Transcript Emergency Contraception, Dr Jill Zellin

Emergency
Contraception
Jill Zelin
March 2014
How to decide
which EC to offer
in clinic and which
is best
Why should
I discuss
IUD if I
can’t fit
one?
Is UPA
worth the
price
difference?
Is it safe?
Will I ever
do any
harm?
Does
weight
matter?
Is there any time
Emergency
Contraception is
not
necessary because
there is no
risk?
What is the most important question to
ask a woman who requests emergency
contraception?
I had sex two nights ago
without protection. I’ve done
it before and got away with it.
Am I at any risk of
pregnancy this time? Is it worth
me going
through the trouble of having
an IUD fitted?
Is it worth the extra cost of
UPA?
Glasier (Contraception 2011)
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Limit of efficacy reached at :
70kg/BMI 26 for LNG
88kg/BMI 35 for UPA
How do you interpret BMI data in
the
clinical scenario?
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There is some evidence to suggest that women with a
BMI >30 may have a higher failure rate of oral EC
So you may want to consider an IUD as this is not
affected
The evidence suggests that UPA may be less affected
No idea if it is dose related
Is it weight or BMI related?
At what BMI/weight should we start to say this?
Need more evidence
Never deny oral EC due to BMI
MHRA position re EC and weight/BMI
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No change to clinical practice
I had UPSI last
night
I had UPSI last
night
Is our choice the same?
Yes!
(But…..)
Belinda
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A 31 year old nullip attends clinic requesting
Emergency contraception. LSI 4+ days ago;
UPSI. No other UPSI this cycle. LMP 22
days ago
How would you manage this patient?
 What other piece of information would be useful
and why?
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What methods are suitable for her?
Discuss pros and cons of each
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What else might be relevant?
Cassie
26 year old lady attends for Repeat COC. Has
run out of pills, is due to restart today.
Missed 1 pill at end of last packet. 2 episodes
of UPSI in PFI. 2 days and 6 days ago
 Does she need EC?
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The nurse seeing her states that she is
currently “day 7 of her cycle”. Comment on
this.
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Assuming you consider her to have had
UPSI because of the missed pills what
method(s) of EC are suitable?
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She has had 2 episodes of UPSI – how does
this affect your decision
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What is a missed pill?
How many pills can you miss before
needing EC?
Which (if any) EC would you give?
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22 year old and uses no contraception. She
takes carbamazepine for epilepsy. She had UPSI
on D22 of a 28 day cycle. This is her only SI
this cycle. Presents on D24 ( i.e. 48 hours
later).
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48 year woman who takes Micronor when she
remembers. She is amenorrhoeic and doesn’t
have a regular partner. Her last SI was 6 weeks
previously. She had UPSI last night.
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15 years old – thinks her periods come every 45 weeks. UPSI on day 12 of her cycle and
presents within 4 hours . Also had sex with her
regular boyfriend 8 days ago with no
contraception.
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25 year old drug addict. Presents on D17 of her
cycle 2 days after UPSI. Has had multiple
episodes of unprotected intercourse prior to
this. She has a regular 4 week cycle.
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38 year old woman who uses COC for
contraception. She has missed a few pills this
month and she had UPSI 3 days ago. Her LMP
was 3 weeks ago.
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21year old woman who has an irregular cycle.
She has PCOS and has a BMI of 32 kg/m2. Her
LMP was 4 weeks ago and she UPSI12 hours
previously. No condom was used. Her last
other SI was 3 weeks ago and this was
unprotected.
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21year old woman who has an irregular cycle.
She has PCOS and has a BMI of 32 kg/m2. Her
LMP was 4 weeks ago and she had UPSI 12
hours previously. Her last other SI with her
partner was 2 weeks ago and this was
unprotected.
When in the cycle is EC effective?
Max risk
Ulipristal
LNG
IUD
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Chances of conception up to 30% from single
episode of intercourse around the time of
ovulation
Much lower 2-4% at other times of cycle
Chances of conception influence how we advise
and treat women after unprotected sexual
intercourse
Young women much more fertile than older ones
So IF you know where a woman is in
her cycle can you tell her if she has a
risk and which methods work?
 Very
little chance
 if all you have is LMP and
cycle length !!!
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How many women are sure of their LMP?
No woman has exact 28 day cycles
The follicular phase is very variable
The luteal phase is variable
Many other factors contribute to risk
including….
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Was there full ejaculation?
Was a condom used at all?
If there was a problem with a condom what was
it?
Has the woman taken any hormones recently?
How many times did they have sex?
What is their natural fertility like?
Risk takers versus risk averse
Am I at any risk of
pregnancy this time?
YES!
Is it worth me going
through the trouble of
having an IUD fitted?
Is it worth the extra cost
of UPA?
Only you know how
important it is to
avoid pregnancy
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When would you expect a women with a 28 day cycle to
ovulate?
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What % of those with 28 day cycles ovulated 14/7 before
their next period?
90%
60%
30%
10%
% of those with 28 day cycles who ovulated 14/7
before their next period
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Of women who conceived, how many were in the fertile
window (days 10-17)?
10%
30%
60%
90%
% women in the fertile window
30%
day s10 to 17
<10 or >17
70%
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What % of women who were shown to be ovulating (on
their blood tests) were actually day 14+/- 1day as per day
counting?
96%
56%
36%
16%
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56% of women with LH>20 were not one day either side of
calculated ovulation from LMP and cycle length
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How many women who were calculated to have already
ovulated (from LMP and cycle length) were correct?
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0/32
4/32
14/32
24/32
30/32
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14/32 women in ‘luteal’ phase (from LMP and cycle length)
had not ovulated yet
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Quantifying risk is an extremely imprecise art
No ‘simple’ chart can cover all situations.
Clinicians can take factors into account and
advise accordingly
The interval dilemma
Are our
choices
the
same?
YES!
EC summary
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Cannot predict, with any confidence, where a woman is in her
cycle
Always mention IUD as most effective - referral pathways
If using oral EC take ASAP
Restrictions on UPA reduced, use where possible if IUD rejected
- referral pathways
Levonorgestrel useful if IUD/UPA not possible
Oral EC (LNG/UPA) may only DELAY ovulation
Subsequent SI is common and risky
Always mention quick start and issue straight away
STI risk assessment as part of consultation
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It is HER choice
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What is the most important question to
ask a woman who requests emergency
contraception?
How important is it for you to avoid
pregnancy today?