Emergency Contraception

Emergency contraception (EC) is a term that encompasses more than the name implies. Rather than being simply a postcoital form of birth control, this method can be used, in certain circumstances, as long as 8 days after the act of unprotected intercourse in hopes of preventing pregnancy. EC can be accomplished by oral route and through the insertion of a copper intrauterine device (IUD). The oral regimens available in the United States include a second-generation antiprogestin, progestin-only pills, and levonorgestrel-containing oral contraceptives. The current second-generation antiprogestin (ella) available in the United States is only available by prescription. The most common regimen is a dedicated progestin-only product that is concentrated so that fewer pills have to be swallowed. The history of U.S. public policy toward EC is convoluted at best. Suffice to say that as of August 2013, Plan B One-Step became available in the United States without prescription to males and females with no age restriction. The generic one-pill products are also now approved for over-the-counter sale. There is an excellent Internet site devoted to EC that was developed by Dr. James Trussell, Princeton University (http://ec.princeton.edu), in collaboration with the Association of Reproductive Health Professions. It contains complete, detailed information on EC for providers as well as resources for patients. See Table 16-1.

Effectiveness rates are difficult to ascertain. All in all, the insertion of a copper-containing IUD has the highest effectiveness rate. The effectiveness rate of oral contraceptive pill (OCP) use varies based on the time in the cycle of unprotected intercourse and study variations. In general, it is usually stated that EC will prevent about 75% of the unintended pregnancies that would have resulted had no treatment been given in those circumstances. The impact of obesity on effectiveness of levonorgestrel products is presently being researched but no current recommendations exist. This is a topic that requires watching.

It is important to remember that acts of unprotected intercourse do not always happen because patients were unprepared. In many cases, the condom breaks, the woman discovers that her diaphragm slipped, or the IUD string can’t be felt. It is important for triage nurses to avoid being judgmental when patients call for help.

You will need to discuss with your providers how they will handle calls for this service. For example, not all practices offer IUD insertion for this purpose. For specific information, including the names of local providers and pharmacies where patients can get assistance if not offered through your practice, refer to the Princeton website (http://ec.princeton.edu/questions/index.html) or the EC National Hotline (1-888-NOT-2-LATE).

» BASIC TRIAGE ASSESSMENT FORM FOR EMERGENCY CONTRACEPTION

How long ago was the first act of unprotected intercourse? (Remember there may have been multiple exposures.)__________________________________________________________________
What (if any) form of contraception were you using?___________________________________
Would you like to continue using this method in the future?___________________________
If not, is there another method you would like to try?________________________________

Emergency Contraception With Dedicated Products or Oral Contraceptives

» Actions

STEP A: Unprotected Intercourse Within 120 Hours

If unprotected intercourse has occurred within 120 hours, the following advice may prevent unintended pregnancy. The timing of dosing is important, so encourage patients to start as soon as possible. Although the original research for EC (and current labeling information for Plan B) was based on a time frame of two doses taken 12 hours apart within 72 hours, recent research has found that some products can be taken at once and that the time interval postcoitus can be expanded to 120 hours.

If using combined OCPs, please refer to Table 16-1.

If the patient wishes to start taking oral contraceptives or use Ortho Evra or NuvaRing, that regimen should be initiated the day after Plan B doses or the day after the second dose of oral contraceptives used as EC. Have her use a backup method of contraception for 7 days.

Refer to the Patient Education section if nausea or vomiting occurs.

STEP B: More than 120 Hours Since Unprotected Intercourse

If it has been more than 120 hours but less than 8 days, offer the patient EC with an IUD (see Emergency Contraception With a Copper IUD protocol on page 325). This not only is the most effective type of EC, it will also provide her with a reliable method. Carefully assess her sexually transmitted disease (STD) risk if she chooses this method.

If it has been more than 8 days, advise the patient to use a backup method until her next period.

Advise the patient to expect a period within 21 days if she usually has 28- to 30-day cycles.

Once menses resumes, she should be encouraged to use a contraceptive method she will use regularly.

If the patient has no menses in 21 days, advise her to take a home pregnancy test and see a clinician if the result is positive.

If the home pregnancy test is negative and she still has no menses, advise her to continue using the backup contraceptive method, take another pregnancy test in 7 to 10 days, and consult a clinician even if that test result is negative.

» Patient Education

If the patient is experiencing nausea, reassure her that it usually passes. If she has used oral contraceptives instead of a dedicated product, she might try taking her next dose with an antinausea medication as approved for use by your office or clinic protocols.
The patient should be advised to call back if she throws up within an hour after taking the pills. She may need to retake the dose and would be better served by doing so with antinausea medication.
Even though dedicated products for EC are available without a prescription to women and men without age restrictions in the United States, not all pharmacies may stock the drug. It would be helpful for patients to know which pharmacies in your area carry a ready supply. There are products available online, but this may not be practical for this pregnancy exposure. However, this does allow a woman to have a dose available on hand.
Patients need to understand that EC is not a substitute for regularly used contraceptive measures. They are not as effective over time as other ongoing methods of contraception. If patients find they are repeatedly failing to use a chosen method of contraception, help them choose a method with which they can succeed.

Table 16-1 Emergency Contraception With Dedicated Products or Oral Contraceptives Available in the United States^a

Brand		Company	First Dose^a	Second Dose^b (12 hr later)	Ulipristal Acetate per Dose (mg)	Ethinyl Estradiol per Dose (µg)	Levonorgestrel per Dose (mg)^c
*Ulipristal acetate (dedicated EC pills)*
ella		Afaxys	1 white pill	None	30	—	—
*Progestin-only (dedicated EC pills)*
Aftera^c		Teva	1 white pill	None	—	—	1.5
AfterPill^d		Syzygy	1 white pill	None	—	—	1.5
Athentia Next		Aurobindo	1 white pill	None	—	—	1.5
EContra EZ^e		Afaxys	1 white pill	None	—	—	1.5
Fallback Solo		Lupin	1 white pill	None	—	—	1.5
MyWay		Gavis	1 white pill	None	—	—	1.5
Next Choice		Actavis	1 peach pill	None	—	—	1.5
One Dose
	Opticon	Sun Pharma	1 white pill	None			1.5
One-Step
	Plan B	Teva	1 white pill	None	—	—	1.5
One-Step
	Take Action	Teva	1 white pill	None	—	—	1.5
*Combined progestin and estrogen pills (regular oral contraceptive pills)*
Afirmelle		Aurobindo	5 white pills	5 white pills		100	0.50
Altavera		Sandoz	4 peach pills	4 peach pills	—	120	0.60
Amethia		Actavis	4 white pills	4 white pills	—	120	0.60
Amethia Lo		Actavis	5 white pills	5 white pills	—	100	0.50
Amethyst		Actavis	6 white pills	6 white pills	—	120	0.54
Aubra		Afaxys	5 white pills	5 white pills	—	100	0.50
Ayuna		Aurobindo	4 orange pills	4 orange pills	—	100	0.50
Aviane		Teva	5 orange pills	5 orange pills	—	100	0.50
Camrese		Teva	4 light blue-green pills	4 light blue-green pills	—	120	0.60
Camrese Lo		Teva	5 orange pills	5 orange pills	—	100	0.50
Chateal		Afaxys	4 white pills	4 white pills	—	120	0.60
Cryselle^f		Teva	4 white pills	4 white pills	—	120	0.60
Elinest^f		Novast	4 orange pills	4 orange pills	—	120	0.60
Enpresse		Teva	4 orange pills	4 orange pills	—	120	0.50
Falmina		Novast	5 orange pills	5 orange pills	—	100	0.50
Introvale		Sandoz	4 peach pills	4 peach pills	—	120	0.60
Jolessa		Teva	4 pink pills	4 pink pills	—	120	0.60
Kurvelo		Lupin	4 peach pills	4 peach pills	—	120	0.60
Lessina		Teva	5 pink pills	5 pink pills	—	100	0.50
Levonest		Norvast	4 light-brown pills	4 light-brown pills	—	120	0.50
Levora		Actavis	4 white pills	4 white pills	—	120	0.60
LoSeasonique		Teva	5 orange pills	5 orange pills	—	100	0.50
Low-Ogestrel^f		Actavis	4 white pills	4 white pills	—	120	0.60
Lutera		Actavis	5 white pills	5 white pills	—	100	0.50
Marlissa		Glenmark	4 peach pills	4 peach pills	—	120	0.60
Myzilra		Novast	4 yellow pills	4 yellow pills	—	120	0.50
Nordette		Teva	4 light-orange pills	4 light-orange pills	—	120	0.60
Orsythia		Vintage	5 pink pills	5 pink pills	—	100	0.50
Portia		Teva	4 pink pills	4 pink pills	—	120	0.60
Quasense		Actavis	4 white pills	4 white pills	—	120	0.60
Seasonale		Teva	4 pink pills	4 pink pills	—	120	0.60
Seasonique		Teva	4 light blue-green pills	4 light blue-green pills	—	120	0.60
Setlakin		Novast	4 pink pills	4 pink pills	—	120	0.60
Sronyx		Actavis	5 white pills	5 while pills	—	100	0.50
Triphasil		Wyeth	4 yellow pills	4 yellow pills	—	120	0.50
Trivora		Actavis	4 pink pills	4 pink pills	—	120	0.50
Vienva		Sandoz	5 white pills	5 white pills	—	100	0.50
^aella and the levonorgestrel emergency contraception products (ECPs) listed in the top section are dedicated products specifically marketed for EC. The regular oral contraceptives listed above have been declared safe and effective for use as ECPs by the U.S. Food and Drug Administration. Outside the United States, about 100 ECPs are specifically packaged, labeled, and marketed. Levonorgestrel-only ECPs are available either over-the-counter or from a pharmacist without having to see a clinician in 60 countries. In the United States, progestin-only ECPs, like Plan B One-Step, is available on the shelf with no restrictions. ella is available by prescription only.^bThe label for Levonorgestrel Tablets says to take one pill within 72 hours after unprotected intercourse and another pill 12 hours later. However, research has found that both pills can be taken at the same time. All of the brands listed here may be effective when used within 120 hours after unprotected sex but should be taken as soon as possible.^cAftera is sold exclusively at CVS stores.^dAfterPill is sold online at www.afterpill.com.^eEContra EZ is sold at family planning clinics and online at www.kwikmed.com.^fThe progestin in Cryselle, Elinest, and Low-Ogestrel is norgestrel, which contains two isomers, only one of which (levonorgestrel) is bioactive; the amount of norgestrel in each tablet is twice the amount of levonorgestrel.
(Reproduced with permission of James Trussell, PhD, Office of Population Research and Association of Reproductive Health Professionals,© 2017. For an updated list, check this website frequently: http://ec.princeton.edu.)