Emergency contraception: Clinical sciences

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Introduction0:00–0:49

Emergency contraception is used to prevent unintended pregnancy after unprotected or inadequately protected sexual intercourse.
Many patients don’t fully understand what emergency contraception is or how it differs from medical abortion, which is why some of them don’t use it when needed.
While medical abortion is used to end a confirmed pregnancy, emergency contraception works by preventing pregnancy after sexual intercourse and is ineffective after implantation.
Different types of emergency contraception are available, including levonorgestrel, ulipristal acetate, combined oral contraceptives, and intrauterine devices.
Okay, let’s talk about what to do when a patient presents after unprotected or inadequately protected sexual intercourse and does not desire pregnancy.The good news is that there are no exams or testing necessary!

Patient presentation0:49–1:58

In fact, emergency contraception should be utilized as soon as possible after unprotected or inadequately protected intercourse.
So, there’s no need to wait for any test results, not even a pregnancy test! First, ask how long it’s been in days or hours since intercourse and go from there.
Here’s a clinical pearl! Always counsel patients on emergency contraception.
Unfortunately, you may not know if your patient is experiencing intimate partner violence or if they’ve been or ever become a victim of sexual assault; so routinely discussing and prescribing emergency contraception can make a big difference.
The oral levonorgestrel product is available over the counter without age restriction. Okay, if it’s been up to 5 days, or 120 hours, since intercourse the patient can receive emergency contraception.

< 5 days since intercourse1:58–11:30

The first and most commonly used option is oral levonorgestrel, commonly known as Plan B. This method is most effective the sooner it’s taken from the act of unprotected sexual intercourse, ideally when taken within 72 hours, but continues to reduce the risk of pregnancy up to 120 hours.
Unlike every other form of emergency contraception out there, a prescription is not required and levonorgestrel can be purchased over the counter!
Now, levonorgestrel is a progestin-only hormonal pill and it works primarily by preventing or delaying ovulation. This medication becomes less effective after the LH surge has begun and is not effective after ovulation has already occurred.
Most patients tolerate it well, however some common side effects include nausea and vomiting.Be sure to give some information to your patient about this method.
First, since ovulation is prevented or delayed, your patient can become pregnant after taking levonorgestrel if they have another unprotected intercourse in the same menstrual cycle.
Therefore, it’s important to counsel them to abstain from intercourse or use barrier protection going forward. Next, if your patient wants to begin using long-term birth control, like oral contraceptive pills, an IUD, or other hormonal methods, you can initiate it right away; however, you must remember to let them know that abstinence or barrier protection is necessary during the first 7 days as the hormones take effect.
As a final piece of advice, tell your patient to try and avoid repeated use of hormonal emergency contraception and instead consider long-term options.
While it is okay to use multiple doses, even in the same menstrual cycle, there’s no long-term information on the safety if used frequently.
Additionally, the high level of levonorgestrel in each dose may cause menstrual irregularities, making it harder for patients to reliably track their cycles.
Let’s move on to another option for emergency contraception, called ulipristal acetate. This is the most effective form of oral emergency contraception and maintains its effectiveness for up to 5 days, or 120 hours, after intercourse.
Now, ulipristal acetate is a selective progesterone receptor modulator or anti-progestin pill. It works similarly to levonorgestrel in that it delays or prevents ovulation, it’s not effective after the LH peak or after ovulation has already occurred, and like levonorgestrel options, it does not affect implantation of a fertilized egg.
The most common side effects are nausea and vomiting as well. If choosing this route, take this opportunity to counsel your patient on its use as an episodic intervention rather than an effective long-term method of birth control, and discuss long-term options if they’re not on them.
Alright, there’s a catch. If your patient wants to begin using long-term hormonal birth control, be sure to let them know that they should wait 5 days after taking ulipristal acetate.
This is because ulipristal acetate and hormonal contraception both compete for the same progesterone receptors and can basically cancel each other out.
This actually increases the risk of an undesired pregnancy! Additionally, advise your patients to use barrier protection for 14 days or until their next menses, whichever comes first.
Here’s a clinical pearl! Body weight influences the effectiveness of oral emergency contraception.
Levonorgestrel and ulipristal acetate might be less effective in patients who are overweight or obese, with data that levonorgestrel could be less effective than ulipristal in these patients.
Both remain viable options nonetheless, and this should not be a reason to withhold them, but consider suggesting an IUD as an alternative in this population.
Okay, another method for emergency contraception is using a high dose of oral contraceptive pills, called the Yuzpe method, to prevent pregnancy.
The Yuzpe method is the least effective form of emergency contraception, but can be a good option if your patient cannot readily access other methods.
Be warned, this one requires some math! So, the Yuzpe method involves taking two calculated doses of combined oral contraceptive pills, 12 hours apart.
The aim is to take a number of pills that provide at least 100 micrograms of ethinyl estradiol and 0.5 milligrams of active progestin, preferably levonorgestrel.
In other words, your goal is to load up on the progestin portion of oral contraceptive pills to reach the effective dose needed to prevent or delay ovulation.
Since there are many different doses of combination pills, the number of tablets needed for each dose will vary. For example, if each combination pill contains 20 micrograms of ethinyl estradiol and 0.1 milligrams of levonorgestrel, you would recommend that a patient takes 5 tablets for the first dose, which adds up to 100 micrograms of ethinyl estradiol and 0.5 milligrams of levonorgestrel.
Their second dose should include another 5 tablets, taken 12 hours later. Due to the high doses of estrogen in this method, it’s associated with more nausea and vomiting than others, so you should prescribe an antiemetic as well!
Let’s move on to intrauterine devices, or IUDs, which can also be used for emergency contraception. IUDs are T-shaped devices that are placed in the uterus and require an office visit for insertion.
There are two intrauterine options that can be used for emergency contraception; the copper IUD and the levonorgestrel. The copper IUD is a non-hormonal long-term reversible contraceptive, whereas the levonorgestrel IUD is hormonal in nature.
The primary mechanism of action, when used as emergency contraception, is by preventing fertilization by inhibiting sperm migration and viability.
These can be placed up to 5 days after the act of unprotected sex! Once placed, IUDs can serve as long-term options for birth control as well.Here’s a high-yield fact!
The copper IUD is the most effective method of emergency contraception. However, Wilson’s disease is a definitive contraindication to placing a copper IUD.Unlike oral emergency contraceptives, a patient’s weight does not reduce the effectiveness of IUDs.
If using this method, counsel the patient on the risks of an IUD, which include expulsion and uterine perforation. Also, discuss possible side effects, like heavy menstrual bleeding for the copper IUD and decreased amount of bleeding or irregular periods for the levonorgestrel IUD.
There are very few contraindications to IUDs. Some of them include pregnancy, active pelvic infection at the time of insertion, or a congenital uterine abnormality, like a bicornuate uterus, that distorts the shape of the uterine cavity.
To end, offer STI screening to all patients who present for emergency contraception. Also, if you haven’t already, now is a great time for contraceptive counseling as well.
Always be sure to discuss the short-term and long-term options available for birth control. Okay, let’s talk about follow-up.
Patients don’t need routine follow-up after utilizing emergency contraception! That being said, you should give them return precautions.
These include calling and coming back to the office or hospital if they have lower abdominal pain, a delayed period by more than a week from their expected menses, or persistent, irregular bleeding.
In these cases, a clinical evaluation and pregnancy test are necessary to assess for an ectopic pregnancy or spontaneous pregnancy loss.Here’s a clinical pearl!
The next menstrual period after emergency contraception use should be within about 1 week earlier or 1 week later of when it would normally be expected.
If your patient’s period is 2 weeks late or more, advise them to take a home pregnancy test. Alright, let’s talk about patients that come in after more than 5 days since the time of intercourse.

> 5 days since intercourse11:30–12:08

Since emergency contraception prevents pregnancy, it’s only effective when taken within 5 days of unprotected sex. If more than 5 days have passed, a pregnancy may already be established, making this therapy ineffective.
If your patient presents after this time period, offer individualized counseling, including follow-up for a pregnancy test, and discussing further options.
To end, offer STI screening.Alright, as a quick recap... Emergency contraception is used to prevent an unintended pregnancy.

Review12:08–12:51

When a patient presents desiring emergency contraception, first assess the time since intercourse. If it has been no more than 5 days, options include oral levonorgestrel, ulipristal acetate, combined OCPs also known as the Yuzpe method, a copper IUD, or a levonorgestrel IUD.
Counsel the patient on long-term birth control options and return precautions. If it’s been more than 5 days, offer individualized counseling on a case-by-case basis.