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Emergency Contraception for pharmacy PGD. (reference FSRH 2017)

Emergency Contraception for pharmacy PGD. (reference FSRH 2017). www.sexualhealthdorset.org. 1. Options. ORAL Levonorgestrel 1.5mg – POEC ( Levonelle One step (P) and L evonelle 1500 (POM ) Ulipristal Acetate 30mg – UPA ( EllaOne ) IUD All copper IUDs.

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Emergency Contraception for pharmacy PGD. (reference FSRH 2017)

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  1. Emergency Contraceptionfor pharmacy PGD. (reference FSRH 2017)

  2. www.sexualhealthdorset.org 1

  3. Options • ORAL • Levonorgestrel 1.5mg – POEC (Levonelle One step (P) and Levonelle 1500 (POM) • Ulipristal Acetate 30mg – UPA (EllaOne) • IUD • All copper IUDs

  4. When in the cycle is EC effective? Max risk Ulipristal LNG IUD

  5. Ongoing contraception? Oral EC delays ovulation and doesn’t provide ongoing contraception; So a woman is at risk of pregnancy if she has more UPSI around the time that she ovulates later in the same cycle

  6. Emergency Contraception EffectivenessIf 1000 women had UPSI and used

  7. When is EC required? • On any day of a natural menstrual cycle ( highest in 6 days leading up to ovulation) • UPSI from Day 21 after childbirth ( unless LAM criteria met) • UPSI from Day 5 after TOP, ectopic pregnancy, miscarriage, or uterine evacuation for gestational trophoblastic disease (GTD) • Incorrect use of regular contraception

  8. Intrauterine Contraception0300 303 1948

  9. Contraindications CU IUD • Pregnancy • Ethical objections of the patient • Active PID • Distorted uterus • (Allergy to copper) • NEVER USE AN IUS FOR PCC

  10. Contraindications UPA EC • Severe asthma controlled by oral steroids • SPC (UPA) , not recommended in patients with severe hepatic impairment • Acute porphyria • Hereditary problems of galactose intolerance • ellaOne contains lactose • Avoid with medication that increases gastric pH

  11. Contraindications to LNG PCC • Nil in UKMEC • SPC ( LNG) , not recommended in patients with severe hepatic impairment • Acute porphyria • Levonelle, Upostelle, Emerres all contain lactose.

  12. PGD Differences • Ectopic pregnancy • Treatment with ciclosporin • Crohn’s disease

  13. Drug interactions-UPA • EIA (carbamzepine, phenytoin, topiramate, st John’s wort. Rifampacin) • PEPSE www.hiv-druginteractions.org/drug • Proton pump inhibitors • Progestogens, (check the week before) and avoid 5 days afterwards • Avoid UPA in women who have severe asthma controlled by oral glucocorticoids

  14. Enzyme Inducing Drugs • Offer CU-IUD if appropriate • A 3mg dose of LNG can be considered but a double dose of UPA-EC is not recommended

  15. Breast feeding • IUD-perforation risk increased up to 36 weeks 6/1,000 • UPA: express and discard for 1 week • LNG: Ok, take tablet after feeding and avoid feeding for 8 hours

  16. COC muddles • More than 2 COC missed week 1, UPSI plus barrier failure • If COC free interval is extended can use Cu IUD up to 13 days after the start of the hormone free interval • If COC has been taken in 7 days prior to EC, effectiveness of UPA –EC may be reduced. Consider using LNG-EC

  17. Patch/Ring muddles

  18. Action to take • Patch detachment or ring removal for more than 48 hours • Extension of patch or ring free interval for more than 48 hours • IF HFI extended Cu IUD can be offered up to 13 days after the start of HFI • Consider LNG rather than UPA if CHC has been used in 7 days prior to EC

  19. DMPA muddle • More than 14 weeks after last injection • Within 7 days after late injection • Cu IUD up to 5 days after the first UPSI that takes place more than 14 weeks after last DMPA • Consider LNG

  20. POP Muddle • More than 27 hours since last traditional POP ( Norgeston, Noriday) • More than 36 hours since last DSG POP • IUD up to 5 days after first UPSI following missed pill • Consider LNG rather than UPA

  21. Quick start after LNG. • Start hormonal contraception immediately

  22. Quick start after UPA • UPA, then wait at least 5 days; then as table

  23. Advice after prescribing EC? • Side effects • Vomiting • Period • Pregnancy test • Contraception • Consider STI risk

  24. More differences between the PGDs • Repeat doses • Weight/BMI • Hormones in the last 7 days

  25. Can oral EC be used more than once in a cycle? • Developing foetus not susceptible to teratogenesis during first 2 weeks after conception • IF UPA EC taken, avoid LNG EC in the following 5 days • IF LNG EC taken, UPA could theoretically be less effective if taken in the following 7 days

  26. What about weight?

  27. >70kg or BMI>26kg/m2 • IUD • UPA • 3mg Levonorgestrel (double dose)

  28. Take home messages • Assess pregnancy risk • Work out which EC methods can be offered • If eligible for IUD, always offer it • For LNG v UPA; how high is pregnancy risk, need to quick start, patient choice. • Refer 0300 303 1948; or GP • www.sexualhealthdorset.org

  29. For each case study discuss: • What options are available for your client • What you need to consider • What will be the best choice • What you will say and do

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