Written by Dr Caitríona Henchion, Medical Director, Irish Family Planning Association (IFPA)
Emergency contraception (EC) is a method of preventing pregnancy after sex. It may be used when contraception has failed, no contraception has been used or in cases of rape.
There are two forms of emergency contraception: oral emergency contraceptive pills and copper intrauterine devices.
The emergency contraceptive pill (ECP)
Two types of ECPs are available from pharmacies; Levonorgestrel (brand names Norlevo and Prevenelle), which can be taken up to 72 hours after unprotected sexual intercourse (UPSI), and Ulipristal Acetate (brand name ellaOne), which can be taken up to 120 hours after unprotected sex.
All ECPs are more effective if given as soon as possible after UPSI.
The ECP works primarily by delaying or preventing ovulation. The ECP is not effective if ovulation has already taken place and will not displace an implanted pregnancy.
The ECP is often called the “morning after pill”. However, ECPs can be used up to 3 or 5 days after an episode of UPSI, depending on the type. Both types are more effective the sooner the pill is taken.
Copper Intrauterine Contraceptive Device (IUCD), also called the “copper coil”
The copper IUCD is effective either before or after ovulation. Copper is toxic to sperm and eggs: the primary mode of action of the IUCD is to prevent fertilisation.
The copper coil is the most effective method of EC, with a failure rate of less than 1%. It can be used up to 5 days after UPSI or 5 days after earliest possible estimated ovulation – although this is very difficult to ascertain with certainty.
An IUCD can remain in the uterus to provide long-term contraception or can be removed at the next period.
If a woman is considering having an IUCD fitted for emergency contraception, the pharmacist should still suggest that she take a hormonal ECP while she is waiting for an appointment. This will prevent a delay in accessing emergency contraception if she cannot find an IUCD provider in the necessary timeframe or if the provider is unable to fit an IUCD.
Emergency Contraceptive consultation
To best advise on the most suitable emergency contraceptive option, the pharmacist needs to know:
• Date of last normal menstrual period (LMP), usual cycle length, whether currently using any hormonal contraception or whether breast-feeding
• Date of UPSI, any other episodes of UPSI since LMP, any previous EC since LMP
• Any serious illness or current medication (think of liver enzyme-inducing medications)
• Weight/BMI (weight over 70 kilos or BMI over 30 may affect the effectiveness of ECPs)
Women should be advised about all methods of EC available and their effectiveness. They should also be advised that ECPs do not provide contraceptive protection for the rest of the cycle, so it is important to avoid sexual intercourse or to use effective contraception after taking them.
Pharmacists should advise women that emergency contraception is not 100% effective. If EC fails and a pregnancy would be a crisis, women still have treatment options and there are supports available. If a woman wants more information or is feeling anxious or confused, she should be advised that the HSE’s dedicated website, MyOptions.ie, is there to help.
It may also be appropriate to advise the woman regarding risk of STIs and availability of testing.
Take the opportunity to dispel myths and misinformation about ECPs during a consultation:
• ECPs are safe even for women who cannot normally take hormonal contraception
• ECPs do not cause abortion; if a woman is already pregnant, emergency contraception will not displace the pregnancy
• ECPs can be taken as often as needed, there is no limit to the number of times they can be used. However, other methods of contraception are more reliable. (NB: information should be provided on more reliable methods if needed)
• ECPs have no impact on long term fertility
• ECPs do not provide any protection from sexually transmitted infections
As these are sensitive consultations, it is important to have a private consulting room available and a visible sign advertising its availability. Staff should be discreet and should not ask intimate questions where they can be overheard.
Ulipristal Acetate (UPA) and interaction with hormonal contraception
UPA binds to progestogen receptors and may displace progestogens or be unable to bind if there are progestogens already bound to the receptor. Therefore, if hormonal contraception containing a progestogen has been taken within the last 5 days, the efficacy of UPA may be reduced. In this case, Levonorgestrel (LNG) might be safer to use. Copper IUCD is always the most effective.
If UPA is given and the woman is starting or restarting hormonal contraception before the next period, she should be advised to wait 5 days after taking UPA before she starts. Otherwise, the hormonal contraception could displace the UPA from the receptors, causing it to fail as an emergency contraceptive. When the hormonal contraception is started after 5 days, the woman should be advised that it will take 7 days for a combined pill and 48 hours for a progestogen only pill to become effective. Barrier methods such as condoms or abstinence should be advised during this time.
Case study 1
Sarah, aged 20 attends for EC.
LMP 3 weeks ago, 4-week cycle, not on hormonal contraception.
UPSI last night but also on the day after her period finished, day 4 of cycle, no EC on that occasion.
Sarah can have the ECP, either type.
Most likely, Sarah has passed ovulation, but there is a possibility that she has ovulated late, in which case the ECP would be beneficial. In the unlikely event that a pregnancy occurred from the earlier episode of UPSI, neither LNG nor UPA will displace that pregnancy or cause any harmful effects. On day 21 of cycle, it is too late to consider a copper IUCD.
Sarah should be advised that the risk of EC failure is higher if there has been more than one episode of UPSI since the last period since the ECP cannot protect against pregnancy from the earlier episode. Sarah should be advised that in the unlikely event that pregnancy occurred from the first episode of UPSI, on day 4 of her cycle, the ECP she receives today will not be effective for this incident.
Case study 2
Anne, aged 25 attends for EC.
UPSI last night. LMP 3 weeks ago, 4-week cycle and not on hormonal contraception.
She also had UPSI 10 days ago and took ECP (ellaOne) at that time.
Anne can have another dose of ellaOne.
Because ellaOne was given around the time of ovulation, it is likely that ovulation was postponed and may be imminent at this stage. This means Anne is at risk of pregnancy from the most recent episode of UPSI. It is again, too late for a copper IUCD as ovulation may have occurred, despite taking ellaOne. If a pregnancy occurred from the earlier episode of UPSI, UPA will neither displace that pregnancy nor cause any harmful effects.
Anne should be advised that the risk of EC failure is higher as there are now 2 chances for EC failure.
Contacts
The Irish Family Planning Association (IFPA) is a leading provider of sexual and reproductive healthcare. IFPA provides a comprehensive range of services including abortion care, contraception, STI screening and treatment and specialist pregnancy counselling.
IFPA clinic Cathal Brugha street 01 872 7088IFPA clinic Tallaght 01 459 7685IFPA Appointment Line 0818 49 50 51
My Options Helpline 1800 828 010. My Options is a HSE freephone line. The helpline provides information and support including contact details for abortion services nationwide and continued pregnancy supports.
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