time of giving EC). • Advise additional condom use as outlined below (see below). Advise to have PT in 3 weeks.
If EC given because hormonal contraception failure:• Continue with Combined Hormonal Contraception (CHC = COC, Evra, Nuvaring) or
Progestogen-only method (POM = POP, DMPA, contraceptive implant). • Advise additional condom use as follows: a) If Levonelle used: 7 days if CHC failure**, 2 days if POM failure, 9 days if missed Qlaira b) If EllaOne used: 14 days if CHC failure **, 9 days if POM failure, 16 days if missed Qlaira • With either EC (a & b) advise to have PT in 3 weeks.
If current enzyme inducing drug (EID) use:-
•
•
• Double dose of Levonelle*. Avoid EllaOne while on/within 28 days of EID use. Consider Cu-IUD.
If breast feeding: Can use Levonelle. Avoid breastfeeding for ≥36 hours after EllaOne. Don’t use Levonelle and EllaOne in same cycle (unless previous EllaOne use with repeat UPSI in same cycle, but Cu-IUD insertion not appropriate or declined → give Levonelle *).
PT = Pregnancy test SPC = Summary of Product Characteristics
All EC methods: • Full counselling, incl. side effects, action to be taken if vomiting within 2-3 hours (hormonal EC only), etc. Guideline Author: Dr. Karin Piegsa Revised: July 2013 Date:as July 2016 approved: August 2013 • Provide written information. • STI testing as appropriate. •Review Follow-up appropriate. •ADTC Accurate documentation.
Sexual Health Service
EMERGENCY CONTRACEPTION (EC) Emergency Contraception Efficacy Method Copper IUD Levonelle ≤ 96 hrs
Unprotected sexual intercourse (UPSI) Coitus interruptus / ejaculation on external genitalia Potential barrier method failure Potential hormonal method or IUD/IUS failure
Pregnancy Rate (%) < 1% ~1-3% Advisable to give asap after UPSI
Levonelle 96-120 hrs EllaOne
Indications for Emergency Contraception (EC)
Efficacy unknown
Contraindications / drug interactions / side effects etc.
~1-2% Consistently low failure up to 120 hrs
Check summary of product characteristics (SPC)
Potential indications for Emergency Contraception (adapted from SPCs and FSRH Guidelines) Combined Oral Contraception Pill (COC) •
•
Potentially lengthened pill free interval (PFI) due to two or more missed COC*/** (i.e. >48 hrs since last COC), eg: a) Missed COC in first week of pill taking & UPSI in the pill-free interval or in first week of pill packet b) Missed COC in last week of packet and next packet st not started immediately & UPSI after 1 late pill But EC usually not required if pills missed midpacket, if first 7 and next 7 pills taken correctly! While on liver enzyme inducing drugs (incl. St John’s Wort) and for 28 days after stopping them
Note: No conclusive evidence that broad spectrum antibiotics actually reduce effectiveness of CHC!
Progestogen-only pill (POP) • •
•
Depo-Provera (DMPA) •
* Similar situation may arise if prolonged vomiting / severe diarrhoea! ** Different advice for missed Qlaira COC → check SPC!
Combined Transdermal Patch (Evra ) •
•
Late patch application (>48 hours) or patch detachment (>48 hours) a) in first week of patch taking cycle & UPSI in the st patch-free interval or in 1 patch week nd rd b) in 2 or 3 week of patch taking cycle & UPSI in previous few days before and 7 days after See COC for advice regarding interacting drug use
John’s Wort) and for 28 days after stopping them
Intrauterine devices (Copper IUD and Mirena IUS) •
Time expired IUD or IUS (> 5-10 years since insertion, depending on type of device)
•
Partial/complete expulsion of Mirena IUS If previous amenorrhoea with IUS → EC to be initiated within 5 days of expulsion If regular cycle with IUS → manage like copper-IUD
•
Partial/complete expulsion of copper-IUD EC to be initiated within 5 days of earliest calculated day of ovulation
Intra-vaginal ring (Nuva Ring ) • Ring removal or expulsion for > 48 hours
•
Extended use > 4 weeks (e.g. late insertion or removal) General assessment and advice regarding need for EC broadly similar to COC or Evra – see above Check FSRH CEU EC Guidance for further details
Late Depo-Provera injection >12 weeks + 5 days ago (SPC advice) >14 weeks ago (FSRH & WHO advice)
Nexplanon • Time expired implant (> 3 years since insertion) • While using liver enzyme inducing drugs (incl. St
• •
Traditional POP taken > 3 hours late (i.e. >27 hours since last POP) & UPSI in the following 48 hours Desogestrel containing POP (Cerelle, Cerazette®) taken > 12 hours late (i.e. >36 hours since last POP) & UPSI in the following 48 hours While on liver enzyme inducing drugs (incl. St John’s Wort) and for 28 days after stopping
Further Information 1. Faculty of Sexual & Reproductive Health (FSRH): www.fsrh.org.uk Clinical Effectiveness Unit (CEU) Guidances on various contraceptive methods, incl. Emergency Contraception and Guidelines on Missed COC & POP and Late Depo-Provera (DMPA) UK Medical Eligibility Criteria for Contraceptive Use (UKMEC 2009 / 2010) 2. Summary of Product Characteristics (SPC) for Levonelle and EllaOne 3. British National Formulary (BNF): www.bnf.org 4. Fife Area Drug & Therapeutic Committee. Website: www.fifeadtc.scot.nhs.uk Sexual Health Service: Tel. 01592 647979 (Appointments) Tel. 01592 729294 (Advice line for health professionals) Guideline Author: Dr. Karin Piegsa
Revised: July 2013
Review Date: July 2016
ADTC approved: August 2013
Appendix 7C - EMERGENCY CONTRACEPTION
Sexual Health Service
ADVICE FOLLOWING MISSED COMBINED ORAL CONTRACEPTION PILLS (COC) From: Faculty of Sexual & Reproductive Health (FSRH) Clinical Effectiveness Unit Guidance ‘Missed Pill Recommendations’ (May 2011).
If one pill has been missed (more than 24 hours and up to 48 hours late)
If two or more pills have been missed (more than 48 hours late)
CONTINUING CONTRACEPTIVE COVER
CONTINUING CONTRACEPTIVE COVER
•
The missed pill should be taken as soon as it is remembered.
•
The most recent missed pill should be taken as soon as possible.
•
The remaining pills should be continued at the usual time.
•
The remaining pills should be continued at the usual time.
•
Condoms should be used or sex avoided until seven consecutive active pills have been taken. This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed.
MINIMISING THE RISK OF PREGNANCY Emergency contraception (EC) is not usually required but may need to be considered if pills have been missed earlier in the packet or in the last week of the previous packet.
MINIMISING THE RISK OF PREGNANCY If pills are missed in the first week of pill taking (Pills 1–7)
If pills are missed in the second week of pill taking (Pills 8–14)
If pills are missed in the third week of pill taking (Pills 15–21)
Emergency Contraception should be considered …
No indication for Emergency Contraception …
No indication for Emergency Contraception …
…if unprotected sex had occurred in the pill-free interval or in the first week of pill taking.
…if the pills in the preceding 7 days have been taken consistently and correctly (assuming the pills thereafter are taken correctly and additional contraceptive precautions are used).
…but omit the pill free interval by finishing the pills in the current pack (or discarding any placebo tablets) and starting a new pack the next day.
Guideline Author: Dr. Karin Piegsa
Revised: July 2013
Review Date: July 2016
ADTC approved: August 2013
Appendix 7C - EMERGENCY CONTRACEPTION
Sexual Health Service
ADVICE FOLLOWING MISSED OR LATE PROGESTOGEN-ONLY PILLS (POP) From: Faculty of Sexual & Reproductive Health (FSRH) Clinical Effectiveness Unit Guidance ‘Progestogen-only Pills (November 2008 / June 2009).
TRADITIONAL POPs (Micronor®, Noriday®, Norgeston®, Femulen®)
DESOGESTREL-ONLY POP (Cerelle®, Cerazette®)
>3 hours late
>12 hours late
(>27 hours since the last pill was taken)
(>36 hours since the last pill was taken)
Take a pill as soon as remembered. If more than one pill has been missed just take one pill. Take the next pill at the usual time. This may mean taking two pills in one day. This is not harmful. An additional method of contraception (condoms or abstinence) is advised for the next 2 days (48 hours after the POP has been taken) until the effect on cervical mucus has been restored. Emergency contraception may be indicated if unprotected sex occurs during this 48-hour period.
Sex occurring before a missed or late pill is protected because the effect on cervical mucus aims to prevent sperm penetration into the upper reproductive tract.
Guideline Author: Dr. Karin Piegsa
Revised: July 2013
Review Date: July 2016
ADTC approved: August 2013
Appendix 7C - EMERGENCY CONTRACEPTION
Sexual Health Service
ADVICE FOLLOWING LATE Medroxyprogesterone Acetate (DMPA) (Depo-Provera®) INJECTIONS From: Faculty of Sexual & Reproductive Health (FSRH) Clinical Effectiveness Unit Guidance ‘Progestogen-only Injectable Contraception’ (November 2008 / June 2009). DMPA is licensed to be given every 12 weeks and can be given up to 12 weeks + 5 days. It can be given up to 2 weeks early or 2 weeks late (‘off-license’ use). If given up to and including exactly 14 weeks since the last injection contraceptive efficacy is maintained and no additional contraceptive protection is required. If a woman present after 14 weeks an assessment should be made of her risk of pregnancy as a result of intercourse from 14 weeks + 1 day (see table below). Timing of DMPA
Has unprotected sex occurred?
Can the injection be given?
Is EC indicated?
Are condoms or abstinence advised?
Should a pregnancy test be performed?
Up to 14 weeks since the date of the previous injection (≤ 14 weeks since last injection)
Not applicable as long as next DMPA injection within 14 weeks
YES
NO
NO
NO
When an injection is overdue (> 14 weeks since last injection)
NO (if abstained or used barrier methods)
YES
NO
YES, for the next 7 days
NO, if abstained
YES, but only in the last 3 days
YES
YES, for the next 7 days if POEC used
YES, at least 21 days later
Yes, should offer POEC or a copper IUD
Yes, if used condoms but at least 21 days later
NO, if copper IUD used YES, but only in the last 5 days
YES
YES, should offer a copper IUD
NO
YES, at least 21 days later
YES, more than 5 days ago
NO
NO
YES, for 21 days until a pregnancy test is confirmed negative and for a further 7 days after giving DMPA
YES, at the initial presentation and at least 21 days later before injection, and possibly also 28 days later in case of unrecognised accident in first 7 days after injection
IUD = Intrauterine Device; POEC = Progestogen-Only Emergency Contraception
Guideline Author: Dr. Karin Piegsa
Revised: July 2013
Review Date: July 2016
ADTC approved: August 2013
