Opening up the emergency contraception talk

New efficacy information and revelations on the impact of patient body weight have been included in updated guidance on the use of emergency contraceptives from the American College of Obstetricians and Gynecologists (ACOG).

The updated ACOG recommendations were released in August as an update to the published recommendations from 2010.

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There have been many changes on the emergency contraception front since this type of therapy first was approved by the US Food and Drug Administration (FDA) in 1998. Also known as post-coital contraception, it is used to prevent pregnancy after unprotected or inadequately protected sexual intercourse. Most commonly, the need for emergency contraception arises from the failure of other forms of birth control (such as a broken condom or missed oral contraceptive doses), says ACOG.

Since the first approval in 1998, emergency contraception now includes multiple options including oral estrogen-progestin, progestin only, selective progesterone receptor modulators, or intrauterine device (IUD) insertion. Due to the bevy of options now available, ACOG reminds physicians that most women are unaware of the emergency contraception available to them or have misconceptions regarding its use.

The updated ACOG bulletin was created to summarize the recommendations for use and efficacy of the various emergency contraceptive options available to women today.

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Treatment options

The first oral emergency contraceptive was an estrogen-progestin pill developed in 1974. The development of oral progestin-only and IUDs also began in the 1970s, and selective progesterone receptor modules were introduced more recently. Progestin-only oral treatments are the most commonly used emergency contraceptive today, says ACOG, and oral contraceptives have been available for purchase without a prescription or age restriction since 2013.

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The formulation of a single dose of 1.5 mg of levonorgestrel has replaced the earlier 2-dose 0.75 mg regimen out of simplicity, and ACOG says the single dose regimen is “at least as effective as the 2-dose product.” Levonorgestrel is indicated for use for up to 72 hours after unprotected sex, but use as soon as possible after intercourse is recommended. Levonorgestrel offers a 2.2% pregnancy rate.

A newer oral medication-a selective progesterone receptor modulator-was approved by FDA in 2010 and requires a prescription. However, the pill-30 mg of ulipristal acetate-has been shown to be effective for up to 120 hours after unprotected sex, says ACOG. Ulipristal acetate users have experience pregnancy rates of 1.4%, according to ACOG.

Estrogen-progestin is no longer available as a dedicated product, ACOG notes, but can be formulated from standard oral contraceptives, says ACOG. The least effective option, estrogen-progestin has a 2.7% pregnancy rate plus more side effects than the levonorgestrel-only regimen.

Copper IUDs can also be used as emergency contraception and are highly effective when placed within 5 days of intercourse, says ACOG. Some studies have even shown effectiveness up to 10 days after intercourse, ACOG says, but notes that FDA has not labeled IUDs for emergency contraceptive use. The FDA is currently investigating levonorgestrel-containing IUDs for use as an emergency contraceptive, ACOG says. Still, ACOG says copper IUDs are the most effective method of emergency contraception and have better efficacy rates in a broader population. For example, women whose body mass index was above 25 experienced greater failure rates when taking hormonal emergency contraceptives like levonorgestrel or ulipristal acetate, according to ACOG, whereas the efficacy of a copper IUD is not affected by body weight. Therefore, ACOG says, IUDs are recommended in cases where the patient is overweight or obese. Additionally, IUDs are beneficial in that they can be used as a long-acting reversible contraception after its use as an emergency contraceptive is fulfilled.

Methods of action

Each regimen works a little differently, ACOG notes. Ulipristal acetate delays ovulation and inhibits follicular rupture even after luteinizing hormone begins to increase. Levonorgestrel inhibits or delays ovulation, and delays follicular development when used before luteinizing hormone begins to increase. Copper IUDs prevent fertilization by altering sperm viability and function, and possible affecting the oocyte and endometrium. Evidence suggests that most emergency contraception methods prevent implantation of a fertilized egg in one way or another and ACOG says emergency contraception should be not be confused with medical abortions, which terminate existing pregnancies rather than preventing pregnancy before implantation. In fact, ACOG notes, hormonal emergency contraceptives are ineffective and pose no risk to established pregnancies and developing embryos.

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Adverse effects and misconceptions

In terms of adverse effects, only short-term adverse effects have been linked to emergency contraceptives, ACOG says. Ulipristal acetate can cause nausea and headaches. Levonorgestrel can cause nausea, headaches, and non-menstrual bleeding within the first week after use. Estrogen-progestin regimens have more complaints of nausea than other treatment regimens, ACOG notes. Other side effects emergency contraceptives may include breast tenderness, abdominal pain, dizziness, and fatigue. American College of Obstetrics and Gynecology says IUD insertion also carries a risk of uterine perforation, uterine cramping, increased menstrual flow, or dysmenorrhea.

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There have been some concerns that making emergency contraceptives widely available will increase high-risk sexual behavior or unintended pregnancy, acknowledges ACOG, but several studies have shown that this is not the case. In some cases, women are being provided emergency contraception at routine gynecologic visits, and ACOG says studies comparing the use of previously provided emergency contraceptive and contraceptives obtained only as needed yielded no difference in self-reported frequency of unprotected intercourse.

Other misconceptions about emergency contraceptives abound, as well, and these misconceptions may be preventing greater knowledge of the availability of these treatments. American College of Obstetrics and Gynecology reports that only 64% of adolescents surveyed at urban emergency departments had ever heard about emergency contraceptives, and even physicians aren’t well versed. One in 5 physicians were reluctant to provide education on emergency contraption in a 2008 study, and ACOG reveals that only 21% to 50% of eligible sexual assault victims treated in emergency departments received emergency contraception.

Availability has improved since the initial approval of emergency contraception, but it is still a problem in some areas and for certain populations. However, ACOG says studies found that the percentage of pharmacies unable to provide emergency contraceptives within 24 hours dropped from 23% in 2005 to 8% in 2007. More recent studies were not available, but ACOG says there have been reports that emergency contraceptives are still difficult for adolescents to obtain in some areas.

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Candidates for emergency contraception

The Centers for Disease Control and Prevention (CDC) does not list any conditions that would prevent a woman who wants to prevent pregnancy after unprotected intercourse from using emergency contraception. The CDC specifically states that women who are breastfeeding; who had previous ectopic pregnancies; or who have cardiovascular disease, renal disease, or migraines may all use these regimens.

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“Therefore, any emergency contraceptive regimen may be made available to women with contraindications to the use of conventional oral contraceptive preparations,” ACOG states. “Reproductive-aged women who are victims of sexual assault always should be offered emergency contraception.”

No clinical examinations or screenings are necessary prior to the use of emergency contraceptives, and treatment should not be delayed for any reason, ACOG says. No clinical follow up is needed after emergency contraceptive use, unless the woman’s regular menstrual period is delayed by a week or more, or if lower abdominal pain or bleeding persists/develops. Women who continue to have intercourse immediately after using an emergency contraceptive must still use protection, and ACOG recommends barrier contraceptive use immediately. American College of Obstetrics and Gynecology notes that regular hormonal contraceptive regimens can be resumed immediately after oral contraceptive use, but abstinence or a backup barrier method of birth control is recommended for 14 days or until the next menses. The FDA also recently updated its recommendation for ulipristal acetate to warn against resuming regular hormonal contraception until at least 5 days after the emergency contraceptive was used.