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.
