Dr Sarah Hardman discusses recommendations from the FSRH on emergency contraception and highlights factors that should be considered for each method

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Read this article to learn more about:

  • the role of emergency contraception and the methods available
  • when each method can be considered and reasons for prescribing them
  • the importance of ongoing contraception and when to start it after emergency contraception.

Key points

GP commissioning messages

NICE Accreditation Mark

NICE accreditation mark

The Faculty of Sexual and Reproductive Healthcare CEU Clinical guidance: emergency contraception has been awarded the NICE Accreditation Mark.

The Faculty of Sexual and Reproductive Healthcare (FSRH) published its updated guideline Emergency contraception (EC) in March 2017.1 Evidence that had emerged since publication of the previous version of the guideline had already resulted in the new recommendation that women should wait 5 days after taking ulipristal acetate EC (UPA-EC) before starting hormonal contraception.1 In addition, the 2017 guidance highlights:1

  • the scope of the EC consultation and the responsibilities of EC providers across the range of healthcare settings
  • the superior effectiveness of the copper IUD (Cu-IUD) for EC compared with oral EC methods
  • the importance of considering in each individual situation:
  • the risk of pregnancy from recent unprotected sexual intercourse (UPSI)
  • which methods of EC are likely to be effective and which are not
  • the continuing risk of unplanned pregnancy if effective ongoing contraception is not commenced after oral EC.

Note: some of the medicines discussed in this article currently (July 2017) do not have UK marketing authorisation for the indications mentioned. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices2 for further information.

The role of emergency contraception

Emergency contraception is not a substitute for effective regular contraception, but offers women the opportunity to reduce the risk of unplanned pregnancy after an episode of unprotected intercourse.

The guideline recommends that EC should be considered in any situation in which a woman does not want to be pregnant but has had UPSI. This may have occurred because contraception was not used, but could also be the result of imperfect use of contraception or of contraceptive failure.

The emergency contraception consultation

Some women present specifically to request EC. However, a woman requesting routine contraception, pregnancy testing, sexually transmitted infection (STI) testing, or attending for follow up after a pregnancy could well be at risk of unplanned pregnancy from recent UPSI. Healthcare professionals need to be alert to the fact that EC could be indicated.

Each consultation for EC requires the provider to help the individual woman understand her risk of pregnancy in the situation in which she finds herself, and the likely effectiveness of the various methods of EC for her. The guideline recognises that no one method of EC is the most appropriate method in all situations.

The new guidance is clear, however, that the scope of the EC consultation is wider than that. A key message from the guideline is that a consultation regarding EC is an opportunity to discuss and facilitate effective ongoing contraception, to reduce risk of unplanned pregnancy from further UPSI.1 The fact that UPSI has taken place suggests that the woman’s current contraception could be improved upon. Commencement of ongoing contraception is an important consideration when discussing choice of EC: the immediate effective contraception offered by the Cu-IUD is a significant benefit; conversely, delaying hormonal contraception after UPA-EC could prove a barrier to women achieving effective ongoing contraception.

Beyond contraception, the guideline reminds providers that this is an opportunity for STI risk assessment and appropriate testing.1

It is recognised that not all EC providers are able to offer the Cu‑IUD, and not all can provide ongoing contraception or STI testing. The guideline recommends that all EC providers who cannot provide these services should have a clear pathway in place for onward referral to a service that can do so.1

Methods of EC available in the UK

Three methods of EC are available in the UK:

  • copper intrauterine device (Cu-IUD)
  • ulipristal acetate 30 mg oral tablet (UPA-EC)
  • levonorgestrel 1.5 mg oral tablet (LNG-EC).

Mechanisms of action

The guideline clarifies that the Cu‑IUD has both pre- and post‑fertilisation mechanisms of action.1 Copper is toxic to gametes and prevents implantation through its effect on the endometrium.3,4 Guidance regarding timing of Cu‑IUD insertion for EC ensures that insertion is avoided when there is a risk that it could disrupt an already implanted pregnancy.1

Oral EC acts by delaying ovulation. Importantly, the evidence indicates that neither method of oral EC is effective after ovulation has taken place.5–7 However, UPA-EC is able to delay ovulation up until closer to the time of ovulation than LNG‑EC,8 which appears to be ineffective after the start of the luteinising hormone (LH) surge.

The evidence suggests that neither UPA-EC nor LNG-EC disrupts an existing pregnancy nor affects pregnancy outcomes if taken in very early pregnancy.9,10 Either of the oral methods can therefore be used if a high sensitivity urine pregnancy test is negative, even if there has been UPSI within the last 21 days and thus very early pregnancy cannot be excluded.

Choice of emergency contraception

The most appropriate method of EC in any given situation depends on a number of factors. The important questions for EC providers to consider are:

  • which methods can be used in this situation?
  • which methods are likely to be most effective in this situation?
  • is the woman likely to be at risk of pregnancy from subsequent UPSI if commencement of ongoing contraception is delayed?

When can EC be used?

Table 1 sets out recommendations from the FSRH on when the various methods of EC can be used.

Table 1: Timing of use of emergency contraception methods1
EC methodTiming of useNotes

Copper IUD

Within 5 days after the first UPSI since the LMP

or

Within 5 days after the earliest likely date of ovulation*

(whichever is later)

These criteria ensure Cu‑IUD insertion prior to implantation

Ulipristal acetate 30 mg orally

Up to 120 hours after the most recent UPSI

Likely to be ineffective if ovulation has already taken place

Can be used:

  • more than once in a cycle
  • if a high sensitivity pregnancy test is negative, but very early pregnancy cannot yet be excluded.

Levonorgestrel
1.5 mg orally

Up to 96 hours after the most recent UPSI

(licensed for use up to 72 hours after UPSI, may be effective up to 96 hours after UPSI)

* The guideline advises that earliest likely ovulation date is estimated as [(length of shortest cycle in days) –14] days after the start of the last menstrual period.1

LMP=last menstrual period; Cu-IUD=copper intrauterine device; UPSI=unprotected sexual intercourse

Effectiveness of EC

Evidence suggests that the Cu‑IUD is about ten times more effective for EC than the oral EC methods.1 Pregnancy risk after appropriate insertion of a Cu‑IUD for EC has been reported to be less than 1 in 1000.11 The Cu‑IUD is the only EC method that is likely to be effective if ovulation has already occurred and has the significant advantage that it provides immediate ongoing contraception. The guideline recommends that the Cu‑IUD should always be considered first line for EC.1

If Cu‑IUD insertion is delayed, oral EC (if indicated) is recommended in the interim, in case the Cu‑IUD cannot later be inserted or the woman changes her mind.1

If the Cu‑IUD is not suitable or not acceptable, oral EC is indicated and should be taken as soon as possible if there has been UPSI in the last 5 days.1 It should be noted that:

  • reported pregnancy rates after oral EC range from 1% to 2% for UPA‑EC5,12–15 and from 0.65% to 2.6% for LNG‑EC5,12,15
  • oral EC should be taken as soon as possible after UPSI to maximise the chances that it is taken in time to delay ovulation1
  • oral EC is unlikely to be effective if ovulation has already taken place1
  • sperm are viable for a maximum of about 5 days in the upper female genital tract.16,17 There is no rationale to give oral EC to delay ovulation if the last UPSI was more than 5 days ago.1

Choosing between LNG-EC and UPA-EC

The updated guideline from FSRH recognises that UPA-EC has been demonstrated to be more effective than LNG-EC,1,12 but it is clear that UPA-EC is not ideal in every situation. Table 2 summarises recommendations from the FSRH guideline that should be considered when choosing between LNG-EC and UPA-EC.

Table 2: Factors to be considered when choosing between oral EC methods
FactorUPA-EC*LNG-EC*Implication

Time after UPSI

More effective than LNG-EC at 0–120 hours after UPSI

Likely to be ineffective if the most recent UPSI was >120 hours ago

Less effective than UPA-EC at 0–120 hours after UPSI Likely to be ineffective if the most recent UPSI was >96 hours ago Only UPA-EC is likely to be effective if there was UPSI 96–120 hours ago

Timing of menstrual cycle

Able to delay ovulation after the start of the LH surge

Likely to be ineffective at >96 hours

Unable to delay ovulation after the start of the LH surge

Target UPA-EC towards situations in which there is a high risk of pregnancy, because UPSI is likely to have taken place during the woman’s fertile window (the 6 days ending with the day of ovulation)

Starting ongoing contraception

Hormonal contraception cannot be started for 5 days, because progestogen taken immediately after UPA-EC reduces the ability of UPA to delay ovulation18

Suitable hormonal contraception can be started immediately

A woman is at risk of pregnancy during the time before she starts contraception and it becoming effective if she has further UPSI after oral EC

There is potential that contraception may not be started at all after a 5-day delay

Cost

The only brand of UPA‑EC available in the UK is significantly more expensive than some brands of LNG-EC

Some brands of LNG-EC are significantly less expensive than the only brand of UPA‑EC available in the UK

Significant cost implication to be considered if a woman is unlikely to be at high risk of pregnancy from recent UPSI

Weight/BMI

Any possible effect of weight or BMI on effectiveness of UPA-EC appears to be less significant than the effect of weight on LNG-EC and to occur at higher weight/BMI threshold1,19

May be less effective for women with weight >70 kg or BMI >26 kg/m21,20

Consider UPA-EC or a double (3 mg) dose of LNG‑EC for women with weight >70 kg or BMI >26 kg/m21

It is unknown which is more effective in this situation

Prior progestogen use

Could theoretically be less effective if a progestogen has been taken in the preceding 7 days

Unaffected by prior use of progestogen

In a ‘missed pill’ situation, effectiveness of UPA-EC could be reduced1 (and hormonal contraception should not be restarted for a further 5 days)

Enzyme-inducing medication use

Effectiveness could be reduced by concomitant use of enzyme‑inducing medications

Effectiveness could be reduced by concomitant use of enzyme‑inducing medications

Consider use of a double dose (3 mg) of LNG-EC1,21

FSRH does not currently support use of double dose UPA-EC

It is unknown whether 3 mg LNG-EC or 30 mg UPA-EC is more effective in this situation

Asthma status

Not suitable for use by women with severe asthma controlled by oral glucocorticoids

   

* For further information refer to the full summary of product characteristics at: www.medicines.org.uk

UPA-EC= ulipristal acetate emergency contraception; LNG-EC=levonorgestrel emergency contraception; UPSI=unprotected sexual intercourse; LH=luteinising hormone; BMI=body-mass index; FSRH=Faculty of Sexual and Reproductive Healthcare

Ongoing contraception

The Cu-IUD provides immediate, effective ongoing contraception.

The FSRH guideline Quick starting contraception22 supports off-licence quick start of suitable hormonal contraception immediately after LNG‑EC, or 5 days after UPA‑EC. Suitable methods for quick start are combined hormonal contraception, progestogen‑only pill, progestogen‑only implant, and progestogen‑only injection (the levonorgestrel intrauterine system should not be inserted until pregnancy can be absolutely excluded).

Follow up

The FSRH guideline on Emergency contraception recommends follow‑up pregnancy testing at least 21 days after the last UPSI if the next menstrual period: is delayed for more than 7 days; is not a typical period; or if hormonal contraception was quick started after oral EC.1

Implementation

Practical barriers to implementation of recommendations in the guideline may be overcome by:

  • using the algorithms in the guideline to facilitate and speed up decision making
  • ensuring that clear, simple referral pathways for Cu-IUD insertion are agreed and in place
  • updating patient group directions used by nurses and pharmacists to reflect the new guidance so that the most appropriate oral EC can be provided in nurse-led clinics and pharmacy settings
  • considering use of self-reported height and weight
  • providing information on general practice websites and local sexual and reproductive health service websites regarding choice of EC and subsequent ongoing contraception; this can be used by women requesting EC both before and after the consultation. An example information sheet for women who have been supplied with oral emergency contraception can be found in appendix 2 of the FSRH guideline.

Conclusion

The FSRH guideline on Emergency contraception1 brings together current evidence and expert opinion, enabling EC providers to support women to choose the EC method that is most appropriate to their needs. The algorithms that accompany the guideline aim to help simplify decision making on this complicated subject. 

Following the update, the emphasis has shifted from prescription of a method of oral EC based solely on the number of hours since UPSI to consideration of the Cu-IUD where it is indicated, choice of oral EC based on individual circumstances, and crucially, initiation of effective ongoing contraception. It is recognised that the EC consultation has become more complicated. 

Key points

  • All women who are at risk of unplanned pregnancy after UPSI should:
    • be advised about all methods of EC
    • have access to their choice of suitable EC method
    • be advised about the importance of ongoing contraception and how to access this
  • When advising women about choice of EC method, providers should be aware that:
    • the Cu-IUD is the most effective method of EC and offers effective ongoing contraception
    • UPA-EC should be considered first-line oral EC if UPSI is considered likely to have taken place during the fertile window
    • oral EC is unlikely to be effective—
      • if ovulation has already taken place
      • if it is more than 120 hours (UPA-EC) or 96 hours (LNG-EC) since the last UPSI
    • there is a risk of pregnancy if further UPSI takes place after oral EC. Suitable hormonal contraception can be quick started immediately after LNG-EC, but should be delayed for 5 days after UPA-EC
    • effectiveness of oral EC could be reduced by—
      • concomitant use of enzyme-inducing medications
      • higher weight or BMI (the evidence is that LNG-EC is more significantly affected and at lower weight/BMI than UPA-EC)
      • recent use of a progestogen (UPA-EC only).

UPSI=unprotected sexual intercourse; EC=emergency contraception; Cu-IUD=copper intrauterine device; UPA-EC=ulipristal acetate EC; LNG-EC=levonorgestrel EC

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GP commissioning messages

written by Dr David Jenner, GP, Cullompton, Devon

  • The updated FSRH guideline on Emergency contraception brings clarity to the advice and interventions that should be given by healthcare providers after UPSI where pregnancy is an undesired outcome
  • Commissioners should:
    • support primary care practitioners in understanding and implementing the guideline through education programmes and audit
    • work with public health colleagues to ensure that Cu-IUD insertion is available at sexual health clinics and/or walk-in centres
    • ensure out-of-hours services, pharmacies, and 111 services have updated their protocols and pathways to reflect the updated guidance and ensure patients get prompt and accurate advice and treatment
  • Opportunistic screening for, and treatment of, sexually transmitted diseases should form part of the consultation for emergency contraception.

FSRH=Faculty of Sexual and Reproductive Healthcare; UPSI=unprotected sexual intercourse; Cu-IUD=copper intrauterine device

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Read the Guidelines summary of the FSRH guideline on Emergency contraception for more information on helping patients choose the right emergency contraception