Emergency Contraception

Methods of Emergency Contraception

1. Oral methods:
   • It must be taken as soon as possible after intercourse for maximum efficiency. o Ulipristal acetate (UPA) is effective within 5 days after unprotected intercourse (30 mg single dose). o             Levonorgestrel is effective within 3 days (1.5 mg tablet), it can be taken on day 4 but is less effective.
2. Copper intrauterine device (Cu-IUD):
   • The most effective method of emergency contraception with a failure rate of <0.01%.
   • Can be inserted within 5 days of unprotected intercourse or estimated ovulation.
   • Effective even after ovulation has occurred – within 5 days of the earliest date of ovulation: [date of LMP + number of days in shortest cycle – 14]

Effectiveness & Considerations

The effectiveness of oral methods can be reduced by:

• Liver enzyme-inducing medications (affecting both UPA and levonorgestrel).
• Levonorgestrel: Reduced effectiveness in individuals with a BMI >26 or a weight >70 kg.
• UPA: Reduced effectiveness if progestogen-containing contraception is taken within 5-7 days after UPA.

Advantages & Disadvantages of Emergency Contraception

• Cu-IUD:
  • Advantages: Can be used postpartum, is most effective, not affected by hormonal changes, and can be left in place for ongoing contraception.

Disadvantages: Potential for unscheduled bleeding, expulsion, perforation, and pelvic inflammatory disease.

• UPA: o Advantages: Readily available and effective within 5 days.
  • Disadvantages: May require repeat doses if vomiting occurs within 3 hours, not effective after ovulation. o Side effects include nausea, headaches, dizziness & mood swings
• Levonorgestrel:
  • Advantages: Can be used within 72 hours. o Disadvantages: Must be repeated if vomiting occurs within 3 hours, not effective after ovulation. o Side effects include abdominal pain, headaches & vomiting

Emergency Contraception After Contraceptive Failure

1. Combined hormonal contraceptive (CHC) patch or ring:
   • Indicated if detached or removed for >48 hours during the first week + UPSI or barrier failure during HFI
   • Use levonorgestrel if CHC was used 7 days prior.
   • Use Cu-IUD if it occurs during the hormone-free interval.
2. COCP – Missed pills:
   • Indicated if >2 pills missed within the first week with UPSI or barrier failure during HFI or in week 1
   • Use levonorgestrel if CHC was used 7 days prior.
   • Cu-IUD is offered for up to 13 days after the hormone-free interval.
3. Progestogen-only pills (POP) – Missed pills:
   • Indicated if the last pill was taken >27 hours (or 36 hours if using desogestrel only pill) ago with unprotected intercourse.
   • Use levonorgestrel if POP was used within 7 days prior.
   • Use Cu-IUD for up to 5 days after unprotected intercourse.
4. Injectable contraception:
   • Indicated for unprotected intercourse after 14 weeks of the last injection.
   • Use Cu-IUD up to 5 days post-intercourse.
5. Implant: Usually does not require emergency contraception.
6. Displaced or expelled IUDs: May require replacement.
7. Enzyme-inducing medication use/within 28 days of use + UPSI:
   • Emergency contraception is indicated if UPSI/failure of barrier methods during or within 28 days of enzyme-inducing drug use
   • Ideally, use Cu-IUD or double-dose levonorgestrel