Cynthia H. Chuang, MD MSc

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EMERGENCY CONTRACEPTION

• Cynthia H. Chuang, MD MSc
• Assistant Professor of Medicine
• Penn State Milton S. Hershey Medical Center
• Massachusetts Emergency Contraception
  Network

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What is Emergency Contraception?

• Birth control used after unprotected sex to
  prevent pregnancy
• Combined estrogen/progestin or progestin only
  pills taken within 120 hrs of unprotected sex
• Also called Morning After Pill

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What is EC?(cont)

• EC is NOT RU-486 (the abortion pill)
• Confusion is perpetuated by lay press
• 45 of newspaper articles on EC suggest confusion
  with RU-486
• Physician knowledge about EC is poor

Pruitt, Contraception 200470(3) Delbanco, Obgyn
199789
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EC Methods

• EC pills
• combined estrogen-progestin
• (Yupze method)
• progestin-only pills
• IUD

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Preven(combined estrogen/progestin)

• 2 pills ASAP
• 2 pills 12 hours later
• Pregnancy test in kit
• gt74 effective

50 mcg ethinyl estradiol and 0.25mg levonorgestrel
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Plan B (progestin only)

• 1 pill ASAP
• 1 pill 12 hours later
• gt85 effective

0.75mg levonorgestrel
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Using OCP Products for EC
Combined method 100 mcg ethinyl estradiol/0.50
mg levonorgestel per dose

• Ovral
• Alesse
• Levlite
• Nordette
• Levlen

• Levora
• Lo/Ovral
• Triphasil
• Tri-Levlen
• Trivora

Progestin-only method 0.75 mg levonorgestel per
dose

• Ovrette (20 pills)

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U.S. Pregnancies Unintended vs. Intended
Intended
51
49
Unintended
22.5
Unintended births
Elective abortions
26.5
3 million unintended pregnancies a year in the
U.S.
Henshaw SK. Fam Plann Perspect. 19983024-29.
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EC Infrequent Use in U.S.

• By US women
• 1 have used EC (1996)1
• 1.3 of women seeking abortions used EC (2000)2
• By US providers
• 70 of OB-GYNs prescribed EC in past year
• (majority 5 times or less)1
• In MA, only 64 of IM ever prescribed EC (less
  than FM or OB-GYN)3

1Delbanco, et al. Obstet Gynecol 199789 2Jones,
et al. PSRH 200234 3Chuang, et al. Contraception
200469
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American College of Obstetricians and
Gynecologists

• EC should be offered to women who have had
  unprotected sexual intercourse within 72 hours
• during a routine visit, physicians may offer
  patients an advance prescription for EC.
• supports an OTC product

ACOG Practice Bulletin, Number 25, March 2001
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American Medical Association

• health care professionals should be encouraged
  to play a more active role in providing EC, by
  discussing it as part of routine contraceptive
  counseling
• ...enhance efforts to expand access to EC

AMA policy H-75.985
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Healthy People 2010

• OBJECTIVE
• Increase the proportion of health care providers
  who provide EC

Healthy People 2010Objectives for Improving
Health Department of Health and Human Services
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Mechanism of Action

• Interferes w/ ovulation
• Interferes w/ transport of sperm egg
• Endometrial changes

EC prevents pregnancy does not interrupt
established pregnancy
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Efficacy

• Relative Risk Reduction
• Combined estrogen-progestin 74
• Progestin-only 85
• Potential Impact in US annually
• 2.3 million fewer unintended pregnancies
• 1.0 million fewer abortions
• prevented 51,000 abortions in 2000

Trussell, et al. Contraception 199957 WHO.
Lancet 1998352 Trussell, et al. FPP
199224 Jones, et al. PSRH 200234
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The 72-120 hour window

• EC is MORE effective when taken ASAP
• lt24hrs 95 effective
• 48-72hrs 66 effective
• Continued efficacy up to 120 hours
• WHO. Lancet 2003
• Ellertson, et al. ObGyn 2003101

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Medical Contraindications

• No absolute contraindications
• NOT indicated if already pregnant
• Not restricted for CV disease, HTN, migraines,
  liver disease, smoking, age, thromboembolic
  disease
• (progestin-only may be preferred)

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Screening for EC Eligibility

• 1) Unprotected sex within 120 hours?
• 2) Last menses within 4 weeks?
• 3) Other unprotected sex since last menses?

• Pregnancy test indicated only if pregnancy
  suspected (not if delays giving EC)
• Physical/pelvic exam unnecessary
• Phone prescriptions save time

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Side Effects Nausea/Vomiting
Nausea
Vomiting
Combined
42
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Progestin- Only
6
16

• Use progestin-only regimens OR
• Recommend meclizine with combined regimens

ACOG Practice Bulletin, Number 25, March
2001 WHO. Lancet 1998352
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Other Side Effects

• Altered Next Menses (50)
• Abdominal Pain/Cramping (18)
• Breast Tenderness (10-47)
• Dizziness
• Fatigue
• Headache
• NO TERATOGENIC EFFECTS

ACOG Practice Bulletin, Number 25, March 2001
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Follow-up Management

• Routine follow-up is usually unnecessary
• Birth control?
• Sexual assault?
• Recommend pregnancy test if no menses 4 weeks
  after EC

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History of EC in the U.S.

• 1970s Yupze method described
• 1997 FDA approval
• 1998-99 Dedicated products (Preven Plan B)

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History of EC in the U.S.(cont)

• 1998 WA statecollaborative pharmacy agreement
• 2001 ACOG supports advance prescription
• 2004 FDA rejects OTC status

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How do you get EC?

• Prescription only in 44 states
• Collaborative pharmacy agreements
• Washington, Alaska, California, New Mexico,
  Hawaii, Maine
• Behind-the-Counter in 28 countries
• Over-The-Counter
• Norway, Sweden, Finland, France, UK

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Advance Provision of EC

• ACOG Supports advance prescription
• 3 RCTs AP vs education only
• AP increases EC use
• EC used appropriately
• AP did not decrease regular birth control use
• fewer unintended pregnancies

Glasier, et al. NEJM 1998 339 Jackson, et al.
ObGyn 2003102 Ellertson, et al. ObGyn 2001 98
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Single Dose Regimens

• Single dose levonorgestrel (1.5mg) as effective
  as two 0.75mg doses q12 hrs
• Label change of Norlevo (France) and Levonelle
  (UK) EC products from two 0.75mg doses to a
  single 1.5mg dose

Von Hertzen, et al. Lancet 2002360
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Resuming Birth Control

• Discuss more effective methods
• Oral Contraceptives
• 1) start the next day, OR
• 2) start new pack with next menses
• OrthoEvra (patch) and DepoProvera start within 5
  days of next menses

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