Pre-service Education on FP and AYSRH

1. Pre-service Education on FP and AYSRH Session II, Topic 4 Emergency Contraceptive Pills (ECPs) Emergency Contraceptive Pills, Session II Topic 4 Slide 1

2. What are ECPs? • ECPs are hormonal methods of contraception that can reduce the risk pregnancy following an unprotected act of sexual intercourse. • There are different types of ECPs. In this training, we will be focusing on the levonorgestrel-only (LNG) and ulipristal acetate (UPA) ECPs. Emergency Contraceptive Pills, Session II Topic 4 Slide 2

3. ECPs: Mechanism of action ECPs interfere with the process of ovulation • ECPs do not inhibit implantation of a fertilized egg. • ECPs do not inhibit implantation of a fertilized egg. • ECPs do not cause abortion of an existing pregnancy • do not cause aboECPsdo not inhibit implantation of a fertilized egg. • ECPs do not cause abortion of an existing pregnancy • rtion of an existing pregnancy Emergency Contraceptive Pills, Session II Topic 4 Slide 3

4. Effectiveness of ECPs • If 100 women each had sex once during the 2nd or 3rd week of the menstrual cycle without using contraception, 8 would likely become pregnant. • If all 100 women used uliprital acetate ECPs, less than one would likely become pregnant. • If all 100 women used progestin (LNG)-only ECPs, one would likely become pregnant. • Effectiveness depends on where a woman is in her menstrual cycle, when she had unprotected sex and when she used ECPs. • Some types of ECP such as ulipristal acetate (UPA) or mifepristone are more effective than LNG-only ECPs and some (regular contraceptives- the Yuzpe regimen) less effective. • Effectiveness may be affected by use of certain medications. • Evidence suggests that ECPs may be less effective in women with higher weight and/or BMI. UPA seems to be more effective in these women than LNG. Emergency Contraceptive Pills, Session II Topic 4 Slide 4

5. Fertilization EC pills have no effect after fertilization, do not cause abortion EC pills work before fertilization Last Day of Menstruation Ovulation Starts Implantation Positive Pregnancy Test First Day of Cycle Day 1 Emergency Contraceptive Pills, Session II Topic 4 Slide 5

6. Side effects of ECPs LNG and UPA ECPs are well tolerated and leave the body within a few days. Some women experience mild and short-term side effects. These may include: Changes in bleeding patterns including: • Slight irregular bleeding for 1–2 days after taking ECPs • Monthly bleeding that starts earlier or later than expected In the week after taking ECPs : • Nausea • Abdominal pain • Fatigue • Headaches • Breast tenderness • Dizziness • Vomiting Emergency Contraceptive Pills, Session II Topic 4 Slide 6

7. Safety of ECPs • ECPs have no known serious complications. • ECPs do not cause abortion • They are safe for use by all women including adolescents. • ECPs are not harmful if taken by a woman who is already pregnant. • ECPs have been widely used in various formulations for over 30 years. Emergency Contraceptive Pills, Session II Topic 4 Slide 7

8. No contraindications to the use of ECPs • ECPs have no medical precautions or contraindications. • No pregnancy test or physical examination is needed • ECPs should not be taken if a woman is pregnant because they will not work. However they will not harm an existing pregnancy • ECP effectiveness may be affected by use of certain medications Emergency Contraceptive Pills, Session II Topic 4 Slide 8

9. ECP regimens • UPA should be given as a single, 30 mg dose Two LNG regimens are packaged and labeled specifically for emergency contraception • 1 tablet levonorgestrel (LNG), 1.5 mg or • 2 tablets of 0.75 mg LNG to be taken at the same time. Emergency Contraceptive Pills, Session II Topic 4 Slide 9

10. Other emergency contraceptive options Other types of emergency contraceptives include: • Mifepristone, 10-25 mg in a single dose (not widely available) • Combined hormonal contraceptive pills (both estrogen and progestin- Yuzpe regimen) • Copper IUD Emergency Contraceptive Pills, Session II Topic 4 Slide 10

11. Indications for use of ECPs • A couple recently had sex without using contraception. • A condom broke or slipped. • A woman using oral contraceptive pills missed three or more pills or started later in the month than instructed. • A woman using contraceptive injections was late for her next shot. • A woman experienced an IUD expulsion or could not locate the IUD string. Emergency Contraceptive Pills, Session II Topic 4 Slide 11

12. Indications for use of ECPs (continued) • Sex was forced (rape). • Failed coitus interruptus (e.g., ejaculation in vagina or on external genitalia). • Miscalculation of the periodic abstinence method or failure to abstain on a fertile day of the cycle. • Failure of a spermicide tablet or film to melt before intercourse. • Diaphragm or cap dislodgment, breakage, tearing, or early removal. Emergency Contraceptive Pills, Session II Topic 4 Slide 12

13. Screening clients for ECP use The most important screening question for ECP use is: Did you have unprotected sex within the last 5 days (120 hours)? If “yes” then the client is eligible for ECPs. Effectiveness will be lower the longer a woman waits to take ECPs. Emergency Contraceptive Pills, Session II Topic 4 Slide 13

14. Screening questions for ECP use You can also ask questions to determine if the woman is pregnant. ECPs will not work if she is pregnant. • Was your last menstrual period less than 4 weeks ago? If “No,” the client may be pregnant. • Was this period normal for you in both its length and timing? If “No,” the client may be pregnant. • Is there reason to believe you may be pregnant? If “Yes,” the client may be pregnant. If the client is not pregnant, ECPs may be given. If the client’s pregnancy status is unclear, ECPs may still be given, with the explanation that the method will not work if she is already pregnant. You can also ask about other drugs the woman is taking: Are you taking the any of these drugs: rifampicin, griseofulvin, Saint John’s Wort, anticonvulsant drugs or ritonavir? ECPs may be less effective if you are taking any of these medications. But ECPs should still be given, as there are no contraindications to ECPs. Emergency Contraceptive Pills, Session II Topic 4 Slide 14

15. How to use ECPs ECP information for the client should include: • How and when to take the pills. • What to expect once the pills are taken. Including possible side effects and what the woman should do. • Effectiveness/failure rates. • Importance of using regular contraception. Emergency Contraceptive Pills, Session II Topic 4 Slide 15

16. Possible side effects of ECPs Some women experience: Changes in bleeding patterns (not serious and will resolve without treatment) • Slight irregular bleeding for 1-2 days or • Monthly bleeding that starts earlier or later than expected Within the week after taking ECPs (these side effects are not serious, require no treatment and usually resolve within 24 hours) • Nausea • Vomiting (rare with LNG-only ECPs) • Abdominal pain • Fatigue • Headaches or dizziness Emergency Contraceptive Pills, Session II Topic 4 Slide 16

17. Need continuing protection? Ask your client: • Could unprotected intercourse happen again? • Do you need dual protection from pregnancy and STIs/HIV/AIDS? • Can you always choose when you have sex? • Have you been using an regular method of contraception? Are you satisfied with it? Emergency Contraceptive Pills, Session II Topic 4 Slide 17

18. Follow up and referral for clients • If the client reports no menses within 4 weeks of ECP use, she may be pregnant. • Invite client to tell her story, including the number of sex partners. If her story suggests STI exposure, refer for treatment. Discuss use of condoms if appropriate. • If at risk for STIs, discuss dual protection from pregnancy AND from STIs/HIV/AIDS • If story suggests coercion or violence, provide more help if possible. • Can start another method right away. If client chooses no regular method now, offer ECPs and male or female condoms with instructions for use. • Contraceptive use should never be made a condition for ECP use. Emergency Contraceptive Pills, Session II Topic 4 Slide 18

19. When to begin a regular method of contraception following LNG ECPs Method When to begin Immediately The day after taking ECPs or wait until next menstrual bleeding The same day as the ECPs or within the first 7 days after the start of her next menstruation The same day as the ECPs, but needs back-up method for first 7 days Same day as ECPs or after menstruation has returned, but needs condoms or COCs until then Can be used for emergency contraception, or on the same day if taking ECPs or within the first 7 days after the start of her next menstruation Condom COCs Progestin-only injectable Monthly injectable Implants IUD Emergency Contraceptive Pills, Session II Topic 4 Slide 19

20. When to begin a regular method of contraception following UPA ECPs Method When to begin Immediately On the 6th day after taking UPA ECPs On the 6th day after taking UPA ECPs On the 6th day after taking UPA ECPs On the 6th day after taking UPA ECPs Can be used for emergency contraception, or on the same day if taking ECPs Condom COCs Progestin-only injectable Monthly injectable Implants IUD All women need to abstain or use a backup method* from the time they take UPA-ECPs until they have been using a hormonal method for 7 days (or 2 days for progestin-only pills). Emergency Contraceptive Pills, Session II Topic 4 Slide 20

21. Resuming contraception after ECP use Contraceptive How to resume the method Use a condom for every sexual encounter Use a condom for the first 7 days. Resume taking COCs as before or continue using condoms until menstruation, then begin a new pack. Use condoms until next menstruation and then begin progestin-only injectable. Need for ECP rare, but If implant or IUD is past expiration and ECP is needed, use a condom until next menstruation. Have a new implant or IUD inserted within first 7 days of menstruation. Condoms COCs Progestin-only injectable Implant and IUD Emergency Contraceptive Pills, Session II Topic 4 Slide 21