Emergency Contraception at a Glance: How to Provide Counseling for Patients

Case History

A 19-year-old female comes in requesting contraception. She is in good health except for asthma for which she was hospitalized twice previously. She reports regular menses, and her last menstrual cycle was 2 weeks ago. Her body mass index (BMI) is 32 kg/m². She has never used any contraceptives in the past but has been sexually active for the past 6 months. She is heterosexual and has two sexual partners and used condoms sporadically. She had intercourse ∼2 days ago without using condoms and is concerned about becoming pregnant. How would you counsel the patient?

EC is defined as contraceptive methods that can decrease the risk of pregnancy after unprotected intercourse (UPI), or when there are concerns about contraceptive failure due to imperfect use or interruption of routine contraceptive method. It is also used after a sexual assault in a victim who is not on any contraception. ¹ These methods are for pregnancy prevention through disruption of ovulation and fertilization and do not interrupt or cause termination of an established implanted pregnancy. Therefore, EC should not be considered as abortifacients. Medication abortion with mifepristone and misoprostol is not considered EC because it is used to disrupt implantation and continuation of pregnancy.

There are safe and effective EC methods available to patients that are over the counter and available through providers' offices. Clinicians should educate and counsel patients about the available methods of EC in these situations.

Options for EC include both IUDs and oral medications.

Intrauterine Devices

Both the copper (Cu 380 mm²) and the LNG IUDs provide highly effective long-term reversible contraception. LNG IUD is now approved for up to 8 years of use with an excellent long-term safety profile. ^2,3 LNG IUD can be used in patients with heavy menstrual bleeding and reduce endometriosis-related pelvic pain. LNG IUD prevents pregnancy by thickening cervical mucus, making it more difficult for sperm to enter the uterus, inhibiting sperm motility so that sperm is less likely to reach the egg, and thinning the uterine lining to decrease chance of implantation. Side effects include acne, irregular vaginal bleeding patterns, uterine cramping, infection, vaginal discharge, headaches, or ovarian cysts. ⁴

Cu 380 mm² IUD is approved for up to 10 years of use, but users can experience more bleeding volume, pain, and cramping than LNG IUD users.

IUDs are used off label and are considered as highly effective form of EC based on strong observational data. ^5,6 Both the Cu 380 mm² IUD and LNG 52 mg IUD have postuse pregnancy rates of <1% ⁷ and in addition can be left in place to provide ongoing highly effective contraception and are generally well tolerated. ^6,7 A systematic review of Cu and LNG IUDs for EC, including 42 studies and 7034 users, showed first-cycle pregnancy rate of 0.1% with Cu IUD and 0.3% with LNG IUD. ⁶

IUDs can be used by individuals of any body mass, making them preferrable and effective choices for patients with BMI >25 kg/m² and can be inserted regardless of timing of menstrual cycle. IUDs can be inserted within 5 days of UPI ⁶ and existing data suggest efficacy even up to 6–14 days after UPI. ^8,9 Both IUDs can be left in place for long-term reversible contraception and have high patient acceptance. ⁶

In a study that included 188 women who received either Cu or LNG IUD as an EC at the time of their presentation, two-thirds of women continued the IUD as a method of long-acting reversible contraception at the end of a 1-year follow-up. ¹⁰ The studies required a pregnancy test before insertion and, therefore, a pregnancy test should be clinically offered before IUD placement for EC.

Oral EC Methods

These include UPA and LNG.

UPA, sold in the United States under the brand name (ellaOne^® or Ella^®) is a selective progestin receptor modulator (i.e., antiprogestin) that can be given as a single dose of 30 mg up to 120 hours (i.e., 5 days) after UPI. ¹¹ Progestin-containing contraceptives should not be used with UPA or for 5 days after UPA administration as it can interfere with UPA action.

Oral LNG is sold in the United States under brand name (Plan B One-Step), also known as the “morning after pill.” A 1.5 mg dose is licensed for use up to 72 hours after UPI, ^12,13 although it is used off-label beyond that time frame with established efficacy up to 120 hours (i.e., 5 days). ¹³ Oral LNG works primarily by delaying or inhibiting ovulation and luteal function. Oral LNG was approved in 2006 for over-the-counter sale to women aged 18 years and older in the United States as a method of EC. However, efficacy is time sensitive as discussed below and is not recommended for patients with increased BMI due to concerns about reduced efficacy. ¹³ One study showed a fourfold increase in oral LNG failure in patients with BMI >30 kg/m² and a twofold increase among those with BMI 25–29.9 kg/m². ^14,15

In addition, a study showed that doubling the LNG dose was not effective in delaying ovulation, therefore, its EC effectiveness is reduced among women with obesity. ¹⁶

Among the oral options for EC, UPA is the most effective oral method ^9,15 but requires a prescription. UPA is not preferred for patients with BMI >30 kg/m²¹⁷ and should not be prescribed for those with reactive airway disease. It should be noted that the efficacy of oral LNG is decreased when used 3 days after UPI. ^14,18 Oral LNG is the less effective oral agent, but more widely available over the counter without a prescription. Women who have UPI around their ovulation window should be offered an IUD EC. ¹⁴

Summary

All women requesting EC should be offered treatment and counseling that includes discussion about the various options available for EC and for ongoing effective contraception. There are still many barriers for women who want to access EC such as lack of privacy in pharmacies, lack of adequate counseling, concerns about safety, misconception that EC can cause abortion, negative provider and pharmacist attitudes, cost, and insurance coverage. Making more of these available as over-the-counter options without requiring consultation, examination with better access especially as EC is time sensitive can help overcome some of these barriers.

Answer: C

Answer A is incorrect as the patient had UPI during her fertility window and is at risk for unintended pregnancy. She needs to be provided emotional support and counseling and prescription for EC.

Answer B is correct if an IUD is considered for EC as the studies have required pregnancy test before IUD placement. If oral EC is chosen, a pregnancy test is not required clinically, as patients requesting EC do not need an examination or any additional testing. Answer D is incorrect as due to her elevated BMI; regular dose LNG will be ineffective, and patients need twice the recommended dose.

Answer E is incorrect as due to her history of severe asthma, UPA use is not recommended. Answer F is incorrect due to the timing of last intercourse and last menstrual period 2 weeks ago. It is unlikely that implantation occurred to warrant medication abortion.