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Contraception - emergency - Management
What information should I provide a woman requesting emergency contraception?
Provide information (verbal and printed) on:
- The confidentiality of the consultation.
- The options that are available for emergency contraception: the levonorgestrel pill, the ulipristal acetate pill, and the copper intrauterine device (IUD).
- The pros and cons of the different emergency contraception methods, including their failure rates and complications/adverse effects.
- Their mechanisms of action.
Clarification / Additional information
- The information provided to the woman should:
- Reassure her that the consultation will remain confidential. However information may need to be passed to other services, for example if she has been raped, sexually abused or if there is a child protection issue.
- Help her with the immediate decision on emergency contraception.
- Help her with future decisions on contraception.
- Sources of printed information:
- Printed leaflets are available on request from the Family Planning Association: www.fpa.org.uk.
- Pros and cons of levonorgestrel, ulipristal acetate, and the copper IUD:
- The advantages and disadvantages of levonorgestrel, ulipristal acetate, and the copper IUD (including information on failure rates and ease of use) are compared in Table 1.
- For more information, see Effect of delay since intercourse.
- Decision aids for emergency contraception:
- A tool that health care professionals can use to help women make decisions about emergency contraception can be found on the website of the World Health Organization: www.who.int [WHO, 2005].
Table 1. Advantages and disadvantages of hormonal (levonorgestrel and ulipristal acetate) and IUD emergency contraception.
Advantages | Disadvantages |
|---|
Common to all methods |
Free (if obtained through the NHS) Safe Treatment is confidential | There is a limited window of opportunity for emergency contraception. No method provides protection against sexually transmitted infections. |
Levonorgestrel |
It is readily available from general practices, pharmacies, and family planning clinics. Some pharmacists can prescribe it on the NHS (in which case it is then free to the user). Women > 16 years of age can buy it (for about £25) from pharmacies without a prescription. | The risk of pregnancy after taking levonorgestrel is clinically important, and may be high relative to the woman's expectations: For example, if 1000 women have unprotected sex in the fertile time of their menstrual cycle and do not use emergency contraception, about 80 of these women will become pregnant. Use of levonorgestrel emergency contraception will prevent pregnancy in 70 of these 80 women, and use of the copper IUD will prevent pregnancy in 79 of the 80 women. There is a high failure rate if levonorgestrel is taken more than 72 hours after unprotected sex. A repeated dose is required if the woman vomits < 2 hours after ingesting the pill. Levonorgestrel does not protect against pregnancy if unprotected sexual intercourse occurs > 12 hours after the dose is taken. Levonorgestrel emergency contraception is less effective than long-acting contraception methods. Levonorgestrel has adverse effects, but these are minor (e.g. spotting, mild bleeding, short-lived changes in the length of the menstrual cycle). Levonorgestrel is not suitable for women using drugs (or certain herbal preparations) that induce liver enzymes. |
Ulipristal acetate |
Ulipristal acetate is available from general practices, and family planning clinics. Ulipristal acetate is as effective as levonorgestrel and can be used up to 120 hours after unprotected sexual intercourse [ABPI Medicines Compendium, 2009]. | The risk of pregnancy after taking ulipristal acetate seems similar to that of levonorgestrel, but it is licensed for use for up to 120 hours after unprotected intercourse. A repeated dose is required if the woman vomits < 3 hours after ingesting the pill. Ulipristal acetate emergency contraception is less effective than a copper IUD. Ulipristal acetate may reduce the effectiveness of regular progesterone containing hormonal contraception. Barrier methods are recommended until the next menstrual period starts. Ulipristal acetate has adverse effects, but these are minor (e.g. spotting, mild bleeding, short-lived changes in the length of the menstrual cycle). Ulipristal acetate is not suitable for women using drugs (or certain herbal preparations) that induce liver enzymes. It is not advisable to take ulipristal acetate more than once in a cycle as the safety and efficacy of repeated exposure has not been studied. Ulipristal acetate should not be used whilst breastfeeding. Breastfeeding women are advised not to breastfeed for 36 hours after taking ulipristal acetate. |
Copper IUD for emergency contraception |
Considerably more effective than hormonal contraception: if 100 women use a copper IUD for long-term contraception, over the course of a year < 1% will become pregnant. The chance of ectopic pregnancy is lower in people using IUDs than in people using no contraceptive method. Provides long-term contraception that is easily reversible. Can easily be removed, and fertility is immediately restored to normal. | The copper IUD is less readily available for emergency contraception than levonorgestrel. Some women find it uncomfortable when the IUD is fitted, and for some the pain may persist for a few days, but any pain is easily controlled with simple analgesia. Some women find that their periods become heavier, longer, or more painful with an IUD. This tends to be in the first few months after insertion, after which it tends to settle. If a woman becomes pregnant while using the IUD, the chance that the pregnancy will be ectopic is higher than normal (although the absolute risk of ectopic pregnancy is reduced). Rarely, the IUD can be expelled without the woman noticing. Rarely, when the IUD is being inserted, it can peforate the uterus. There is a small risk that the uterus might be infected when the IUD is inserted. |
|
Basis for recommendation
- These recommendations reflect guidelines published by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FFPRHC, 2006b]. The recommendations include the following:
- As a Good Practice Point, the clinician should summarize evidence of effectiveness and the need for emergency contraception in each woman's individual circumstance to allow her to make an informed choice regarding its use.
- Women should be given written and verbal information on the failure rates of oral and intrauterine emergency contraception to allow them to make informed choices and to increase compliance and efficacy.
- Confidentiality is important for people of all ages, however guidance from the Department of Health emphasizes that it is particularly important to reassure young people requesting sexual health services that their consultation will remain confidential. Concern about confidentiality remains the biggest deterrent to seeking advice about emergency contraception [DH, 2004].
- A study of the reasons women choose regular contraception found that the most important reasons for choosing a contraceptive were how well it works (53%) and ease of use (13%) [Steiner et al, 2003].
- Recently it has been suggested that the levonorgestrel is most likely to fail if it is taken after ovulation has occurred [Novikova et al, 2007]. As the date of ovulation cannot be accurately estimated without special investigations that are not practical to provide routinely, the results of this study suggest that it is particularly important to recommend an IUD for emergency contraception if unprotected sexual intercourse occurred during the fertile period.
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