Characteristics of Levonorgestrel Emergency Contraceptive Pills

1. Levonorgestrel (LNG) Emergency Contraceptive PillsSession I: Characteristics of LNG Emergency Contraceptive PillsAdapted by Dr Rodica Comendant, based on Training Resource Package for Family Planning: https://www.fptraining.org/

2. Objectives 1. Discuss the consequences of unintended pregnancy. 2. Describe the characteristics of emergency contraceptive pills (ECP) in a manner that clients can understand: a. What ECPs are and how they work (mechanism of action) b. Effectiveness c. Side effects d. Safety e. Who can use emergency contraceptive pills f. ECP regimens g. Key points for providers and clients At the end of this session, participants will be able to:

3. Objectives (continued) 3. Describe the indications for use of LNG ECPs 4. Demonstrate how to screen clients for LNG ECP use 5. Demonstrate counseling LNG ECP clients including: a. Characteristics of LNG ECPs b. How to address common concerns, rumors and misconceptions about ECPs c. How to use LNG ECPs d. Possible side effects of LNG ECPs and how to manage them e. The importance of on-going contraception after ECP use

4. What is an unintended pregnancy? Definition: Unintended pregnancy is “a pregnancy that is mistimed, unplanned, or unwanted.” Unintended pregnancy mainly results from the lack of, inconsistent, or incorrect use of effective contraceptive methods. Unintended pregnancy does not mean unwanted births or unloved children.

5. What are the consequences of unintended pregnancy? The consequences may include: • Health risks to mother. • Unsafe abortion. • Discontinuation of schooling (for adolescents). • Emotional distress. • Economic difficulties. • Disapproval from the community, especially for young, unmarried women. • Possible health risks to infants.

6. What are ECPs? • ECPs are hormonal methods of contraception used to prevent 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 ECPs.

7. LNG ECPs: Mechanism of action LNG ECPs interfere with the process of ovulation • ECPs do not inhibit implantation of a fertilized egg. • LNG ECPs do not inhibit implantation of a fertilized egg. • LNG 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

8. Effectiveness of ECPs • The LNG regimen reduces a woman’s chance of pregnancy after a single sex act by at least half and possibly by as much as 80-90%. • Effectiveness for an individual woman depends on where she 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 (rifampicin, griseofulvin, Saint John’s Wort, anticonvulsant drugs or ritonavir).

9. 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

10. Side effects of ECPs LNG ECPs are well tolerated and leave the body within a few days. Some women experience mild and short-term side effects. These may include: • Altered bleeding patterns • Nausea (in up to 20% of women) • Vomiting (rare) • Headache • Abdominal pain • Breast tenderness • Dizziness • Fatigue

11. 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.

12. 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

13. ECP regimens 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 12 hours apart (as labeled by the FDA) yet evidence shows that it is best if both pills are taken at the same time.

14. Other emergency contraceptive options Other types of emergency contraceptives include: • Ulipristal acetate, 30 mg in a single dose • Mifepristone, 10-25 mg in a single dose (not widely available) • Combined hormonal contraceptive pills (both estrogen and progestin- Yuzperegimen) • Copper IUD

15. Key points for providers and clients ECPs are: • The only currently available contraceptive method that prevents pregnancy after sexual intercourse and before implantation. • Safe and effective. • No medical precautions or contraindications. • Few side effects. • Must be taken within 120 hours (5 days) after unprotected sex. • The sooner they are taken, the more effective they appear to be. • Do not affect an existing pregnancy if taken when a woman is already pregnant.

16. 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.

17. 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.

18. Screening customers 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.

19. Addressing common concerns, rumors and misconceptions about ECPs Correct common concerns, rumors or misconceptions by emphasizing: • The availability of ECPs does not increase risky sexual behavior. • ECPs do not prevent implantation • ECPs do not cause abortions • ECPs do not cause deformed babies • ECPs are not dangerous

20. 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