Important clinical details before prescribing

Before prescribing emergency contraception (EC) to a woman make sure to:

• rule out pregnancy by obtaining an accurate history of last menstrual period, usual cycle, date and time of last unprotected sexual intercourse and whether she has had other episodes of unprotected sexual intercourse during that cycle (1)
  • emergency contraception should not be prescribed to women with established pregnancy (2,3)
  • start of last menstrual period
  • cycle length
  • day in cycle when unprotected intercourse occurred
  • how many risks this cycle? - some patients may ask for treatment but not mention, unless questioned, that they have had other episodes of unprotected intercourse during the cycle
    
    
• obtain a list of currently using medication e.g - any enzyme inducing drugs which may reduce the efficacy such as antiepileptics, St John's wort (1)
  • inform the patients that IUD is the preferred option for women using liver enzyme inducing drugs (4)
  • Ulipristal acetate (UPA) is not recommended for women currently on enzyme inducing drugs or who have taken them within the last 28 days (5)
• give written and verbal information about methods of emergency contraception and the failure rates of oral and intrauterine methods in order to make informed choices and to increase compliance and efficacy (4)
  
  
• obtain a sexual health history to assess the risk of STI's
  • before emergency IUD insertion, the following women at high risk of STI's should be offered testing for Chlamydia trachomatis
    • age <25 years
    • change in sexual partner, or more than one partner in the last year
  • if the results of are not available immediately, use of prophylactic antibiotics may be considered before the emergency IUD insertion (but routine prophylactic antibiotics for IUD insertion is not recommended) (4)
    
    
• assess for any risk of abuse
  • practitioner must have an access to local and national child protection guidelines (1)
    
    
• check whether the women is breastfeeding
  • levonorgestrel can be used from day 21 postpartum in breastfeeding women -to minimise the exposure of an infant to levonorgestrel (which is excreted in small amounts in to breast milk), breast-feeding woman should take the tablet immediately after feeding or avoid feeding following levonorgestrel administration (6)
  • if a copper IUD is to be used in breastfeeding women, it should be inserted 28 days (4 weeks or more) postpartum
  • breastfeeding should be avoided (and to discard expressed breast milk) for at least 36 hours by women taking ulipristal (7)
    
    
• obtain a medical history
  • past ectopic pregnancy
    • levonorgestrel (LNG) is not recommended for patients who are at risk of ectopic pregnancy (6) (although the Faculty of Sexual and Reproductive Health consider that the overall risk does not appear to be increased following LNG (3)
  • severe hepatic impairment
    • hormonal EC is not recommended (6,8)
  • asthma insufficiently controlled by oral glucocorticoid
    • ulipristal acetate is not recommended (8)
  • severe malabsorption syndrome such as Crohn's
    • efficacy of hormonal EC may be impaired by malabsorption (6)
  • uterine fibroids
    • in case of distorted uterine cavity IUD is contraindicated
  • pelvic inflammatory disease
    • IUD is contraindicated

The respective summary of product characteristics must be consulted before the medication mentioned is prescribed.

Reference:

• 1. Sharma A. Emergency contraception. BJMP 2009: 2(3) 64-65
• 2. Faculty of Sexual & Reproductive Healthcare (FSRH) 2010. Quick starting contraception.
• 3. Weismiller DG. Emergency contraception. Am Fam Physician. 2004;70(4):707-14
• 4. Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. FFPRHC Guidance (April 2006). Emergency contraception. J Fam Plann Reprod Health Care. 2006;32(2):121-8
• 5. Faculty of Sexual and Reproductive Healthcare (FSRH) 2011. Drug interactions with hormonal contraception.
• 6. ABPI Medicines Compendium 2009. Summary of product characteristics for Levonelle 1500 microgram tablet
• 7. Faculty of Sexual and Reproductive Healthcare (FSRH) 2009. Frequently Asked Questions on Ulipristal Acetate (EllaOne®) Emergency Contraception
• 8. ABPI Medicines Compendium 2010. Summary of product characteristics for ellaOne 30 mg
• 9. BNF 61