1. 1

2. When is there risk of pregnancy?
•Any day in the menstrual cycle. Highest risk of pregnancy in the 6 days leading up to and including ovulation
•From Day 21 after childbirth unless all the criteria for lactational amenorrhoea are met
•From day 5 after miscarriage, abortion & ectopic pregnancy 2

3. When is emergency contraception indicated?
Unprotected sexual intercourse
Withdrawal method
Reduced efficacy of other forms of contraception:
torn, leaking condom
missed pills or if vomiting occurred
late implant or injection
detached contraceptive patch
Late injection the FSRH emergency contraception, 2017 guidance states that EC is indicated
if there has been UPSI or barrier failure: >14 weeks after the last injection or within the first 7 days after late injection
Following and expired implant but also that women can be advised that the risk of pregnancy in the fourth year of use of the progestogen-only implant Nexplanon is extremely low.
Please explain that if a patch becomes detached then it needs to be replaced, it cannot be held in place with micropore tape or plasters we will discuss this
Ask attendees to vote on whether the following women, that they encountered in their pre- workshop book task 3, needed emergency contraception, possible answers are yes, no or unsure:
Alisha comes to see you, she had sex last night but is not sure if the condom came off or not.
Nasia used the withdrawal method and thinks she might have got ejaculate on her external genitalia – it definitely went on the top of her legs
Explain that we will look at the other women in task 3 later in the presentation.
Ask attendees to vote on whether the following woment, that they encountered in their pre-workshop book task 3, needed emergency contraception, possible answers are yes, no or unsure:
Tell attendees that we will look at the other woment from task 3 as we go through the presntation. 3 3

4. Combined oral contraceptive pills4

5. Advice for women missing combined oral contraceptives
If two or more pills have been missed (more than 48 hours late)
She:
should take the most recent missed pill as soon as possible
should continue taking the remaining pills at the usual time
should use condoms or avoid sex until seven consecutive pills have been taken
Point 3:
This may be over cautious in Weeks 2 and 3 but is a backup in case further pills are missed. 5

6. In addition… If pills are missed in Week 1 (Days 1-7):
Because the pill-free interval has been extended, EC should be considered if she had unprotected sex during this period
If pills are missed in Week 2 (Days 8-14):
There is no indication for EC if the previous seven pills have been taken consistently and correctly and are taken correctly thereafter
If pills are missed in Week 3 (Days 15-21):
Omit the pill-free interval by finishing the active pills in her current pack and starting a new pack the next day
For pills missed in week 2:
7 days of additional contraception is needed, eg, condom use
If UPA is given then remember 5 day delay recommended by FSRH in restarting COCs 6

7. Scenarios
Please ask attendees to vote on whether EC is needed in the scenarios on the slide, options are yes, no, unsure. These scenarios were included in the pre-workshop book, task three
Please advise the learners what you would want them to do if these women presented at a pharmacy in your locality and why.
Suggested answers:
Libby doesn’t actually need emergency contraception as long as the missed pills were preceded by one week of correct pill taking and she takes her pill correctly for the following seven days. But as Libby has made the effort to come in, is she is still very keen to have emergency contraception they you might decide to offer it. Note ulipristal would interact with her pill so levonorgestrel might be preferred. This might also be a great opportunity to discuss long acting reversible contraception for example the copper IUD.
Kaela, contraceptive patches that are have become unstuck will not work. The FSRH advocate that you consider emergency contraception if a patch is detached or ring is removed for greater than 48 hours. Emergency contraception is indicated if patch detachment or ring removal occurs in Week 1 and there has been UPSI or barrier failure. So Kaela does not need emergency contraception if she applies another patch within 48 hours of it falling off. Ulipristal emergency contraception could theoretically be less effective as hormonal contraception has been used in the last 7 days. Again this might be a good opportunity to promote long acting reversible contraceptives.
Ellie does need emergency contraception as she has extended her pill free interval. 7

8. Advice for women who miss or are late taking POP
TRADITIONAL POPs
(Micronor , Noriday etc)
DESOGESTREL-ONLY
(Cerazette)
More than three hours late
(more than 27 hours since the last
pill was taken)
More than 12 hours late
(more than 36 hours since the last
pill was taken)
Take a pill as soon as possible.
If more than one pill has been missed just take one pill. Take the next pill at the usual time. This may mean taking two pills in one day.
An additional method of contraception is advised for the next 48 hours after the POP has been taken.
Emergency contraception is indicated if unprotected sexual intercourse occurs after the missed pill and with 48 hours of restarting.
If UPA is given, then advise 5 day delay in restarting POP 8

9. Please ask attendees to vote on whether EC is needed in the scenario on the slide, options are yes, no, unsure. These scenarios were included in the pre-workshop book, task three
Please advise the learners what you would want them to do if these women presented at a pharmacy in your locality and why.
Scenario with Sara, emergency contraception is not indicated. The FSRH advice that emergency contraception should be considered for late or missed progestogen only pills if there have been more than 27 hours since last traditional POP or more than 36 hours since last desogestrel-only pill (Cerazette®) 9

10. Emergency contraception: what are the options ?
Ulipristal acetate (ellaOne)
Levonorgestrel (Levonelle)
IUD 10

11. How does oral EC work? •Works by delaying ovulation
•The aim is to delay ovulation for 5 days so that any sperm from the UPSI are dead.
•No effect after ovulation 11

12. Oral EC Ulipristal-EC Ulipristal acetate 30 mg
Licenced up to 120 hours (five days) after unprotected intercourse or contraceptive failure. 12

13. Levonorgestrel- EC
Contains high-dose progesterone (levonorgestrel 1500 μgm)
One tablet taken as soon as possible after unprotected intercourse (Use between 72 and 120 hours after unprotected intercourse is an off-licence use)
Ineffective > 96 hours after UPSI 13

14. Copper IUD IUD – 10 times more effective than oral EC
•Works by preventing implantation. Copper is toxic to sperm and eggs and creates an endometrium which is hostile to implantation
•A Cu-IUD can be inserted within 5 days of the FIRST UPSI since the LMP Or
Within 5 days of the EARLIEST estimated date of ovulation
A Cu-IUD is immediately effective for ongoing contraception 14

15. When in the cycle is EC effective?15

16. Both UPA-EC and LNG-EC can be given:- More than once in a cycle
Which EHC to give???
Both UPA-EC and LNG-EC can be given:-
More than once in a cycle
There is evidence that oral EC does NOT disrupt an existing pregnancy and is NOT associated with foetal abnormality
Avoid LNG-EC for 5 days after UPA-EC
Avoid UPA-EC for 7 days after LNG-EC 16

17. Enzyme inducers
•Both LNG-EC and UPA-EC could be less effective if a woman is taking an enzyme inducer or has taken in the past 28 days
•A double dose (3mg of LNG-EC) can be given
•A double dose of UPA-EC is not recommended
•It is not known if double dose LNG-EC or single dose UPA-EC is more effective for a women using an enzyme inducer 17

18. Breast feeding UPA is excreted in the breast milk
FSRH do not advocate breastfeeding for seven days following ulipristal acetate (UPA)
Express and discard breast milk for 7 days
LNG not contraindicated. Advice to take immediately after feeding to reduce the potential exposure to the infant 18

19. Confidentiality and under 16s
The legal age of consent for sex in England, Scotland and Wales is 16 years old
Although not legal, children between the ages of 13 and 15 are considered able to consent to sexual intercourse, if Fraser guidelines criteria is met
In England, children under the age of 13 years are legally considered unable to consent to sexual activity – this is considered non-consensual and must be reported to the safeguarding lead
It is important to explicitly state that children under the age of 13 years having sexual intercourse needs to be reported to the safeguarding lead.
Reference FSRH Service Standards in obtaining valid consent in sexual health services, 2014,
FPA The law on sex factsheet 2015 19

20. Fraser Guidelines
 that the young person understands the advice and has sufficient maturity to understand what is involved
 that the doctor could not persuade the young person to inform their parents, nor to allow the doctor to inform them
 that the young person would be very likely to begin, or continue, having sexual intercourse with or without contraceptive treatment
 that, without contraceptive advice or treatment, the young person’s physical or mental health would suffer
 that it would be in the young person’s best interest to give such advice or treatment without parental consent. 20

21. CONFIDENTIALITY 21

22. Case Scenario Sarah 16 years old •Using no contraception
•UPSI 2 days ago
•Also UPSI 10 days ago
•LMP 15 days ago (normal)
•Cycle is always 28 days
•Definitely doesn’t want to be pregnant! 22

23. Case Scenario Chloe 42 years old
Not currently on any form of contraception
UPSI 6 days ago
LMP 9 days ago
Cycle is usually 32 days long but has been two days early once or twice
Does not want to be pregnant 23

24. Case scenario Jess 14 years old
“messing about” with boyfriend but didn’t go all the way
He came on the inside of her legs and this has happened before
LMP finished 4 days ago but are very irregular
Weight 95kg
Height 1.52m 24

25. ALWAYS GIVE EHC EVEN IF REFERRING FOR IUD
Points of advice
ALWAYS
ALWAYS GIVE EHC EVEN IF REFERRING FOR IUD
Most women do not suffer many side effects, but if vomiting occurs within two hours of oral emergency contraception, then another supply is needed.
The timing of the next period can be altered: if it is more than seven days late then follow-up is required.
The 4 Cs
Coil (IUD) is the most effective method of emergency contraception – give EHC in case the woman does not present for fitting within five days after UPSI or ovulation
Contraception – ongoing needs should be assessed
Condoms – to reduce STI risk
Chlamydia and other STIs; there is a two-week window for chlamydia screening – consider the need for post-exposure HIV prophylaxis 25

26. Decision making….. FSRH – Emergency Contraception Guideline including
Decision-making Algorithms 26

27. Any Questions??? 27