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Emergency Contraception

Emergency Contraception. Jill Zelin March 2014. Why should I discuss IUD if I can’t fit one?. Is UPA worth the price difference?. How to decide which EC to offer in clinic and which is best. Is it safe? Will I ever do any harm?. Does weight matter?. Is there any time Emergency

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Emergency Contraception

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  1. Emergency Contraception Jill Zelin March 2014

  2. Why should I discuss IUD if I can’t fit one? Is UPA worth the price difference? How to decide which EC to offer in clinic and which is best Is it safe? Will I ever do any harm? Does weight matter? Is there any time Emergency Contraception is not necessary because there is no risk?

  3. What is the most important question to ask a woman who requests emergency contraception?

  4. I had sex two nights ago without protection. I’ve done it before and got away with it. Am I at any risk of pregnancy this time? Is it worth me going through the trouble of having an IUD fitted? Is it worth the extra cost of UPA?

  5. Glasier (Contraception 2011) • Limit of efficacy reached at : • 70kg/BMI 26 for LNG • 88kg/BMI 35 for UPA

  6. How do you interpret BMI data in theclinical scenario? • There is some evidence to suggest that women with a BMI >30 may have a higher failure rate of oral EC • So you may want to consider an IUD as this is not affected • The evidence suggests that UPA may be less affected • No idea if it is dose related • Is it weight or BMI related? • At what BMI/weight should we start to say this? • Need more evidence • Never deny oral EC due to BMI

  7. MHRA position re EC and weight/BMI • No change to clinical practice

  8. I had UPSI last night I had UPSI last night Is our choice the same? Yes! (But…..)

  9. Case studies

  10. Belinda • A 31 year old nullip attends clinic requesting Emergency contraception. LSI 4+ days ago; UPSI. No other UPSI this cycle. LMP 22 days ago • How would you manage this patient? • What other piece of information would be useful and why?

  11. What methods are suitable for her? • Discuss pros and cons of each

  12. What else might be relevant?

  13. Cassie 26 year old lady attends for Repeat COC. Has run out of pills, is due to restart today. Missed 1 pill at end of last packet. 2 episodes of UPSI in PFI. 2 days and 6 days ago • Does she need EC?

  14. The nurse seeing her states that she is currently “day 7 of her cycle”. Comment on this.

  15. Assuming you consider her to have had UPSI because of the missed pills what method(s) of EC are suitable?

  16. She has had 2 episodes of UPSI – how does this affect your decision

  17. What is a missed pill? • How many pills can you miss before needing EC?

  18. Case studies Which (if any) EC would you give?

  19. Anya 22 year old and uses no contraception. She takes carbamazepine for epilepsy. She had UPSI on D22 of a 28 day cycle. This is her only SI this cycle. Presents on D24 ( i.e. 48 hours later).

  20. Mavis 48 year woman who takes Micronor when she remembers. She is amenorrhoeic and doesn’t have a regular partner. Her last SI was 6 weeks previously. She had UPSI last night.

  21. Shiraz 15 years old – thinks her periods come every 4-5 weeks. UPSI on day 12 of her cycle and presents within 4 hours . Also had sex with her regular boyfriend 8 days ago with no contraception.

  22. Lara 25 year old drug addict. Presents on D17 of her cycle 2 days after UPSI. Has had multiple episodes of unprotected intercourse prior to this. She has a regular 4 week cycle.

  23. Mandy 38 year old woman who uses COC for contraception. She has missed a few pills this month and she had UPSI 3 days ago. Her LMP was 3 weeks ago.

  24. Macey (1) 21year old woman who has an irregular cycle. She has PCOS and has a BMI of 32 kg/m2. Her LMP was 4 weeks ago and she UPSI12 hours previously. No condom was used. Her last other SI was 3 weeks ago and this was unprotected.

  25. Macey (2) 21year old woman who has an irregular cycle. She has PCOS and has a BMI of 32 kg/m2. Her LMP was 4 weeks ago and she had UPSI 12 hours previously. Her last other SI with her partner was 2 weeks ago and this was unprotected.

  26. Conception Chances of conception up to 30% from single episode of intercourse around the time of ovulation Much lower 2-4% at other times of cycle Chances of conception influence how we advise and treat women after unprotected sexual intercourse Young women much more fertile than older ones

  27. Calculating risk of pregnancy

  28. So IF you know where a woman is in her cycle can you tell her if she has a risk and which methods work? • Very little chance • if all you have is LMP and cycle length !!!

  29. Pitfalls of quantifying risk of pregnancy How many women are sure of their LMP? No woman has exact 28 day cycles The follicular phase is very variable The luteal phase is variable Many other factors contribute to risk including….

  30. Other factors Was there full ejaculation? Was a condom used at all? If there was a problem with a condom what was it? Has the woman taken any hormones recently? How many times did they have sex? What is their natural fertility like? Risk takers versus risk averse

  31. Am I at any risk of pregnancy this time? YES! Is it worth me going through the trouble of having an IUD fitted? Is it worth the extra cost of UPA? Only you know how important it is to avoid pregnancy

  32. When would you expect a women with a 28 day cycle to ovulate?

  33. What % of those with 28 day cycles ovulated 14/7 before their next period? • 90% • 60% • 30% • 10%

  34. % of those with 28 day cycles who ovulated 14/7 before their next period

  35. Of women who conceived, how many were in the fertile window (days 10-17)? • 10% • 30% • 60% • 90%

  36. % women in the fertile window

  37. What % of women who were shown to be ovulating (on their blood tests) were actually day 14+/- 1day as per day counting? • 96% • 56% • 36% • 16%

  38. 56% of women with LH>20 were not one day either side of calculated ovulation from LMP and cycle length

  39. How many women who were calculated to have already ovulated (from LMP and cycle length) were correct? • 0/32 • 4/32 • 14/32 • 24/32 • 30/32

  40. 14/32 women in ‘luteal’ phase (from LMP and cycle length) had not ovulated yet

  41. So….. Quantifying risk is an extremely imprecise art No ‘simple’ chart can cover all situations. Clinicians can take factors into account and advise accordingly

  42. The interval dilemma I had UPSI 12h ago and want EC I had UPSI 53h ago and want EC Are our choices the same? YES!

  43. EC summary • Cannot predict, with any confidence, where a woman is in her cycle • Always mention IUD as most effective - referral pathways • If using oral EC take ASAP • Restrictions on UPA reduced, use where possible if IUD rejected - referral pathways • Levonorgestrel useful if IUD/UPA not possible • Oral EC (LNG/UPA) may only DELAY ovulation • Subsequent SI is common and risky • Always mention quick start and issue straight away • STI risk assessment as part of consultation • It is HER choice

  44. What is the most important question to ask a woman who requests emergency contraception?

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