Emergency Contraception for Clinical Providers in Washington State

1. Emergency Contraceptionfor Clinical Providersin Washington State

2. The New Yorker, July 23, 1999

3. Learning Objectives Understand the history and expanding role of emergency contraception (EC) in pregnancy prevention Understand the differences between EC regimens and their effectiveness Identify mechanisms for raising awareness of EC within the client population Increase awareness of EC resources Facilitate integration of EC into routine family planning, reproductive health, and primary care activities

4. Around 10 million couples have sexual intercourse every night in America Approximately 27,000 condoms break or slip Even perfect contraceptors can and do experience contraceptive failure Why Is Emergency Contraception Needed?

5. Current Proportion of Unintended Pregnancies

6. Definition of Unintended Pregnancy

7. The Institute of Medicine Recommends That the Nation Adopt a New Social Norm

8. Emergency contraceptionprevents pregnancyAFTER sex

9. Awareness of Emergency Contraception is Limited Public uninformed about the method 11% of women know the basic facts about EC 1% have used it These data are supported by PATH�s local assessment, which found that most clients have not heard about EC

10. Kaiser Family Foundation Survey:Client Education

12. What Is Emergency Contraception? Emergency Contraceptive Pills (ECPs) Often referred to as �the morning-after pill� Birth control pill hormones taken in high dose within 3 days (72 hours) of unprotected sex IUD Insertion Within 5 days (120 hours) of unprotected sex Can also be a long-term contraceptive method

13. IUDs as Emergency Contraception 99% effective in preventing pregnancies Can be retained for up to 10 years Screening should follow regular IUD screening criteria plus ascertain unprotected intercourse within 5 days of seeking treatment

14. Two Types of ECPs Progestin-only Reduces the risk of pregnancy by 89% Side effects Nausea (23%) Vomiting (6%) Estrogen and Progestin Reduces the risk of pregnancy by 75% Side effects Nausea (50%) Vomiting (20%)

16. Effectiveness: Single-Use Progestin Only

17. Dedicated Estrogen and Progestin (Combined) Product Preven� Gyn�tics FDA approved March 1998

18. Effectiveness: Single-Use Combination Pill

19. Regular Oral Contraceptives Used for Emergency Contraception In addition to dedicated ECP products, regular birth control pills can be prescribed in special doses for emergency contraception (See table in your packet)

20. Treatment Is More Effective the Sooner It Begins

21. ECP Mechanism of Action Clinical studies have shown that ECPs can inhibit or delay ovulation Evidence regarding endometrial alterations equivocal Not clear that changes observed would inhibit implantation Biologic plausibility regarding inhibition of fertilization Thickening of cervical mucous Alterations in tubal transport of sperm or egg

22. ECP Mechanism of Action Timing impacts how ECPs work: Cycle day on which intercourse occurred Cycle day on which treatment is used Statistical evidence suggests there must be an additional mechanism beyond delaying or preventing ovulation

23. Medical Definition of Pregnancy NIH, FDA, and ACOG all define pregnancy as beginning with implantation Takes about 6 days for a fertilized egg to begin to implant Intervention within 72 hours cannot result in abortion ECPs are not effective if a woman is already pregnant

24. Providing EC Information For some women, clearly understanding the mechanism of action will be critical to making an informed choice about ECP use.

25. Key Points on Mechanism of Action ECPs work through various mechanisms ECPs will not interrupt or harm an established pregnancy ECPs are not the same as mifepristone (RU486), which is used after pregnancy is already established 

26. ECP Safety:Women�s Health According to the World Health Organization, there are no absolute contraindications for ECPs. ECPs are believed to have no clinically significant impact on conditions such as cardiovascular disease, angina, acute focal migraine, or severe liver disease. However, ECPs do not protect against STDs.

27. ECPs do not interfere with an established pregnancy. No evidence that ECP hormones have an adverse effect on fetal development.

28. What are the key messages to communicate to your clients?

29. Key Messages for Clients: 72-hour time frame for ECPs (but sooner is better) Safe and effective Mechanism of action (informed choice) Do not cause abortion Side effects: nausea and vomiting Not as effective as other contraceptives for regular use Do not protect against STDs

30. What other issues might be of importance to clients?

31. Key Topics of Importance to Clients No future impact on childbearing No threat to potential pregnancy Not abortion Religion (individual�s religious background not always predictive of EC interest) Expense of ECPs (covered by Medicaid) Confidentiality Adolescents Diverse communities Interpreters

32. No menses within 3 weeks after treatment 98% of women have menses within 21 days If client has concerns or problems For initiation of routine birth control method For information or screening for STDs

34. Advance Distribution or Advance-of-Need Prescribing of ECPs ECPs are more effective when taken sooner Advance prescription reduces access barrier Women are not more likely to use ECPs repeatedly Advance prescription does not decrease the use of other birth control methods

35. Expanded Access Through Pharmacies in Washington State Collaborative drug therapy agreement between pharmacist and independent prescriber Trained pharmacists participating in a collaborative agreement can provide ECPs directly to women who request them Currently over 145 pharmacies participating In the first 16 months of project pharmacists wrote and filled almost 12,000 prescriptions for ECPs

36. Medicaid Coverage of ECPs Medicaid covers ECP prescriptions Covers Preven� and Plan B� Covers regular birth control pills prescribed in special doses for emergency contraception Medicaid covers pharmacist counseling time For women who receive ECPs directly from pharmacist, the pharmacist�s counseling time and the ECP prescription are covered.

37. Cost of ECPs For prescriptions written by medical providers (MDs, ARNPs, PAs): If covered by insurance: $5-10 co-pay If no insurance coverage: Plan B�: $18-35 Preven�: $20-35 Note: client also must pay for office visit to get prescription For prescription and consultation at pharmacy: Pills and counseling: $35-45 As dedicated products become more widely used, cost may rise slightly: $40-45

38. Tools Included in Provider Packet Q & A for medical providers Key messages to convey to clients Telephone screening protocol EC referral card Emergency Contraception: Client Materials for Diverse Audiences booklet List of pharmacies that provide ECPs in Washington State EC reference list

39. EC Materials for Diverse Audiences Provides EC information in 13 languages: Amharic Arabic Cambodian Chinese English Haitian-Creole Korean Laotian Portuguese Russian Somali Spanish Vietnamese

40. Clinics and Pharmacies that Provide ECPs in Your Area EC Hotline 1-888-NOT-2-LATE (1-888-668-2528) EC website http://not-2-late.com Planned Parenthood website http://plannedparenthood.org Washington State Family Planning Hotline 1-800-770-4334

41. How will you emphasize ECPs in your practice?

42. Tell Your Clients About ECPs by: Routinely advising about ECPs Making ECP materials available in clinic settings Encouraging advance-of-need prescribing Signing up to be listed as an EC provider on the national hotline by calling 1-888-NOT-2-LATE (1-888-668-2528)