There is more to emergency contraception than just the morning-after pill, writes Dr Deborah Bateson
There is more to emergency contraception than just the morning-after pill, writes Dr Deborah Bateson
Emergency contraception is used after unprotected sex has occurred, for whatever reason – “heat of the moment” non-use by consenting couples, contraceptive mishaps such as broken condoms or missed pills, or after sexual assault.
Until recently, women in Australia have had two main options for emergency contraception: the 1.5mg levonorgestrel emergency contraceptive pill (Postinor, Levonelle and others) licensed for 72 hours after unprotected intercourse and available over the counter since 2004, or the insertion of a copper-IUD within five days of unprotected intercourse.
The latter is the most effective method, and has the added advantage of providing highly effective ongoing contraception for up to five or even 10 years. In an ideal world, every woman requiring emergency contraception should be offered one. However, not all women may want an intrauterine device, and even if they do, finding a trained clinician to insert it within five days of unprotected intercourse may be a challenge. For this reason, this article will focus on oral methods, although it is not out of the question that Australia will eventually follow the UK in actively promoting emergency copper-IUDs through streamlined insertion services.
Since April 2016, another oral option has been available in Australia – ulipristal acetate (UPA). This brings us in line, if somewhat belatedly, with the other 89 countries where it is available. UPA is a selective progesterone receptor modulator (SPRM) first registered in 2009 in France. Since then, over five million packs have been sold worldwide. The product is marketed as Ellaone in a single 30mg dose licensed for use up to 120 hours (five days) after unprotected intercourse.
Currently it is only available by private prescription, but hopefully Australia will follow the lead of the 25 countries, including the UK and Switzerland, where UPA has been down-scheduled to over-the-counter status in order to improve its accessibility.
There are many myths about emergency contraception, stemming from a complex mixture of medical, social, ethical and political factors. It is therefore important that, as clinicians, we are clear about the scientific and clinical evidence related to each method, including the way they work, so that we can help dispel myths and appropriately advise our patients.
One of the myths surrounding emergency contraception is that it is associated with increased sexual risk-taking, and that women who use emergency contraception are somehow careless or irresponsible. There is no evidence to suggest that the availability of emergency contraception reduces the use of more effective long-term contraception, increases the risk of sexually transmitted infections, or results in intercourse occurring at a younger age. Women should be able to access this useful medication without fear of judgment.
Another common area of misunderstanding around emergency contraception is that it is the same as mifepristone (previously known as RU486), and the two are sometimes confused. This is not helped by media reports that continue to misrepresent emergency contraceptive methods as abortifacients.
To help us dispel this myth, it is useful to remind ourselves of gamete survival as well as the physiology of ovulation: sperm are viable in the upper female genital tract for up to five days or in the case of a few “super sperm” seven days after intercourse, while the ovum can only survive for up to 24 hours after ovulation, which is preceded by a surge in luteinising hormone (LH) from the pituitary gland.
Research studies show that both types of oral emergency contraception act by inhibiting the LH surge, which in turn prevents or delays ovulation until sperm in the genital tract are no longer viable. While an effect on the endometrium cannot be absolutely excluded for UPA, neither method has any effect after implantation has occurred and neither results in an abortion.
It’s also important to know that UPA, unlike levonorgestrel, can prevent ovulation even after the LH surge has started. A meta-analysis has shown that UPA prevents pregnancy more effectively than levonorgestrel when taken at 24, 72 and 120 hours after unprotected intercourse. While UPA is effective for five days after unprotected intercourse, the data show that levonorgestrel, while still effective if taken up to 96 hours after intercourse, is no better than placebo in preventing pregnancy on day five.
A word of warning though. Although it may be tempting to label UPA the “five-day after pill”, as some popular media have, it remains important to advise women to take either of the oral options as soon as possible after unprotected intercourse in order to optimise the chance of delaying ovulation. Trying to work out whether EC is needed based on whether ovulation has occurred is generally a futile exercise due to the variability and unpredictability of ovulation even among women with regular menstrual cycles. A low but considered threshold for recommending emergency contraception is appropriate, given that it does no harm if taken unnecessarily.
The effectiveness of emergency contraception is measured differently than for other contraceptives. Instead of looking at the percentage of pregnancies that occur in the first year of contraceptive use when used either perfectly (under research conditions) or typically (in real life use), it is measured as the percentage of pregnancies prevented which would have otherwise occurred had it not been used. Clearly this is a bit of a challenge since it presupposes that all women included in the research studies have the same level of fertility and have the same amount of intercourse.
In a nutshell, it is essential that women understand that no method is 100% effective, with around 85% of expected pregnancies being prevented. UPA has been shown to have superior effectiveness to levonorgestrel across five days – the meta-analysis shows it to be approximately three times more effective than LNG-EC if taken within 24 hours. There is also some evidence to suggest that there may be a higher failure rate for levonorgestrel in women with a BMI > 30, and UPA may be a preferred option in this instance.
Explanation of the variability of bleeding patterns after emergency contraception is essential. While the next menstrual period may come at the expected time, it may also occur earlier or later. Most women experience bleeding within seven days of the expected period but in about 20% of women who have taken UPA, the next menstrual period occurs more than seven days late. All women who’s bleeding is more than seven days late, or is light or unusual in any way at all, should be advised to perform a urine pregnancy test. Not all bleeding is menstrual, and implantation of a fertilised ovum may be associated with vaginal bleeding – definitely something not to be missed.
If a pregnancy is diagnosed following administration of oral emergency contraception, or if these medications are taken inadvertently during pregnancy, women can be reassured there will be no adverse effects to either the pregnancy or the fetus, and no increased risk of ectopic pregnancy. The location of the pregnancy should be determined, as for all pregnancies.
Safety and side-effects
Anecdotally, some women, as well as their partners, worry about the effect of emergency contraception on long term. These women should be reassured there is no evidence of any effect on future fertility and that repeat use is not harmful. However, switching to a longer-term method of contraception will be significantly more effective and less expensive. Oral emergency contraception can be used more than once if required within a cycle, although using UPA in the same cycle as levonorgestrel is not recommended because of the potential for reduced efficacy.
Misplaced concerns about other side-effects and risks may put some women off using emergency contraception, but according to the World Health Organisation, it its safety is well-established with very few contraindications or precautions to its use. Of course, neither LNG-EC nor UPA should be used by women with allergy or sensitivity to its constituents, and UPA should not be used in women with severe asthma treated with oral glucocorticoids or severe liver impairment. Breastfeeding women are advised to express and discard breast milk for one week after they have taken UPA, which means that levonorgestrel may be the preferred option in this case.
As with all medications, interactions with concurrent medications also need to be considered. Liver enzyme-inducing medications, such as some anti-epileptics and anti-retrovirals, will reduce the efficacy of both types of oral emergency contraception. Ideally, women using these medications should be advised to have an emergency copper-IUD inserted, but if this is not an option the next best choice would be to advise a double dose (off label) of levonorgestrel. UPA is not recommended in this situation.
Women can also be reassured about the low risk of short-term side effects. Some readers may remember the so-called Yuzpe regimen made up of multiple combined hormonal contraceptive pills taken as a stat dose then repeated 12 hours later, which could mean getting up in the middle of the night!. Due to its lower effectiveness and a higher chance of nausea and vomiting, this old method is now only recommended if no other is available.
Family Planning clinics usually supplied women using the Yuzpe regimen with an accompanying dose of an anti-emetic and an extra dose of pills in anticipation of such an event. Unfortunately some women believe that today’s single dose “modern” EC pills still have the same side effects, while in reality vomiting is rare, with as few as 1% affected. Other side-effects such as headache and bloating may occur but the risk is low with no significant difference between the two oral medications.
As both forms of oral emergency contraception act by preventing or delaying ovulation, women will be at risk of unintended pregnancy later in the cycle if they have further unprotected intercourse. Advice about ongoing contraception is therefore essential. While condoms or abstinence may be acceptable for some women until the next normal menstrual period occurs, other women may prefer to start an effective method immediately.
Furthermore, some women may be using emergency contraception because they missed a contraceptive pill or did not re-insert their vaginal ring on time. While immediate initiation or resumption of a hormonal method of contraception is appropriate following the administration of levonorgestrel (with precautions in place whilst waiting for the method to become effective), a five-day delay is advised after taking UPA. This is because the progestogen in the combined pill or vaginal ring, the progestogen only pill, etonogestrel implant or depot medroxyprogesterone acetate injection may reduce the effect of the UPA – remembering that UPA is a selective progesterone receptor modulator. After waiting these five days, women would then need to use additional precautions (condoms or abstinence) until contraceptive effectiveness kicks in. Levonorgestrel may be an easier option in this case.
The earlier emergency contraception is used, the better, so we need to consider how we can best support timely access for women who have made a decision to use it. UPA currently requires a prescription, and this certainly creates an additional barrier. But as it is now available as a non-prescription product in 25 European countries, including the UK and Switzerland, it may be hoped that Australia will follow. That said, we must also be aware that over the counter status does not always mean automatic access.
Research suggests that young women in particular may occasionally be subjected to unnecessary, intrusive or even judgmental questioning at some pharmacies, while concerns about privacy and confidentiality, especially in small country towns, can still make it challenging to obtain the product.
The Pharmaceutical Society of Australia provides excellent guidance for pharmacists in relation to promoting emergency contraception access, which includes the requirement for pharmacists with a conscientious objection to make this known to the woman, and to refer on in a timely manner. Writing a prescription for a young person under the age of 16 for either the levonorgestrel or UPA may also be helpful in promoting access, as can the provision of a prescription for an advanced supply.
While emergency contraception is provided free of charge in countries such as the UK, in Australia it is likely that cost unfortunately plays a role in determining choice, especially for young women who are at their peak fertility. Levonorgestrel can range in price from $15 to $45 and UPA is likely to be relatively more expensive again. And accessing either as soon as possible does not sit well with cheap online pharmacy supply options.
Dr Deborah Bateson is Medical Director, Family Planning NSW
Factsheets on EC options are available from Family Planning Organisations including www.fpnsw.org.au
World Health Organisation. Fact sheet on the safety of levonorgestrel-alone emergency contraceptive pills (LNG ECPs). [Online, updated 2010]. Available at: http://whqlibdoc.who.int/hq/2010/WHO_RHR_HRP_10.06_eng.pdf. Accessed on 2 May 2016.
Faculty of Sexual and Reproductive Healthcare. Clinical guidance: Emergency Contraception. London, 2011 (updated 2012). Available online at: http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf. Accessed on 23 May 2016.
Glasier et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. The Lancet 2010; 375: 555-562
Brache et al. ulipristal acetate prevents ovulation more effectively than levonorgestrel : analysis of pooled data from three randomised trials of emergency contraception regimens. Contraception. 2013; 88:611-618