Emergency Contraception

For our third GUM episode Dr Katie Boog once again joins us this time going through emergency contraception

Here is our #TakeVisually for this episode:

Here are her notes, which Katie again kindly shared:

When do you need to think about emergency contraception?

Every sexually active female who is not on contraception or where contraception may have failed

What do you mean where contraception may have failed?

Condom not used/ condom accident

Missed COCP (≥2 pills)

Late POP (>36 hours for Desogestrel, 27 for traditional)

Late Depo >14w since last injection

Impalpable implant or > 3 yrs

IUD expulsion, lost threads

Whilst taking liver enzyme inducers and for 28 days after

What types of emergency contraception are there?

Levonorgestrel or Levonelle (LNG) - oral

Ulipristal acetate or ellaOne (UPA) - oral

Copper Coil (cuIUD)

How do they work?

LNG - works until LH surge begins

UPA - works until LH peaks (midcycle)

cuIUD - no effect on ovulation, prevents implantation

How effective are they?

Oral - Depends when they are taken

cuIUD >99.9% at any time

When can they be used?

LNG lic 72, used 120, efficacy decreases with time

UPA – 120 hours

cuIUD 5 days after first UPSI, 5 days after ovulation

How do you know when someone has ovulated?

Cycle – 14

Why are there different time options for the copper coil?

Preventing implantation

<5 days from fertilisation = no implantation

Are there any side effects?

Oral – Nausea/vomiting; 2 hour rule; spotting; delayed/early menses

cuIUD – painful fit, heavy/painful/prolonged menses

What would make you choose one oral method over the other?

UPA most effective mid cycle

UPA more effective between 72-120 hours

UPA – can’t use if progestogen in last 7/7

UPA – can’t quickstart

UPA not suitable if taking glucocorticoids for asthma

UPA and breastfeeding – discard 7/7

OK so for example, you see a lady who is not using contraception and she had unprotected sex 2 days ago. What do you need to know?

Is she at risk of pregnancy? Assume: partner is male, no condom used, not on contraception.

When was her last period?

Does she know how long her cycle is?

OK so her last period was 7 days ago and they come every 30 days like clockwork.

OK so she is day 7 of a 30 day cycle. Her expected date of ovulation would therefore be day 16. So she is eligible for all types of EC

cuIUD – could be fitted up to day 21 for her (5 days after ovulation)

EllaOne can be given up to 5 days after UPSI. She has not yet ovulated. But what does she want to start on for contraception? She will have to wait 5 days

LNG – pre-ovulation, licensed up to 72 hours, could then quickstart new method

Discuss her options, PT in 3 weeks

What about if she was day 18 of her cycle and she had had unprotected sex every day and she had had emergency pills 3 times this month?

Day 18 of a 30 day cycle.

Earliest day of ovulation would have been day 16.

Oral methods ineffective after ovulation.

She could have a coil fitted up to day 21 (5 days after ovulation) this would cover her for all sex that cycle

But couldn’t she already be pregnant from all the sex she had earlier that month?

Pregnancy starts at implantation

Implantation is not until >5 days after fertilisation

Earliest possible day of fertilisation was day of ovulation

We are within 5 days of ovulation