1. Updates in Emergency Contraception
Penina Segall-Gutierrez, M.D.
Assistant Professor of Clinical
Obstetrics and Gynecology
Keck School of Medicine
University of Southern California

2. Objectives
Upon completion of this presentation, the learner should be able to:
1. List all methods of Emergency Contraception in order of effectiveness
2. Understand the mechanism of Levonorgesterel EC
3. Understand when and to whom one should talk about EC

3. What is Emergency Contraception?
Therapeutic option available for women to prevent pregnancy after a coital act not adequately protected by a regular method of contraception.
This is an underutilized therapeutic option
Trussell et al. American Journal of Obstetrics and Gynecology. (2004) 190; S30-8

4. Emergency Contraception Could Help Prevent Unintended Pregnancies in the U.S.
Unintended births 44% (22% of total)
Data from Summarizes data from the 2002 NSFG, with birth abortion and population data from federal state and nongovernmental sources.
Trussel estimates could prevent 1.7million ub and 0.8 abs Guttmacker estimates currently only 51,000 tabs in US Qyr prevented by EC
Half of all pregnancies in the U.S. are unintended. Of the 3.1 million unintended pregnancies, 44% ended in births, 42% ended in elective abortion. So 20% of all pregnancies end in elective abortion.
Equally concerning are the numbers of unintended pregnancies that end in unintended births. These pregnancies are associated with increased risk of detrimental prenatal parental behaviors such as smoking and drinking as well as negative health and social outcomes for both the mother and child. This is a public health problem
Elective Abortions 42% ( 20% of total)
6.4 million pregnancies
Henshaw. Perspectives on Sexual and Reproductive Health (2006) 38; 2: 90-6

5. Case Presentation #1: Cathy

6. Case Presentation #1: Cathy
You are at home Friday night when you get a frantic call from your med student Cathy. She forgot to take her OCP Wed AM, when you were on call. She was so tired post-call that she slept all day and forgot her pills. She was nervous about the final exam this AM and she forgot her pills again!!
Someone in audience reads cases

7. Case Presentation #1: Cathy
She flew up to visit her boyfriend in S.F. right after exams, and forgot to bring her pills with her. She says she always uses condoms for STI prophylaxis, but one just broke ! Her last normal period was 11 days ago, and she did not miss any other pills this cycle.
She gives you the phone number of a pharmacy that accepts her student health insurance. Can you help her?

8. Indications for the Use of EC
No contraceptive used when intercourse took place
≥ 14 days late for DMPA shot or unknown last injection date
≥ 2 days late inserting new ring or applying new patch
Missed ≥2 missing C-OCPs (*)
Missed ≥ 1 progestin-only pill or took it ≥ 3 hrs late
Male condom slipped, broke, or leaked or Female condom inserted/removed incorrectly or penis inserted between condom and vaginal wall resulting in intravaginal ejaculation (*)
Coupled erred in practicing periodic abstinence or coitus interuptus
IUD partially or totally expelled or has been removed ≤7 days after last act of sexual intercourse
Diaphragm or cervical cap inserted incorrectly, dislodged, removed too early, or found to be torn
Woman exposed to possible tetratogen or cytotoxic medication while not protected by effective contraception
Rape victims
Hatcher, R. et al Contraceptive Technology 18th ed. Ardent Media, Inc. New York 2004

9. Indications for EC for Cathy
Missed ≥2 missing C-OCPs (*)
Male condom slipped, broke, or leaked or Female condom inserted/removed incorrectly or penis inserted between condom and vaginal wall resulting in intravaginal ejaculation (*)

10. Contraceptive Use in the US: 2002
15-44 yrs
Over 1/3 of American women do not use any method of contraception. 7% have had intercourse in last 3 months, are not pregnant or sterile, and do not desire pregnancy
Over ½ contraceptors using method likely needing EC
2002 National Survey of Family Growth, US Dept of Health and Human Services

11. “When Plan A fails, there’s Plan B”
Plan B ii tabs PO STAT

12. Plan B Levonorgesterel 0.75mg = i tab Plan B
Progestin only
Equivalent to 20 tabs Overette (P-OCPs) -$
Equally effective dosing regiments:
ii PO x1
i PO q12 x 2 (FDA approved Rx)
less effective if second dose missed
Ovrette is more expensive
I po q24 is also effective
No increase in GI side effects ii at once
von Hertzen, H et al. Lancet 7 December 2002; 360:
Ngai SW, et al. Hum Reprod. Jan 2005;20(1):

13. Effectiveness Effective up to 120 hours after unprotected intercourse
FDA approved up to 72 hrs
Pregnancy Rate overall = 1.1%
<24 hrs after unprotected sex
hrs after unprotected sex
Task Force on Postovulatory Methods of Fertility Regulation. Lancet 8 August 1998; 352(9126);

14. Does this mean Plan B is 98.9% effective?
No!
Chance of Pregnancy in Normal Fertile Women =
20%/cycle
Average single act of unprotected intercourse = 3.1%
Single act on cycle day #12 or 13 = %
Overall Effectiveness
For single act overall = 64.5%
For single act on day #12 or 13, EC < 12 hrs = 95.7%
Proportion of Pregnancies Prevented in WHO Trial = 85%
WHO trial = 85% effective
Figure from Wilcox, A. et al. Likelihood of Conception with a Single Act of Intercourse: Providing Benchmark Rates for Assessment
of Post-Coital Contraceptives. Contraception 2001; 63:

15. Clinical Pearl – Give EC !
Despite that at any given time an individual’s risk at may be low for pregnancy, EC should not be withheld in a patient asking for it.
Feb 2007 Contraception only 43% subjects seeking EC were correct in self-report coinciding w/ where they were in menstrual cycle Novika

16. Cathy’s Questions…
She is concerned because she has heard that “the morning after pill” contains the same medication as “the abortion pill” and causes birth defects. What do you tell her?

17. Mechanism of Emergency Contraception
LNG delays or inhibits ovulation, but does not interfere w/ implantation after fertilization in monkeys
Pregnancy not prevented in women after ovulation had occurred
evident by follicular diameter >18mm
evident by hormone markers
Ortiz, M et al. Human Reproduction 2004; 19(6):
Croxatto, H et al. Contraception 2002; 65:
Nokivia, N et al. Conmtraception 2007; 75:

18. EC Does Not… …Affect sperm transport or function
…Interfere w/ endometrial receptivity to implantation
…Cause Abortion
Lalitkumar, P et a.l Human Reproduction 2007; 1-7
Do Nascimento J et al. Human Reproduction 2007; 22(8):
Croxatto, H et al. Steroids November 2003; 68:

19. EC and Pregnancy
Early concerns re: progesterone-only hormonal contraception interfering w/ implantation DISPROVEN
Works via ovulation delay / inhibition
No increase in congenital malformations or pregnancy complications in live births after EC administration.
De Santis M, et al. Fertil Steril. Aug 2005;84(2):

20. EC Knowledge
Multiple studies show pharmacists surveyed don’t know how EC works
Pharmacists In South Dakota re: Plan B
43% certain + 31% not sure if it caused birth defects if taken while pregnant
21% believed health risks from repeated use
37% of were wrong re: mechanism of action
5% answered all 3 questions regarding scientific knowledge re: EC correctly
Similar study pp ny, only 3% got all ec questions correct
Riper, K et al. Perspectives on sexual and reproductive health 2005; 37(1):19 -24

21. Cathy’s Question
She says she has enough condoms to last her through the rest of this trip. She wants to know if she should wait until she gets home to resume taking her birth control pills?

22. Start or Restart Method Right Away
No lasting effect with Plan B
Multiple use in a single month decreases effectiveness
Also Rx regular OCPs to start day after EC
home, could resume OCPs where left off
Use a back-up method for ≥7 days for patch, ring, DMPA, or OCPs

23. Other Contraceptive Choices
Also OK to start DMPA, Cu-IUD, or barrier methods now
For LNG- IUS or Contraceptive Implant, use another method x 2 weeks.
If (-) urine HCG, insert within 5 days of next menses
For Fertility Awareness Method, use abstinence or barrier method until next normal menses.
Hatcher, R. et al Contraceptive Technology 18th ed. Ardent Media, Inc. New York 2004

24. Other Concerns for Cathy
No increase risk for ectopic
No affect on future fertility
Bleeding Profile:
May have spotting after taking EC
Menses may be few days early or late
Office Visits:
Pregnancy test or physical exam not required prior to administering Plan B
May come in any time for STI testing
If no menses in 3 weeks, come in for HCG √
Acog and who don’t include routine pregnancy test in protocol
Ectopic 1% with plan b vs 2% gen pop. Decreases risk by decreasing pregnancy overall

25. Case Presentation #2: Doris

26. Case Presentation #2: Doris
You are in practice in rural Alaska. Doris, a 35 y.o. G6P5SAB1, comes in to your office. She has Qmonthly menses with an LMP 18 days ago. When she called your office 5 days ago, you informed her she could get Plan B OTC.
The only pharmacist in a 200 mile radius does not stock Plan B as he is misinformed about its mechanism of action (too bad he didn’t come to grand rounds!).

27. Case Presentation #2: Doris
It has now been 6 days since she had unprotected sex, but she was unable to come in sooner because of a snow storm.
She and her husband have never used birth control, but lately they’ve been talking about getting one of them “fixed” because they really don’t want to have any more children.
She wants the most effective method of emergency contraception. Can you help her?

28. Most Effective Form of Emergency Contraception
After Copper IUD for Emergency Contraception Pregnancy Rate %
Insertion of Copper IUD
up to 5 days after unprotected sex or
up to 5-7 days after suspected ovulation
Trussell et al. American Journal of Obstetrics and Gynecology. (2004) 190; S30-8

29. Copper T380A
Same precautions for Cu-IUD for emergency contraception as for long term contraception (no current acute pelvic infection, no Wilson’s Disease, etc.)
On return visit
If HcG (-), leave in up to 10 years
If HcG (+), IUD must be removed for termination or continuation of pregnancy

30. Ethical Considerations
EC is effective way of preventing unwanted pregnancies & abortions
Interference w/ EC access interferes w/ principles of
non-malfeasance
autonomy (those capable of deliberation about personal choices should be treated w/ respect for capacity of self determination)
beneficence (ethical principle to minimize harms & wrongs & maximize benefits).
Faundes, A et al. International Journal of Gynecology and Obstetrics 2003; 82:

31. Ethical Considerations
Respect individual rights of pharmacists, but ensure patients have timely access to timely medications
Resolution passed at the AAFP Congress of Delegates in 2005 to address this issue
Stock Plan B in your office
Use pharmacies that will supply EC
Education is Key!

32. Which pharmacies have a policy to “ensure patients’ access to their prescriptions in-store, without discrimination or delay”?
Aurora Pharmacies, Inc.
Brooks Pharmacy/ Eckerd Corporation
CVS Pharmacy
Fagen’s Pharmacy
Kmart Pharmacy
Medicine Shoppe
Rite-Aid Corporation
Walgreens
Wal-Mart Stores, Inc.
8/08/07

33. Case Presentation #3: Margie

34. Case Presentation #3: Margie
Margie is a 16 y.o. G1P1 here for her 6 week post-partum visit. This pregnancy was unplanned, as a result of forgetting to return for her Depo shot and lack of knowledge about Emergency Contraception.
Despite your best efforts to encourage her, she has already stopped breastfeeding. Her PMH and Family Hx is (-) for DVT, early MI or stroke, or other medical problems. Her best friend is on “the patch” and she wants to get on it too.

35. Case Presentation #3: Margie
She wants to know what she should do if she forgets to put the patch on or it falls off, because she is very concerned with getting pregnant again.
What do you tell her?

36. Contraceptive Options
Discuss abstinence and contraceptive options (including IUD) as pregnancy resulted from missed DMPA
If Ortho Evra Patch chosen, needs 2 additional Rxs
Ortho Evra apply to skin w/in 24 hours of patch falling off
Plan B use as directed WITH REFILLS

37. Advance EC Provision
First RTC of condom users in high risk population (Urban Family Planning Clinic), advanced EC provision vs. information only
No significant difference in unprotected sex rates
Advanced Provision group used EC 2x more often
All in advanced provision group found it useful
All in info-only group expressed desire for advanced provision ≥1 x in 12 month study
Ellertson, C. et al. Obstetrics and Gynecology October 2001; 98(4): 570-5

38. Advanced Provision Advanced Rx in teens and adult women:
does not tempt contraceptors to abandon ongoing method
does not affect rates of STI
shortens time from unprotected intercourse to EC administration and increases administration
but…. IT WON’T WORK FROM THE MEDICINE CABINET, YOU MUST ACTUALLY TAKE THE PILLS!!!!!!!!!!!!!!!!!!!!!!!!!!!!
64-79% of Advanced Rx vs 97%-100% in info only group who got pregnant in study had unprotected sex and report NO EC use. Other studies report inconsistent or WRONG use.
Polis, C. et al. Cochrane Database of Systematic Reviews 2007

39. Can’t Margie get EC OTC?
OTC Plan B available behind counter starting Nov if ≥ 18 years old
Patients < 18 years old can get EC with Rx
safety data for teens
Insurance Coverage vs. expense of OTC
MediCal and FPACT
Teens- not more likely to abandon ongoing method, similar SE and pharmacokinetics
Jones in JAMA /5 teens would use no method or withdrawl if parental consent was mandate 46% would switch to OTC. 1% would stop having sex
MediCal and FPACT: pt needs Rx (can be pharmicist generated if completed training course). Can get 2 pills at a time for total of 6 refills Q12 months
American Academy of Pediatrics Committee on Adolescence. Pediatrics. 116(4): , 2005 Oct

40. Margie’s Myths
She tells you her friend told her that if you use emergency contraception you have to take a lot of pills and you will get really sick.
What is Margie’s friend talking about?

41. “The Yuzpe Method”
Yuzpe originally described 100mcg ethinyl estradiol + 1mg dL-norgesterel
“Modified Yuzpe”
Preven no longer marketed
C-OCPs = 0.5mg levonorgestrel + 100mcg ethinyl estradiol PO Q12hrs X2
Can use 2mg norethindrone as progestin
If nothing else available, use when deployed
Yuzpe, A. J Reprod Med Aug;13(2):53-8.
Ellertson, C. et al. Obstetrics and Gynecology 2003; 101(6);

42. Combined Oral Contraceptives as EC
2+2
4+4
5+5
Ovral (white)
Tri-Leven (yellow)
Alesse (pink)
Ogestrel (white)
Lo-Ovral (white)
Levlite (pink)
Levora (light orange)
Aviane (orange)
Nordette (light orange)
Seasonale (pink)
Triphasil (yellow)
Low-Ogestrel (white)
Trivora (pink)
Table modified from

43. The Yuzpe Method C-OCP regimen = Estrogenic Effect
Rates of Nausea and Vomiting = >2x Plan B!
Nausea 50% vs. 23%
Vomiting 19% vs. 6%
Significant increase in Dizziness & Fatigue
Rx with an anti-emetic
Administer 1 hour after PO anti-emetic
Repeated if vomiting occurs w/in 1 hour of administration
Meclizine 25mg i-ii tabs PO
lasts 24 hrs & decreases dizziness
Raymond EG, et al. Obstet Gynecol. Feb 2000;95(2):

44. The Yuzpe Method Pregnancy Rate after Yuzpe administration:
<24 hrs after unprotected sex
hrs after unprotected sex
Not as effective as Plan B
57% Pregnancies Prevented in 1998 WHO Trial
Plan B FDA approved in 1999
Task Force on Postovulatory Methods of Fertility Regulation. Lancet 8 August 1998; 352(9126);

45. Observed vs. Expected Number of Pregnancies
Levonorgesterel
Yuzpe
Figure From: Task Force on Postovulatory Methods of Fertility Regulation. Lancet 8 August 1998; 352(9126);

46. Yuzpe vs. Plan B Yuzpe Plan B Effectiveness 57% 85% Nausea 50% 23%
Vomiting
19% 6%
Contra-indications to Repeated Use
YES NO
Acute migraine, hx dvt / pe, etc…don’t want to use E2 repeatedly, but safe to use Plan B many times

47. Other Oral Methods Mifepristone (Mifeprex or RU-486) Antiprogesterone
As effective as Plan B
One time dose of 10mg (available in U.S. as 200mg tablets)
Not FDA approved for EC
Causes more delayed menstruation than other methods
$$$
von Hertzen, H et al. Lancet 7 December 2002; 360:

48. Case Presentation#4 : Jenny

49. Case Presentation#4 : Jenny
Jenny is a 35y.o. G2P2 who presents to the emergency room stating that she was just raped by a stranger. Her LMP was 11 days ago. She is not on any long acting hormonal method of birth control, as she and her husband always use condoms.

50. Case Presentation#4 : Jenny
You do a complete H&P (including documenting all injuries and collecting specimens as outlined by your ER’s protocol). You also contact a counselor and police.
In addition to offering her STI prophylaxis and treatment, you also offer her what medication?

51. Offer EC to Rape Victims
EC!!!! (as recommended by ACOG and American College of Emergency Physicians).
Hx of Emergency Contraception
1960s- High dose estrogen first used to prevent pregnancy in rape victims
EC helps prevent pregnancy, not prevent STIs
ACOG Technical Bulletin “Sexual Assault” November 1997

52. Conclusions
“Any women who has been exposed to an unprotected vaginal coitus and does not want to have a child can use the emergency contraception pill”
Faundes, 2003

53. Conclusions
No Physical Exam or Pregnancy Test Needed Prior to Plan B Administration
(OK to call in Rx)
No Absolute Contraindications to Plan B
Give Advance Rx for Plan B with refills
Along with long term method of contraception

54. Conclusions
EC can be given up to 120 hours after unprotected sex, but taking EC sooner increases effectiveness
Plan B (EC) is not an abortifacent and does not interfere with an existing pregnancy
Offer EC to Rape Victims

55. Conclusions
Most effective method of emergency contraception is Copper IUD
Leave in for long term contraception
Yuzpe is acceptable method is if:
Plan B is unavailable, but C-OCPs are
Patient without contraindications

56. Emergency Contraception Resources
For providers:
For patients and providers:
1-888-NOT-2-LATE