CONTRACEPTION.....CONTINUED

EMERGENCY CONTRACEPTION (EC)

It is human nature to depend on emergency protection even if many means are available to keep our life simple. The same is true for contraception.  In spite of many reliable methods of contraception, variety and availability of medical practitioners, 25% of women still use a douche after a sexual accident.ie: The condom breaks, unprotected sex, (UPSI). It is been mentioned that some very young girls have even used coco cola to douche before seeking medical advise. In years gone by just about anything was shoved in the vagina, all sorts of concoctions were used. None of these things really helped. The sperm are very very fast swimmers. They can be found in the cervical canal within 90 seconds after the condom bursts or after ejaculation. This EC in the past or even now is called the morning after pill. This is a bit of a misnomer in the current methodology. Currently there are three main methods of EC; it is important in each case which will be the best for each individual and what is the woman’s choice. It is also very important for the care giver to understand these methods so that proper counselling can be done. One of the methods is insertion of a copper intrauterine device (cu–IUD).  For this a trained clinician is required.

What are the situations where an EC is required?

1) If the couple are not on any contraception, when they have had unprotected sexual intercourse (UPSI).What part of the menstrual cycle was the woman in. After one single episode of UPSI their chances of getting pregnant are about 6%, unless it was during the fertile time in the cycle, then it increases to about 35%.

2) If the pill has been missed for more than 2 days, either at the start or in the middle of the course. It is most important in the initial two weeks of starting the pill not to miss any doses. If you are on OC, severe diarrhoea also upsets the pill. This 2 day rule also applies to hormone patch or vaginal ring.

3) If your depo provera injection or subdermal implant is more than 2 weeks over due you are not protected

4) If you were using an IUCD, if is partially or totally expelled. If a missing IUCD can be  located by an ultrasound you are safe ,you do not need EC.

5)If you are taking any liver enzyme inducing drugs eg: antibiotics and epilepsy drugs you need EC, especially if you are on progesterone only pill or progesterone implant. Non liver enzyme inducing antibiotics don’t interfere with OC or progesterone only pill, unless they are causing diarrhoea.

6)If you have missed the progesterone only pill for more than 3 hours.

7) If you have been raped. You have to think about STD’s as well.

8) If the barrier contraceptive male or female were not properly used.

9) If you are breast feeding and not have had a period as yet.

10) Any other reason a women feels that it is appropriate.

WHAT ARE THE METHODS OF EMERGENCY CONTRACEPTION AND WHICH METHOD IS FOR YOU

There are various methods of emergency contraception (EC) which are used around the world depending on what is available locally and what clinicians can offer and do, and within the legal rules. Initially the normal OC was offered in higher dosages, but this was not satisfactory. Now there are three well documented methods:

1) Levonorgestral (Prostinor1, Prostinor 2, levonell 1and2, nextchoice, Plan B, in general we will call them LNG.

LNG as an EC is not very effective,

if there is any delay in taking it.

They must be taken as soon as possible after UPSI not any longer than 72 hours.12 hours is the best. It is licensed to be used only once in one cycle but it can be given twice or a double dose can be given. The normal dose is 1.500mgm as a single dose. It can also be given as 2tabs of 750 mgm 12 hours apart. This can sometimes make you vomit, if that happens within 2 hours you should repeat the dose. With the second or repeat dose your Dr can give you some anti vomiting tablets, depending on how bad the vomiting was.

The exact mechanism of how LNG tablets work is not understood, it is believed that they delay ovulation for 5-7 days. Therefore if UPSI was about 5 -7 days ago the sperm will not be in time to fertilize the egg. The tablet must be taken before LH is released, from the Pituitary Gland. LH is required for the release of mature egg from the ovary. In does not affect the fertilization it is also supposed to interfere with implantation by changes in the lining of the uterus. It is also supposed to cause thickening of the cervical mucus so that the sperm cannot enter the cervix.

If there is any doubt that the woman may be pregnant it should not be given. However if it is inadvertently used, it has not shown any harmful affect on the foetus or the pregnancy.

This tablet is easily available from a pharmacy, nursing groups, FPC. The success rate of preventing pregnancy is 85% if the tablet is taken within 48 hours and 95% if taken within 24 hours. It decreases to 58% if taken after 72 hours.

LNG loses its efficacy if the woman’s BMI is more than 30.When you take LNG your periods may be somewhat irregular. If they are more than 7 days late do a pregnancy test and make sure you are not pregnant. Always have follow up advise for future contraception and STD.

2) Ulipristol (UPA) ellaOne

It is a progesterone receptor modulator.This is the latest oral EC. It is supposed to be useful up to 120 hours after UPSI .It is also better  for overweight women. It works by inhibiting or delaying ovulation. It suppresses the growth of the leading follicle. The good thing is that it works even after LH surge has started. It has many restricting factors. It should not be used for women who have severe asthma, renal or hepatic failure and rare hereditary conditions. It is metabolised in the liver therefore it cannot be used in women using liver enzyme inducing medication.UPA and LNG cannot be used together.

UPA cannot be used if the woman is breast feeding.

UPA has a single dose of 3o mgm. It cannot be repeated in the same cycle.  It is a prescription only drug.

Rules about the period, the pregnancy test, future contraception and STD all apply here as well as after LNG. Some places mifepristone (Ru 486) is also given in doses of 200 -600 mgm . It acts by interfering with progesterone. Many women have a moral objection to it thinking it is an abortant.

3) Copper Intrauterine Device (cu-IUD)

Cu-IUD is probably the best method of EC.

This is for many reasons . It has a failure rate of less than1%. It needs to be fitted within 5 days of UPSI or within 5 days after ovulation as worked out by the last menstrual period and cycle length. It needs to be fitted in by someone who knows’ how to do it. It is somewhat invasive. Many women do not like to do it because of its invasive nature and also they think it is causing an abortion. Even if the cu-IUD inserted after fertilization provided within 5 days of UPSI it prevents implantation due to the endometrial inflammatory reaction it causes. Although it is a fertilised egg, it is not a pregnancy. However in the latest legal definition of pregnancy, the start of pregnancy is supposed to be at implantation of the embryo. Copper works by being toxic to the ovum and sperm. Cu- IUD should not be used if there is any Suspicion of STD’s or a PID It is suggested that in high risk women we should test for Chlamydia at the time of insertion and give appropriate antibiotics at the same time. I have always done it, even if I am inserting an IUD as a routine and not necessarily as EC. The main advantage of using a cu-IUD is that after the emergency is over, and the woman has had a normal period, she can continue to use it as a long term reversible contraceptive. The idea that IUD causes tubal infertility has shown not to be true.

Many clinicians ask the women to feel the IUD thread at the cervix, I am not sure if it is that easy. This cu-IUD is the best EC for young monogamous nulliparous women but it is invasive, however it can be done if they are agreeable to it. If the periods do not return within 7 days of EC, do a pregnancy test and make sure that you are not pregnant. Another pregnancy test should be repeated after 3weeks.

They should watch for any irregular bleeding, pelvic pain, smelly discharge or any temperature, to make sure they are not getting any pelvic infection.

There is a suggestion that women are more fertile after an EC. Therefore contraception should be discussed and started at this time. They probably will be more receptive to it. They can abstain, use condoms, use progesterone only contraceptive, or a combined oral contraceptive. If they have used cu–IUD then of course they do not need another method. Discuss this with your care giver, as different methods take different time to protect you.

In summary EC is a very important part of family planning, there will always be accidental and undesired pregnancies, we need to provide help in these situations

KEY POINTS

1) Unplanned pregnancy happens when no contraception was used, or contraception failed, or sex was not consensual.

2) Help should be sought as soon as possible and no later than 5 days after UPSI

3) This can be achieved by three different

type of tablets. If used within 3 days the success rate of pregnancy not happening is 85%.  The other method is cu–IUD  

If used within 5 days the success rate is 99%

4) They work by interfering with ovulation, prevent implantation of the embryo, and slow the sperm

5) In most countries you can get the tablets easily from a pharmacy. For the pill called ellaO you need a script. For cu-IUD you have to attend a clinician. In some parts of the world you can get the Tablets from vending machines.

6) When you request EC the caregiver will ask you many questions about your health, allergies, any drugs you may be on,  why did the need arise, was the sex forced, your sex life history including

 STD’s.

7) There may be need for a pregnancy test

If your period is more than 7 days overdue or after the use of EC and a pregnancy test is done three weeks after EC.

8) STD tests may be required. They will give you advice regarding reducing the risk of STD’s.

9) Side effects of EC will be explained, eg headaches, nausea, breast tenderness, dizziness and tiredness. They are generally short lived.EC can only be used once in one cycle.

10) Advice regarding immediate and future contraception is very important.