Emergency Contraception

“Clinicians should proactively talk to their patients of reproductive age about ECPs and offer advance prescriptions for ECPs during routine gynecologic office visits….”

1. EmergencyContraception
“the
morning-after pill”
Dr.Sujnanendra Mishra
MD(O&G)

2. Emergency contraception (EC)
Emergency contraception
(EC) is any method of
contraception which is
used after intercourse and
before the potential time
of implantation

3. Emergency Contraception
Also known as:
•Morning-After Pills
•Postcoital Contraception
•Secondary Contraception
These terms do not convey the correct timing of use nor that these
methods should be used only for emergencies.
Emergency contraception (EC) is
any method of contraception
which is used after intercourse
and before the potential time of
implantation

4. HISTORY of EC -
•"First immediately after ejaculation
let the two come apart and let the
woman arise roughly, squeeze and
blow her nose seven times and call
out in a loud voice. She should
jump violently backwards seven to
nine times."
»Abu Bakr Muhammad ibin Zakariya' al-Razi
(865 AD-925 AD)

5. •Hormonal methods originated in
mid-1920s with discovery that
estrogenic ovarian extracts have
anti-fertility effect
•High-dose estrogen (DES or EE)
post-coitally as a treatment for rape
survivors in the 1960s

6. •How about a post-coital
Coca-Cola douche!
•The New England Journal of Medicine
published a study on that one as late
as the 1980s.

7. CURRENT EC -
•Yuzpe’s original article – 1974
•Dosage was two doses of two
Ovral tablets, 12 hours apart
–within 72 hours of unprotected
intercourse
•Effectiveness believed to be about
95%
•Problems = nausea, time frame

8. Women Who May Need Emergency
Contraception (Primary Users)
Women who:
–Have unplanned, unprotected intercourse
–Used a condom that may have leaked or broken
–Missed multiple COC pills
–Waited > 16 weeks beyond last injection (DMPA)
–Failed in using withdrawal method of contraception
(ejaculation in vagina or external genitalia)
–Failed to abstain when needed while using NFP
–Incorrectly used a diaphragm or the diaphragm or
cervical cap dislodged, broke or tore, or was
removed early
–Are rape victims

9. No contraceptive method currently in
use
• Infrequent or unplanned intercourse
Contraceptive failure
• Breakage or dislodgement of a condom, diaphragm,
or cervical cap
• Failure of contraceptive film or spermicidal tablet
to dissolve
Incorrect contraceptive use
• Missing 3 or more consecutive combined oral
contraceptive pills
• Taking a progestin-only (mini pill) dose more than
3 hours late
• More than 2 weeks late for a progestin-only
contraceptive injection
• Delay in placing a new contraceptive ring or patch
• Expulsion of an intrauterine device
• Miscalculation of periodic abstinence
• Failure to abstain on fertile days
• Weaning from exclusive breastfeeding
Cases of sexual assault
• When the woman is not protected by another
contraceptive method
Adapted from the WHO
Fact Sheet.

10. “the morning-after pill”
EMERGENCY
CONTRACEPTION
“the abortion pill”
MIFEPRISTONE
WHAT
DOES
IT DO?
Prevents a pregnancy from
occurring
after unprotected sex.
Ends a pregnancy
without
surgery.
WHAT IS
IT?
A high dose of birth control
pills.
One of two pills used to end
a pregnancy without
surgery.
WHEN CAN
I TAKE IT?
Effective within 5 days of
unprotected sex, but the
sooner the better.
Effective to terminate
pregnancies up to 8 weeks
duration.
IS IT
SAFE?
Yes. effective contraceptive
for pregnancy prevention
after unprotected sex.
Yes. effective for
pregnancy
termination.
WHAT’S THE DIFFERENCE ?
Between “the morning-after pill” and “the abortion pill”

11. Emergency Contraception
•These methods have enormous
potential for use as safe and
effective postcoital contraceptives.
•If integrated with ongoing family
planning information and services,
may encourage new clients to come
to clinic.
•Emergency contraception should be
promoted to reduce unwanted
pregnancies.

12. Emergency Contraception: Benefits
•All are very effective (failure rate
less than 2% in women who use it
correctly)
•IUDs also provide long-term
contraception
Source: Consortium for Emergency Contraception 1998.

13. :
EmergencyContraception Methods
Combined Oral Contraceptives
(COCs):
–Low-dose (30–35 µg EE and 150 µg
LNG), or
–High-dose (50 µg EE and 250 µg LNG)
Progestin-Only Pills (POPs):
750 µg LNG (preferred)
30 µg LNG
37.5 µg LNG
75 µg norgestrel
IUDs:
TCu 380A, Multiload 375, Nova T
Antiprogestins

14. Emergency Contraception: COCs
•Mechanisms of action
–May alter endometrium (mixed
proliferative/secretory pattern)
–May block ovulation
–May alter tubal motility
•Effectiveness
–2% failure rate when used correctly
1
•Safety
–No long-term problems in nearly all women
–Nausea (and vomiting) most common
short-term side effect (due to estrogen)
1
Source: Consortium for Emergency Contraception 1999.

15. DOSE for Combine OCP
Low-dose (30–35 µg EE
and 150 µg LNG), Total =
8 tablets
High-dose (50 µg EE and
250 µg LNG)
Total = 4 tablets
1
STEP I Take 4 tablets of a low-dose
COC (30–35 µg EE) orally
within 72 hours of
unprotected intercourse.
Take 2 tablets of a high-
dose COC (50 µg EE) orally
within 72 hours of
unprotected intercourse.
STEP II Take 4 more tablets in 12
hours.
Take 2 more tablets in 12
hours
STEPIII If no menses (vaginal bleeding) within 3 weeks, the client
should consult the clinic or service provider to check for
possible pregnancy.

16. DOSE for POP (Prog. Only Pills)
Plan- B
750 µg LNG (preferred)
Total = 2 tablets
30 or 37.5 µg of LNG or
75 µg of norgestrel
Total = 40 tablets
STEP I Take 1 tablet (750 µg of
LNG) orally within 72
hours of unprotected
intercourse.
Take 20 tablets (30 or
37.5 µg of LNG or 75 µg
of norgestrel) orally within
72 hours of unprotected
intercourse.
STEP II Take 1 more tablet in 12
hours.
Take 20 more tablets in
12 hours.
STEP III If no menses (vaginal bleeding) within 3 weeks, the
client should consult the clinic or service provider to
check for possible pregnancy.

17. First single dose emergency
contraceptive now OTC
The first one-tablet oral emergency contraceptive
as i-pill, Unwanted-72 , (1.5mg levonorgestrel), is
now available as an over-the-counter medication.

18. No evidence suggests that repeated use of LNG is
harmful; however, neither the WHO nor ACOG
recommend its use as an ongoing contraceptive
method.
Regular contraceptive use is more effective
in preventing pregnancy than intermittent
postcoital use of LNG, although it remains to be
seen whether this option might prove safer in the
long run for some women.
Halpern V, Raymond EG, Lopez LM. Repeated use of postcoital
hormonal contraception for prevention of pregnancy.

19. Effects on menstrual bleeding
•Depending on when it is taken during the menstrual
cycle, LNG can affect menstrual bleeding patterns.
•Women should be aware of these potential changes
to their menstrual cycle after using emergency
contraception
•If used during the follicular phase may hasten the
next menses by up to 7 days.
•Used during the luteal phase does not seem to
significantly affect cycle length.
• Prolonged bleeding during the first post treatment
menses is more likely, especially after taking the
single 1.5-mg regimen.
• Breakthrough bleeding is uncommon but possible.

20. When to seek medical advice
•if their period is more than a week
late
•if they experience significant Inter
menstrual bleeding and
• abdominal pain.

21. IUDs: Instructions for Use as
Emergency Contraception
•Step 1: Insert IUD within 5 days of
unprotected intercourse.
•Step 2: If no menses (vaginal
bleeding) within 3 weeks, the client
should consult the clinic or service
provider to check for possible
pregnancy.
•Step 3: If pregnancy not prevented,
counsel client regarding options.
An option when hormonal contraception is contraindicated

22. ANTIPROGESTINS
•Different action from its use in medical
abortion, same dose
•A single 600mg dose of Mifepristone
(RU-486) within 72 hrs after unprotected
intercourse is highly effective
•Fewer side-effects than Yuzpe
•10mg dose may be equally effective

23. Emergency Contraception: Limitations
•COCs are effective only if used within 72
hours of unprotected intercourse.
•COCs cause nausea and vomiting.
•POPs must be used within 72 hours of
unprotected intercourse but cause much
less nausea than COCs.
•IUDs are effective only if inserted within 5
days of unprotected intercourse.
•IUD insertion requires minor procedure
performed by a trained provider.
•IUDs are not best choice for women at risk
for STDs (e.g., HBV, HIV/AIDS).

24. CONCERN………
Concerns have been raised
that widespread availability of
LNG emergency contraception
would increase sexual risk-
taking behavior, especially
among teens, or reduce
compliance with regular birth
control methods

25. Emergency contraception is using a drug or copper intrauterine device (Cu-
IUD) to prevent pregnancy after unprotected sex. This is for backup, not regular
contraception. Mifepristone and levonorgestrelare very effective with few
adverse effects, and are preferred to oestrogenand progestogencombined.
Levonorgestrelcould be used in a single dose (1.5 mg) instead of two split
doses (0.75 mg) 12 hours apart. Another effective method for emergency
contraception is Cu-IUD and it can be kept for ongoing contraception.
FINAL WORDS….