An Update on Emergency Contraception



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Am Fam Physician. 2014 Apr 1;89(7):545-550.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: See related handout on emergency contraception written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Emergency contraception decreases the risk of unintended pregnancy after unprotected sexual intercourse or after suspected failure of routine contraception (e.g., a condom breaking). Oral methods include combined contraceptive pills (i.e., Yuzpe method), single- or split-dose levonorgestrel, and ulipristal. The Yuzpe method and levonorgestrel are U.S. Food and Drug Administration–approved for use 72 hours postcoitus, whereas the newest method, ulipristal, is approved for up to 120 hours postcoitus. The copper intrauterine device may be used as emergency contraception up to seven days after unprotected intercourse. It is nonhormonal and has the added benefit of long-term contraception. Advanced provision of emergency contraception may be useful for all patients, and for persons using ulipristal because it is available only by prescription. Physicians should counsel patients on the use and effectiveness of emergency contraception, the methods available, and the benefits of routine and consistent contraception use.

Emergency contraception has the potential to prevent more than 3 million unintended pregnancies in the United States each year.1,2 Each method has a different level of effectiveness depending on the timeliness of use. Although it can be effective up to 120 hours postcoitus, it is most effective within the first 12 hours after unprotected intercourse or if the routine contraception method fails (e.g., a condom breaking).2,3

The use of emergency contraception has increased significantly, with more than 5 million women reporting use at least once between 2006 and 2008.1 This may be largely because of increased availability. In 2006, levonorgestrel was approved for over-the-counter use in women 18 years and older, and in 2009, the age was lowered to include those 17 years of age.4,5 Most recently, in 2013, the U.S. Food and Drug Administration (FDA) announced that Plan B One-Step, a single-dose levonorgestrel product, is available over the counter without age restrictions.6 However, the generic single-dose and the split-dose levonorgestrel are still behind the counter for those 17 years or older, and available by prescription only to those 16 years or younger.7

There are four methods of emergency contraception currently approved by the FDA: combined oral contraceptive pills (i.e., Yuzpe method), progestin-only pills containing levonorgestrel, ulipristal (Ella), and the copper intrauterine device (IUD; Paragard). Table 1 provides information on dosing and cost.8

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ulipristal (Ella) is marginally more effective than levonorgestrel at preventing unintended pregnancy within 72 hours postcoitus. Levonorgestrel appears to be equally effective in the single- and split-dose regimens.

A

12

The copper intrauterine device is the most effective method of emergency contraception and can be considered by women who are not at high risk of sexually transmitted infections and who desire long-term contraception.

A

12

There is no absolute contraindication to the use of oral emergency contraception, with the exception of pregnancy.

C

28

Advanced provision of emergency contraception increases the rate and timeliness of use, and does not increase the rate of sexually transmitted infections or change the use of routine contraceptive methods.

C

3335


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ulipristal (Ella) is marginally more effective than levonorgestrel at preventing unintended pregnancy within 72 hours postcoitus. Levonorgestrel appears to be equally effective in the single- and split-dose regimens.

A

12

The copper intrauterine device is the most effective method of emergency contraception and can be considered by women who are not at high risk of sexually transmitted infections and who desire long-term contraception.

A

12

There is no absolute contraindication to the use of oral emergency contraception, with the exception of pregnancy.

C

28

Advanced provision of emergency contraception increases the rate and timeliness of use, and does not increase the rate of sexually transmitted infections or change the use of routine contraceptive methods.

C

3335


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

BEST PRACTICES

The Authors

MICHELE C. BOSWORTH, MD, is an associate professor of family medicine at the University of Texas Health Science Center at Tyler (UTHSCT) Family Medicine Residency Program, where she also serves as the co-chief medical information officer.

PATTI L. OLUSOLA, MD, is an assistant professor of family medicine at the UTHSCT Family Medicine Residency Program.

SARAH B. LOW, MD, is an assistant professor of family medicine at the UTHSCT Family Medicine Residency Program. At the time the manuscript was written, Dr. Low was chief resident of the UTHSCT Family Medicine Residency Program.

Address correspondence to Michele C. Bosworth, MD, University of Texas Health Science Center at Tyler, 11937 US Hwy. 271, Tyler, TX 75708 (e-mail: Michele.Bosworth@uthct.edu). Reprints are not available from the authors.

REFERENCES

1. Mosher WD, Jones J. Use of contraception in the United States: 1982–2008. Vital Health Stat 23. 2010;(29):1–44.

2. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90–96.

3. Rodrigues I, Grou F, Joly J. Effectiveness of emergency contraceptive pills between 72 and 120 hours after unprotected sexual intercourse. Am J Obstet Gynecol. 2001;184(4):531–537.

4. U.S. Food and Drug Administration. FDA approves over-the-counter access for Plan B for women 18 and older: prescription remains required for those 17 and under. August 24, 2006. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2006/ucm108717.htm. Accessed October 20, 2011.

5. U.S. Food and Drug Administration. Updated FDA action on Plan B (levonorgestrel) tablets. April 22, 2009. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm149568.htm. Accessed October 20, 2011.

6. U.S. Food and Drug Administration. FDA approves Plan B One-Step emergency contraceptive for use without a prescription for all women of child-bearing potential. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm358082. Accessed September 15, 2013.

7. Office of Population Research at Princeton University and the Association of Reproductive Health Professionals. The Emergency Contraception Website. What is emergency contraception? http://ec.princeton.edu/emergency-contraception.html. Accessed September 29, 2013.

8. Office of Population Research at Princeton University and the Association of Reproductive Health Professionals. The Emergency Contraception Website. Answers to frequently asked questions about types of emergency contraception. Updated August 26, 2013. http://ec.princeton.edu/questions/dose.html. Accessed September 9, 2013.

9. Yuzpe AA, Smith RP, Rademaker AW. A multicenter clinical investigation employing ethinyl estradiol combined with dl-norgestrel as postcoital contraceptive agent. Fertil Steril. 1982;37(4):508–513.

10. Leung VW, Soon JA, Levine M. Measuring and reporting of the treatment effect of hormonal emergency contraceptives. Pharmacotherapy. 2012;32(3):210–221.

11. Trussell J, Ellertson C, Dorflinger L. Effectiveness of the Yuzpe regimen of emergency contraception by cycle day of intercourse: implications for mechanism of action. Contraception. 2003;67(3):167–171.

12. Cheng L, Che Y, Gülmezoglu AM. Interventions for emergency contraception. Cochrane Database Syst Rev. 2012;(8):CD001324.

13. Ragan RE, Rock RW, Buck HW. Metoclopramide pretreatment attenuates emergency contraceptive-associated nausea. Am J Obstet Gynecol. 2003;188(2):330–333.

14. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Task Force on Postovulatory Methods of Fertility Regulation. Lancet. 1998; 352(9126):428–433.

15. von Hertzen H, Piaggio G, Ding J, et al.; WHO Research Group on Post-ovulatory Methods of Fertility Regulation. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002;360(9348):1803–1810.

16. Gemzell-Danielsson K, Rabe T, Cheng L. Emergency contraception. Gynecol Endocrinol. 2013;29(suppl 1):1–14.

17. Hansen LB, Saseen JJ, Teal SB. Levonorgestrel-only dosing strategies for emergency contraception. Pharmacotherapy. 2007;27(2):278–284.

18. Noé G, Croxatto HB, Salvatierra AM, et al. Contraceptive efficacy of emergency contraception with levonorgestrel given before or after ovulation. Contraception. 2010;81(5):414–420.

19. Marions L, Cekan SZ, Bygdeman M, Gemzell-Danielsson K. Effect of emergency contraception with levonorgestrel or mifepristone on ovarian function. Contraception. 2004;69(5):373–377.

20. Palomino WA, Kohen P, Devoto L. A single midcycle dose of levonorgestrel similar to emergency contraceptive does not alter the expression of the L-selectin ligand or molecular markers of endometrial receptivity. Fertil Steril. 2010;94(5):1589–1594.

21. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555–562.

22. Fine P, Mathé H, Ginde S, Cullins V, Morfesis J, Gainer E. Ulipristal acetate taken 48–120 hours after intercourse for emergency contraception. Obstet Gynecol. 2010;115(2 pt 1):257–263.

23. Brache V, Cochon L, Jesam C, et al. Immediate preovulatory administration of 30 mg ulipristal acetate significantly delays follicular rupture. Hum Reprod. 2010; 25(9):2256–2263.

24. Wu S, Godfrey EM, Wojdyla D, et al. Copper T380A intrauterine device for emergency contraception: a prospective, multicentre, cohort clinical trial. BJOG. 2010; 117(10):1205–1210.

25. ParaGard T 380A (intrauterine copper contraceptive) [prescribing information]. Sellersville, Pa.: Teva Women's Health, Inc. http://paragard.com/images/ParaGard_info.pdf. Accessed October 17, 2013.

26. World Health Organization. Family planning. Updated May 2013. http://www.who.int/mediacentre/factsheets/fs351/en/index.html. Accessed August 13, 2013.

27. Centers for Disease Control and Prevention. Effectiveness of family planning methods. http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/PDF/Contraceptive_methods_508.pdf. Accessed October 23, 2013.

28. Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep. 2010;59(RR-4):1–86.

29. Gurney EP, Murthy AS. Obesity and contraception: metabolic changes, risk of thromboembolism, use of emergency contraceptives, and role of bariatric surgery. Minerva Ginecol. 2013;65(3):279–288.

30. Ella (ulipristal acetate) tablet [prescribing information]. Morristown, N.J.: Watson Pharma, Inc.; August 2010. http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf. Accessed September 29, 2013.

31. Plan B One-Step (levonorgestrel) tablet, 1.5 mg, for oral use [prescribing information]. Pomona, NY: Gedeon Richter, Ltd; August 2009. http://www.planbonestep.com/pdf/PlanBOneStepFullProductInformation.pdf. Accessed June 11, 2012.

32. Guttmacher Institute. State policies in brief: emergency contraception. September 1, 2013. http://www.guttmacher.org/statecenter/spibs/spib_EC.pdf. Accessed September 22, 2013.

33. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev. 2007;(2):CD005497.

34. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention: a meta-analysis. Obstet Gynecol. 2007;110(6):1379–1388.

35. Belzer M, Sanchez K, Olson J, Jacobs AM, Tucker D. Advance supply of emergency contraception: a randomized trial in adolescent mothers. J Pediatr Adolesc Gynecol. 2005;18(5):347–354.

36. Rubin AG, Gold MA, Kim Y, Schwarz EB. Use of emergency contraception by US teens: effect of access on promptness of use and satisfaction. J Pediatr Adolesc Gynecol. 2011;24(5):286–290.

37. American Academy of Family Physicians policy statement on Contraceptive Advice, 2007. http://www.aafp.org/about/policies/all/contraceptive.html. Accessed August 9, 2013.


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