Emergency Postcoital Contraception

Description
Emergency postcoital contraception is defined as the use of a drug or device
to prevent pregnancy after unprotected sexual intercourse.  The expected risk
of pregnancy after unprotected intercourse without emergency contraceptive
treatment is 5.6%. [29]  Emergency contraception should never be utilized as a
patient's primary method of contraception and all patients with user dependent
methods or no method should be educated regarding the acquisition and use
of emergency contraception..  
A variety of different methods of emergency contraception have been
described. Emergency contraceptives available in the United States include,
the Copper T380 IUD, emergency contraceptive pills (combined and
progesterone-only), and a progesterone agonist/antagonist. Levonorgestrel
(Plan B) and ulipristal acetate (Ella) are marketed as emergency
contraceptives in the United States.
Candidates for emergency contraception include reproductive-aged women
who have had unprotected sexual intercourse within 120 hours of presentation
independent of the menstrual cycle. No known absolute contraindications to
any of these methods have been described because exposure to the high
dose of hormones is short lived. Exposure to the Yuzpe method (taking high
doses of a combined birth control pill) may be contraindicated in patients with
cardiovascular risk factors.
A study by Wilkinson et al analyzed the availability and access to emergency
contraception for female adolescents since the FDA removed age restrictions
to emergency contraception in 2013. The study reported that 83% of the 979
pharmacies in the study had emergency contraception available, however,
8.3% of the pharmacies, which were more often in low-income
neighborhoods, said it was impossible to obtain emergency contraception
under any circumstances. [30]
The American College of Obstetricians and Gynecologists makes the
following recommendations regarding emergency contraception [31] :
 Advise patients that a copper intrauterine device (IUD) is the most
effective form of emergency contraception and OBGYNs and other
providers should consider integrating copper IUD emergency
contraception provision into their practices and allow same-day provision
of IUDs.    
 Ulipristal acetate is more effective than levonorgestrel and should be
prescribed when possible up to 5 days after unprotected intercourse.
  In order to increase awareness and reduce barriers to immediate
access, advance prescriptions for emergency contraceptions can be
written.
 Provide information about all contraceptive methods to initiate a
consistent method during a patient’s appointment for emergency
contraception.
 Counsel all women at risk of pregnancy about emergency
contraception.
 Clarify that emergency contraception will not terminate an established
pregnancy.
 Social media should be used for emergency contraception campaigns.
 Provide a referral if a patient’s pharmacy or institution will not provide
emergency contraception.
 Ensure timely access to emergency contraception by working with
pharmacies and other retail outlets to avoid misinformation.
Copper T380 Intrauterine Device
The Copper T380 IUD can be inserted as many as 7 days after unprotected
sexual intercourse to prevent pregnancy. Insertion of the IUD is significantly
more effective than either levonorgestrel or ulipristal acetate regimen,
reducing the risk of pregnancy following unprotected intercourse by more than
99%.
Progesterone only Emergency Contraception Method
Only the progestin levonorgestrel has been studied for use as emergency
contraception. It is marketed as Plan B. Its treatment schedule comprises 1
dose of 750 mcg levonorgestrel taken as soon as possible and no later than
72 hours (for optimal effectiveness) but can be used up to 120 hours after
unprotected intercourse.  Plan B One-Step is an enteric-coated 1.5mg
levonorgestrel emergency contraceptive pill (E-LNG-ECP) that both dissolves
and is absorbed in the intestine.   This high dose of levonorgestrel delays
ovulation up until the point of LH surge through inhibition of follicular
development and maturation.
In June 2013, the FDA approved Plan-B One-Step as a nonprescription
product for all women of childbearing potential. This action complies with
allowing levonorgestrel-containing emergency contraceptives to be available
as OTC products without age or point-of-sale restrictions. [32]  Generic tablets
were approved February 2014 and include My Way, Take Action, and Next
Choice One-Dose.
Progesterone agonist/antagonist
Ulipristal is a selective progesterone receptor modulator with antagonistic and
partial agonistic effects. When taken immediately before ovulation, ulipristal
postpones follicular rupture and works through the LH surge. It is thought that
the primary mechanism of action for emergency contraception is inhibition or
delay of ovulation; however, alterations to the endometrium that may affect
implantation may also occur. The treatment regimen is 30 mg (1 tablet) PO as
soon as possible (within 120 hours [5 days]) after unprotected intercourse or a
known/suspected contraceptive failure. If vomiting occurs within 3 hours after
the dose, consider repeating the regimen. [33]
Combined Hormone Emergency Contraception Method
The Yuzpe regimen is one of the first methods studied for emergency
contraception but is less common now with the availability of the options
mentioned above. The patient takes additional doses of her own prescribed
birth control pills. The regimens for the various methods can be found at
www.bedsider.org. This method is associated with side effects of nausea,
vomiting, and possibly spotting, breast tenderness and headaches.
Efficacy
Placement of a copper IUD within 5 days of unprotected intercourse is the
most effective method of emergency contraception, with a failure rate of only
0.09%.  Ulipristal acetate is more effective than levonorgestrel alone,
preventing about 2/3 of undesired pregnancies. Levonorgestrel loses
effectiveness over time, preventing about 1/2 of undesired pregnancies up to
72 hours. Despite this significant reduction in the rate of pregnancy, patients
must understand that this method of contraception should be used only in
emergencies and that they should be encouraged to use other more
consistent forms of contraception.
Several factors complicate the calculation of a failure rate. Factors include
dependence on the patient's history of their last menstrual period and day of
exposure, effect of regular and irregular menstrual cycles on the calculation of
the estimated time of ovulation, the possibility of the patient being pregnant,
and the possibility that more than one unprotected coitus has occurred during
that period.
Studies have demonstrated a lower effectiveness for levonorgestrel in women
weighing more than 165 pounds. One study has suggested doubling the dose
for women with a BMI>30 kg/m2. [34]
Disadvantages
Adverse effects include nausea and emesis, minor changes in menses, breast
tenderness, fatigue, headache, abdominal pain, and dizziness. See above for
disadvantages related to obesity and levonorgestrel only.  Emergency
contraceptive methods are not effective once implantation of a fertilized egg
has occurred and thus effectiveness is completely dependent upon cycle
timing with act(s) of unprotected intercourse.
https://emedicine.medscape.com/article/258507-overview#a8