Category Archives: Emergency contraception

  • Several studies have shown that facilitating access to EC does not increase sexual or contraceptive risk-taking behaviour1
  • A number of studies show that women and adolescents with greater access to EC are not more likely to engage in unprotected intercourse, and are more likely to adopt an ongoing contraceptive method after EC use2,3
  • Use of ECPs has no effect on future fertility1,4
  • There is no indication demonstrating that ECPs harm a developing foetus if they are mistakenly taken early in preg­nancy1,5
  • ECPs do not interrupt an existing pregnancy1,4
  • Women find the label and instructions easy to understand1,6
  • ECPs do not protect against STIs.7 Only condoms protect against sexually transmitted infections
  • ECPs do not provide contraceptive cover for unprotected intercourse in the days after intake7

 

References
1.World Health Organization. (In association with the International Consortium for Emergency Contraception, International Federation of Gynaecology and Obstetrics, International Planned Parenthood Federation, Department of Reproductive Health and Research). Fact sheet on the safety of levonorgestrel-alone emergency contraceptive pills. Available at: http://whqlibdoc.who.int/hq/2010/WHO_RHR_HRP_10.06_eng.pdf. Accessed October 2013.
2.Polis et al. The Cochrane Library 2013, Issue 7.
3.Gainer E et al. Contraception 2003; 68(2): 117-24.
4.ellaOne® European Summary of Product Characteristics.
5.HRA Pharma Data on file. Clinical overview.
6.ellaOne® readability testing
7.NHS choices – emergency contraception. Available at http://www.nhs.uk/Conditions/contraception-guide/Pages/emergency-contraception.aspx. Accessed October 2013.

30% of women aged 16-45 year old reported at least one UPSI in the last 12 months.

76% of these did not use emergency contraception, putting themselves at risk of unintended pregnancy.

11.Web EC after UPSI

The reasons given for not using EC included:1

• Lack of awareness of pregnancy risk

• Lack of immediate connection to EC – did not think about it

• Lack of knowledge about time-related efficacy

• Access issues

• Misconceptions about EC or fear of being judged/embarrassment

EC provides women with a last chance to prevent pregnancy after unprotected sex, yet it is still largely underused.

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Women who take EC understand they need to act fast1

Of those who took EC, the vast majority (87%) took it within 24 hours with just 10% waiting until the second day.1 Intake of EC after 72 hours is rare.1

 

To ensure maximum efficacy, it is important to take EC as soon as possible after unprotected sexual intercourse.

 

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References

1. Data on file. HRA Pharma Report. Women and emergency contraception in 2012. A European Survey.

Current emergency contraception solutions are :

• Fitted, as an intrauterine device

• Oral, as a tablet

The IUD which is suitable for EC is a Copper-T IUD

IUDs are considered the most effective EC option1, but they may not be a practical option for many women. The advantage of an IUD is that it provides an ongoing contraceptive solution.1 But when speed is of the essence, women may not want to rush a decision to fit this long acting reversible contraceptive (LARC).

The Copper-T IUD can be fitted up to 120 hours (5 days) after unprotected sex.2 Its use is restricted by its availability and the need to be inserted by a skilled healthcare professional.

Women who may need a copper IUD for emergency contraception must be advised to contact a GP, a gynaecologist or family planning service as a matter of urgency.2 Pharmacists should direct women to a local service known to provide IUDs.2

Copper IUD is considered the most effective EC method1, but in a situation where you need to act very quickly, IUD fitting takes time and involves an invasive and uncomfortable procedure.3

 

There are two oral ECs available4

• One containing levonorgestrel which was first made available in 1999

• One containing ulipristal acetate (ellaOne®), which was launched in 2009. Unlike other ECs, it was specifically developed for EC

 

The mechanism of action of oral ECs is to inhibit or postpone ovulation, so that no ovum is released5,8. Oral ECs are also called ECPs (Emergency Contraceptive Pills).

Mechanism of action of oral EC

ECPs work by inhibiting or delaying ovulation (the release of an egg), so that fertilisation cannot take place.5,8

Emergency contraceptive pills will not prevent pregnancy in 100% of cases.5 This is because there is a chance that the woman has already just ovulated when she takes an emergency contraceptive pill.6 Taking emergency contraceptive pills as soon as possible after unprotected sex gives the best chance of success.7  

ECPs have no effect on fertilisation if ovulation has already happened. They do not interfere with an implanted egg (pregnancy),5,8 so they do not cause abortion. 5,6

ECPs are suitable for women of reproductive age and have a very good safety profile.5,9 ECPs do not protect from sexually transmitted infections (STIs).8

As ECPs work by preventing or delaying ovulation, they are not 100% effective. If ovulation has just occurred before unprotected intercourse, ECPs will not be effective. Therefore, ECPs are back-up contraception solutions, which do not replace a regular contraceptive method. 

References
1.Cheng L et al. Cochrane Database Syst Rev. 2012; 8: CD001324.
2.Royal Pharmaceutical Society of Great Britain. Practice guidance on the supply of emergency hormonal contraception 2004.
3.Glasier AF et al. The Lancet 2010; 375: 555-562.
4.HRA Pharma Data on file. Clinical overview.
5.ellaOne® European Summary of Product Characteristics.
6.Faculty of Sexual and Reproductive Healthcare. Guideline on Emergency contraception 2012. Available at http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf. Accessed October 2013.
7.NHS choices – emergency contraception. Available at http://www.nhs.uk/Conditions/contraception-guide/Pages/emergency-contraception.aspx. Accessed October 2013.
8.World Health Organization. (In association with the International Consortium for Emergency Contraception, International Federation of Gynacology and Obstetrics, International Planned Parenthood Federation, Department of Reproductive Health and Research). Fact sheet on the safety of levonorgestrel-alone emergency contraceptive pills. Available at: http://whqlibdoc.who.int/hq/2010/WHO_RHR_HRP_10.06_eng.pdf AccessedOctober2013.

Pharmacists are front line health care providers around the world. For many people they are the first point of contact with the health system. Emergency contraceptive pills are available without a prescription directly from pharmacists in most European countries, making pharmacists key EC providers in these settings.1

 

HRA-Paharmacie-Situations-368 (1280x853)

The OTC availability of emergency contraceptive pills is critical to increase access and minimise delay of intake. This is especially significant given that emergency contraceptive pills are more effective the sooner they are taken after unprotected intercourse.

When a woman must visit a doctor or other appropriate healthcare provider before she can get an ECP, she often has to make two trips:

• One to a clinic to obtain a prescription

• A second to a pharmacist to fill the prescription

This presents a significant barrier for many women, especially those who do not have transport, or who live in rural areas, without easy access to doctors or pharmacies. Having to make two trips before she can obtain an emergency contraceptive pill causes a delay in intake. In addition, the need for a prescription makes access to ECPs on weekends and at night (when many contraceptive mishaps occur) more difficult.

 

Pharmacists offer advantages in terms of location, convenience and opening times.2 OTC availability of ECPs means that women only have to make one trip. This means women can get oral emergency contraception within 24 hours of unprotected intercourse, when treatment is known to be most effective.2 Women may also like the anonymity of the pharmacy as they can feel embarrassed about needing emergency contraception.3

An International Pharmaceutical Federation (FIP) paper on the pharmacists’ role in improving maternal, newborn, and child health highlights the benefits of pharmacy ECP involvement:4

• When women obtain ECP from a pharmacy instead of a physician or clinic, there are cost-savings for both private and public payers4

• Pharmacists promote dialogue on contraceptive alternatives and influence the beliefs and the outcomes through effective counselling on ECPs. The supply of emergency contraception from pharmacies can be accompanied by patient education from pharmacists, who have expertise on this topic4

• Pharmacists provide information to patients at the time of ECP dispensing, which allows women to understand proper use of this medicine. Pharmacists ensure consistency of information about ECPs, in particular for women less than 16 years of age4

Pharmacy access to ECPs has not led to any negative consequences

When EC is available through pharmacies without a prescription, the use of the medication increases compared to when it is available from doctors, clinics or hospitals.4 Increased access to EC through pharmacies does not have a negative impact on the use of other forms of contraception.4

Studies show that women and adolescents with greater access to EC are more likely to adopt an ongoing contraceptive method after EC use 9. Notably, it has been shown that greater level of use through non-prescription availability:

Does not lead to increased rates of STIs6

Does not increase sexual risk-taking behaviour in adolescents7,8

Does not lead to increased frequency of unprotected sex5

Does not lead to decreased use of other contraceptive methods5

Does not lead to decreased use of contraception, including the most effective methods such as hormonal methods, and including condoms5,8

• Women’s EC experience is actually a motivating factor leading to more consistent use of regular contraception5

14.Web contraceptive use change

 Good Pharmacy Practice can include :

• Asking the right questions; avoiding unnecessary, personal or intrusive questioning
• Providing quality advice in a sensitive way, without lecturing
• Providing an environment where women feel comfortable and not judged

 

The quality of the pharmacy interaction is an important determinant of proper use, leading to fewer unwanted pregnancies and appropriate use of the product. It is also likely to be an important factor in a woman’s decision to take action in the event of a future UPSI.

 

References
1.International consortium for EC. Available at www.cecinfo.org. Accessed October 2013.
2.Taylor B. Journal of Family Planning and Reproductive Health Care 2003: 29(2): 7.
3.HRA data on file. Hamell research, Pharmacists’ recommending behaviour in emergency contraception. April 2013.
4.International Pharmaceutical Federation (FIP): FIP reference paper on the effective utilization of pharmacists in improving maternal, newborn and child health (MNCH) 2011. Available at http://www.fip.org/www/uploads/database_file.php?id=325&table_id=. Accessed October 2013
5.Polis et al. The Cochrane Library 2013, Issue 7.
6.Walker et al. J Adolesc Health 2004; 35(4): 329-34.
7.Raine TR et al. JAMA 2005; 293: 54–62.
8.Moreau C et al. 2009. Am J Public Health 2009; 99: 441–442.
9.Gainer E et al. Contraception 2003; 68(2): 117-24.
10.Good Pharmacy Practice. Joint FIP/WHO Guidelines on GPP: Standards for quality services 2012. Available at: http://www.fip.org/www/uploads/database_file.php?id=331&table_id=. Accessed October 2013.

Definition

Emergency contraception (EC) is defined as the use of any drug or device after unprotected intercourse to prevent an unintended pregnancy.1

It is an ‘after-sex’ or ‘back-up’ contraception solution.

It is also commonly known as the ‘morning-after pill’ or ‘day-after pill’

When is EC used?

Emergency contraception can best prevent pregnancies when used soon after intercourse. It provides an important back-up in cases of unprotected intercourse or contraceptive accident (such as forgotten pills, torn condoms) and after rape or coerced sex.2

How women might explain their need for EC

  • Condom broke or slipped off
  • Missed Pill, forgot to insert contraceptive ring or apply patch
  • Diaphragm or cap slipped out of place
  • Failure of withdrawal method
  • No contraception used
  • They were forced to have unprotected sex

Overview of EC history

The idea of EC is not new. Investigation into post-coital contraception began in the 1920s.

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References
1.Consensus statement on emergency contraception. Contraception 1995; 52: 211–3.
2.World Health Organization. (In association with the International Consortium for Emergency Contraception, International Federation of Gynaecology and Obstetrics, International Planned Parenthood Federation, Department of Reproductive Health and Research). Fact sheet on the safety of levonorgestrel-alone emergency contraceptive pills. Available at: http://whqlibdoc.who.int/hq/2010/WHO_RHR_HRP_10.06_eng.pdf. Accessed October 2013.
3.Ellertson C. Fam Plann Perspect 1996; 28(2): 44-8.
4.Haspels AA and Andriesse R. Europ J Obstet Reprod Biol 1973; 3/4: 113-117.