Abstract
Keywords
1. Background
2. Clinical questions
2.1 What options are available for EC?
2.1.1 Emergency contraceptive pills (ECPs)
International Consortium for Emergency Contraception. EC pill types and countries of availability, by brand, https://toolkits.knowledgesuccess.org/toolkits/emergency-contraception/emergency-contraceptive-pills-registration-status-country; 2022 [accessed December 29, 2022].
2.1.1.1 Mechanism
Duramed pharmaceuticals Inc. Plan B one-step (levonorgestrel) tablet, 1.5 mg, for oral use [package insert], https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/021998lbl.pdf; 2009 [accessed December 29, 2022].
Watson Pharma Inc. Ella (ulipristal acetate) tablet [package insert], https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf; 2010 [accessed December 29, 2022].
2.1.1.2 Efficacy
2.1.2 IUDs
2.1.2.1 Types
2.1.2.2 Mechanism
2.1.2.3 Efficacy
- ○The copper IUD is more effective than ECPs (GRADE 1A).
- ○UPA ECPs are more effective than LNG ECPs (GRADE 1A).
- ○LNG and UPA ECPs prevent pregnancy through preovulatory effects (GRADE 1A).
- ○The LNG 52 mg IUD is noninferior to the copper IUD for EC within 5 days of unprotected intercourse (GRADE 1B).
2.2 What are the indications for EC?
Sexual intercourse when no contraceptive has been used Sexual assault when the person was not protected by an effective contraceptive method Sexual intercourse where there is concern for contraceptive failure or misuse, including: | |
Condoms | Breakage, slippage, or incorrect use |
Combined hormonal contraceptive pills | Three or more consecutively missed pills or Three days late during the first week of the cycle |
Progesterone-only contraceptive pills | Three or more hours late from usual pill use time or more than 27 h after the previous pill |
Desogestrel-only contraceptive pills | Twelve or more hours from usual pill use time or more than 36 h after the previous pill |
Norethisterone enanthate injection | Two or more weeks late for injection |
Depot-medroxyprogesterone acetate injection | Four or more weeks late for injection |
Combined injectable contraceptive | Seven or more days late for injection |
Cervical cap or diaphragm | Dislodgement, breakage, tearing, or early removal |
Withdrawal | Failed withdrawal |
Spermicide | Failure to melt prior to intercourse |
Fertility awareness methods | Miscalculation of abstinence period, or failure to abstain or use a barrier on the fertile days |
Intrauterine device or implant | Device expulsion |
2.3 What clinical considerations may impact the use of EC?
2.3.1 Medical conditions
Watson Pharma Inc. Ella (ulipristal acetate) tablet [package insert], https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf; 2010 [accessed December 29, 2022].
2.3.2 Weight and BMI
2.3.3 Medications
Watson Pharma Inc. Ella (ulipristal acetate) tablet [package insert], https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf; 2010 [accessed December 29, 2022].
Watson Pharma Inc. Ella (ulipristal acetate) tablet [package insert], https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf; 2010 [accessed December 29, 2022].
2.4 What are counseling considerations regarding repeated use of EC, use by an unknowingly pregnant individual, and use with other hormonal contraceptives?
2.4.1 Repeated use of EC in the same cycle
Medicines and Healthcare products Regulatory Agency UK. Esmya (ulipristal acetate): suspension of the licence due to risk of serious liver injury, https://www.gov.uk/drug-safety-update/esmya-ulipristal-acetate-suspension-of-the-licence-due-to-risk-of-serious-liver-injury; 2021 [accessed 29 December 2022].
Watson Pharma Inc. Ella (ulipristal acetate) tablet [package insert], https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf; 2010 [accessed December 29, 2022].
2.4.2 EC use by an unknowingly pregnant patient
2.4.3 Use with other hormonal contraceptives
2.5 What follow-up and additional services should be offered to individuals seeking EC?
2.5.1 Urine pregnancy testing (at time of provision and at follow-up)
2.5.2 Sexually transmitted infection (STI) screening and treatment
2.5.3 Intimate partner violence and human trafficking screening
2.5.4 Ongoing contraception
2.6 How can clinicians support EC use in special populations?
2.6.1 Use by gender diverse individuals (particularly those taking testosterone)
American Society for Emergency Contraception. Emergency contraception for transgender and nonbinary patients, https://www.americansocietyforec.org/reports-and-factsheets; 2021 [accessed 29 December 2022].
2.6.2 Use while breastfeeding, lactating, or chest feeding
National Library of Medicine (US). Intrauterine Copper Contraceptive [Internet]. (2021). Available from: https://www.ncbi.nlm.nih.gov/books/.
Watson Pharma Inc. Ella (ulipristal acetate) tablet [package insert], https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf; 2010 [accessed December 29, 2022].
2.7 What are the barriers to EC use?
2.7.1 IUDs
- Davis S.A.
- Braykov N.P.
- Lathrop E.
- Haddad L.B.
2.7.2 ECPs
Guttmacher Institute. Emergency Contraception, https://www.guttmacher.org/state-policy/explore/emergency-contraception; 2022 [accessed 29 December 2022].
American Society for Emergency Contraception. Emergency contraception: a guide for pharmacies and retailers, https://www.americansocietyforec.org/_files/ugd/7f2e0b_fc23debfbd29451685a17bec4cb8518f.pdf; 2020 [accessed 29 December 2022].
2.7.3 Populations most negatively impacted by barriers to EC access
American Society for Emergency Contraception. Emergency contraception for transgender and nonbinary patients, https://www.americansocietyforec.org/reports-and-factsheets; 2021 [accessed 29 December 2022].
2.8 Is there a role for ECPs as a primary contraceptive method?
3. Clinical recommendations
- Please see Appendix 1 for a key to interpreting GRADE.
- •We recommend that the LNG 52 mg IUD be offered as a first-line EC option, along with other EC methods (GRADE 1B).
- •We recommend that clinicians counsel individuals considering EC on the following:
- ○The copper IUD is more effective than ECPs (GRADE 1A).
- ○UPA ECPs are more effective than LNG ECPs (GRADE 1A).
- ○LNG and UPA ECPs prevent pregnancy through pre-ovulatory effects (GRADE 1A).
- ○The LNG 52 mg IUD is noninferior to the copper IUD for EC within five days of unprotected intercourse (GRADE 1B).
- ○
- •Based on this data, we recommend that clinicians counsel individuals that UPA ECPs, if available, are more effective than LNG ECPs in overweight and obese persons and those with bodyweight 70 kg or greater (GRADE 1C).
- •We recommend advising patients currently or recently taking cytochrome P450–3A4 and P450–3A5 inducers or glucuronidation enzyme inducers that ECPs may be less effective and that IUD placement for EC should be considered (GRADE 1C).
- •We recommend routine hormonal contraception be initiated as soon as desired following LNG ECP use, with abstinence or a nonhormonal contraceptive method used as back-up for seven days or until the next menstrual period/withdrawal bleed, whichever occurs first (GRADE 1A).
- •Following UPA ECPs, we recommend generally delaying initiation of routine hormonal contraception for five days and abstinence or a nonhormonal contraceptive method used as back-up for an additional seven days or until the next menstrual period/withdrawal bleed. However, the specific timing of routine hormonal contraceptive initiation should be individualized through shared decision-making (GRADE 1B).
- •We recommend against withholding or delaying ECPs for pregnancy testing (GRADE 1B).
- •We recommend offering urine pregnancy testing for post-EC pregnancy assessment as needed (GRADE 1C).
- •We recommend offering or referring persons requesting EC for sexually transmitted infection screening, postexposure prophylaxis, pre-exposure prophylaxis, and treatment as indicated (GRADE 1C).
- •We recommend screening persons who use EC for intimate partner violence and human trafficking as indicated (GRADE 1C).
- •We recommend offering or referring persons who use EC for ongoing contraception as desired (GRADE 1C).
- •We recommend clinicians provide EC counseling and advanced prescription of ECPs to individuals relying on the lactational amenorrhea method (GRADE 1B).
- •We recommend that clinicians counsel individuals that breastfeeding does not need to be disrupted because of LNG ECP use (GRADE 1A).
- •We recommend offering regular pericoital use of LNG ECPs for individuals who desire this method either alone or as a supplement to nonhormonal coitus-dependent methods, such as periodic abstinence, barrier methods, or withdrawal (Grade 1B).
4. Recommendations for future research
- •Effectiveness of the copper IUD compared to the 52 mg LNG IUS for EC.
- •Effective dosing of LNG and UPA ECPs for individuals with elevated BMI or body weight.
- •Effective dosing of LNG ECPs for individuals concurrently or recently using CYP3A4 inducers.
- •Clinically relevant medication interactions with UPA ECPs.
- •Effects of initiation or reinitiation of various methods of regular hormonal contraception on the effectiveness of UPA ECPs.
- •Effects on ovulation of repeat dosing of UPA ECPs at different times during the same menstrual cycle.
- •Effects of UPA on lactation and breastfeeding infants.
- •Acceptability of EC methods to gender diverse individuals.
Sources
Intended audience
Disclaimer
Author contributions
Appendix. Supplementary materials
References
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Footnotes
Conflicts of interest: The authors have no conflicts of interest to report. The Society of Family Planning receives no direct support from pharmaceutical companies or other industries for the production of clinical recommendations.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.