Emergency Contraception

“the morning-after pill”

Dr.Sujnanendra Mishra MD(O&G)
Emergency contraception (EC)

Emergency contraception (EC)

is any method of contraception
which is used after intercourse
and before the potential time
of implantation
Emergency Contraception
Emergency contraception (EC) is
any method of contraception
which is used after intercourse
and before the potential time of
implantation
Also known as:
• Morning-After Pills
• Postcoital Contraception
• Secondary Contraception

These terms do not convey the correct timing of use nor that these
methods should be used only for emergencies.
HISTORY of EC -

• "First immediately after ejaculation let

the two come apart and let the woman
arise roughly, squeeze and blow her
nose seven times and call out in a loud
voice. She should jump violently
backwards seven to nine times."
» Abu Bakr Muhammad ibin Zakariya' al-Razi
(865 AD-925 AD)
• Hormonal methods originated in mid-
1920s with discovery that estrogenic
ovarian extracts have anti-fertility effect
• High-dose estrogen (DES or EE) post-
coitally as a treatment for rape survivors in
the 1960s
How about a post-coital
Coca-Cola douche!

(The New England Journal of Medicine

published a study on that one as late as the
1980s.)
CURRENT EC -

• Yuzpe’s original article – 1974

• Dosage was two doses of two Ovral

tablets, 12 hours apart
– within 72 hours of unprotected intercourse
• Effectiveness believed to be about 95%
• Problems = nausea, time frame
Women Who May Need Emergency
Contraception (Primary Users)
Women who:
– Have unplanned, unprotected intercourse
– Used a condom that may have leaked or broken
– Missed multiple COC pills
– Waited > 16 weeks beyond last injection (DMPA)
– Failed in using withdrawal method of contraception
(ejaculation in vagina or external genitalia)
– Failed to abstain when needed while using NFP
– Incorrectly used a diaphragm or the diaphragm or
cervical cap dislodged, broke or tore, or was removed
early
– Are rape victims
Other Situations When Emergency Contraception May
Be Used
(Secondary Users)
Although EC is intended for primary users,
there may be other situations or circumstances
when other users may need EC.
The other users may be women who:
– Are sexually active adolescents in need of
contraception
– Are currently not using a contraceptive
– Have intercourse infrequently
– Are postpartum (before menses returns)
– Are over age 35 (presumed decreased fertility)
– Are post abortion (before menses returns)
 WHAT’S THE DIFFERENCE ?
Between “the morning-after pill” and “the abortion pill”
“the morning-after pill” “the abortion pill”
EMERGENCY CONTRACEPTION MIFEPRISTONE

WHAT DOES Prevents a pregnancy from Ends a pregnancy without

IT DO? occurring after unprotected sex. surgery.

WHAT IS IT? A high dose of birth control pills. One of two pills used to end
a pregnancy without surgery.

WHEN CAN Effective within 5 days of Effective to terminate

I TAKE IT? unprotected sex, but the sooner pregnancies up to 8 weeks
the better. duration.

IS IT SAFE? Yes. effective contraceptive for Yes. effective for pregnancy

pregnancy prevention after termination.
unprotected sex.
Emergency Contraception
• These methods have enormous potential for
use as safe and effective postcoital
contraceptives.
• If integrated with ongoing family planning
information and services, may encourage
new clients to come to clinic.
• Emergency contraception should be
promoted to reduce unwanted
pregnancies.
 Emergency Contraception:
Benefits
• All are very effective (failure rate less than
2% in women who use it correctly)
• IUDs also provide long-term contraception

Source: Consortium for Emergency Contraception 1998.

Emergency Contraception: Methods
 Combined Oral Contraceptives (COCs):
– Low-dose (30–35 µg EE and 150 µg LNG),
or
– High-dose (50 µg EE and 250 µg LNG)
 Progestin-Only Pills (POPs):
 750 µg LNG (preferred)
 30 µg LNG
 37.5 µg LNG
 75 µg norgestrel
 IUDs:
 TCu 380A, Multiload
 375, Nova T
Antiprogestins
 Emergency Contraception:
COCs
• Mechanisms of action
– May alter endometrium (mixed
proliferative/secretory pattern)
– May block ovulation
– May alter tubal motility
• Effectiveness
– 2% failure rate when used correctly1
• Safety
– No long-term problems in nearly all women
– Nausea (and vomiting) most common short-term
side effect (due to estrogen)
1
Source: Consortium for Emergency Contraception 1999.
 DOSE for Combine OCP
Low-dose (30–35 µg EE and High-dose (50 µg EE and 250
150 µg LNG), Total = 8 tablets µg LNG)
Total = 4 tablets1

STEP I Take 4 tablets of a low-dose Take 2 tablets of a high-dose

COC (30–35 µg EE) orally COC (50 µg EE) orally within 72
within 72 hours of unprotected hours of unprotected
intercourse. intercourse.

STEP II Take 4 more tablets in 12 hours. Take 2 more tablets in 12 hours

STEPIII If no menses (vaginal bleeding) within 3 weeks, the client should

consult the clinic or service provider to check for possible
pregnancy.
 DOSE for POP (Prog. Only Pills)
750 µg LNG (preferred) 30 or 37.5 µg of LNG or 75
Plan- B Total = 2 tablets µg of norgestrel
Total = 40 tablets

STEP I Take 1 tablet (750 µg of LNG) Take 20 tablets (30 or 37.5 µg

orally within 72 hours of
unprotected intercourse.
STEP II Take 1 more tablet in 12
hours.
of LNG or 75 µg of norgestrel)
orally within 72 hours of
unprotected intercourse.
Take 20 more tablets in 12
hours.

STEP III If no menses (vaginal bleeding) within 3 weeks, the client

should consult the clinic or service provider to check for
possible pregnancy.
 Plan B One-Step
First single dose emergency
contraceptive now OTC

The first one-tablet oral emergency contraceptive

as i-pil , Unwanted-72 , (1.5mg levonorgestrel), is
now available as an over-the-counter medication.
New emergency contraceptive
Ulipristal is a selective progesterone
receptor modulator. By preventing
progesterone from occupying its receptor,
ulipristal is thought to inhibit or delay
ovulation and possibly also suppress
maturation of the endometrium necessary
for implantation of the embryo.

1. Ellaone Summary of Product Characteristics, 2009.

2. CHMP Assessment Report for Ellaone. EMEA/261787/2009
The two emergency
contraceptives work differently:
• Plan B One-Step contains levonorgestrel, a progestin
hormone used in lower doses in many birth control pills.
• Ellaone contains ulipristal, a non-hormonal drug that blocks
the effects of key hormones necessary for conception.
• Plan B should be taken as soon as possible after sex. It
may work for up to 72 hours, but is ineffective once the
hormonal surge that leads to ovulation occurs.
• Although emergency contraception should not be delayed,
Ellaone's efficacy does not fade for 120 hours (five days)
after sex, regardless of whether the hormonal surge has
occurred.
 The two emergency
contraceptives
Difference Plan B One-Step Ellaone
Active ingredients Levonorgestrel ,a progestin ulipristal, a non-hormonal
hormone used in lower doses drug that blocks the
in many birth control pills. effects of key hormones
necessary for
conception.

TIMING As soon as possible after As soon as possible after

sex. It may work for up to 72
hours, but is ineffective once
the hormonal surge that leads
to ovulation occurs.
Drawbacks It ineffective once the
hormonal surge that leads to
ovulation occurs.
sex., Ella's efficacy does
not fade for 120 hours
(five days) after sex,
regardless of whether
the hormonal surge has
occurred.
Ella may be less
effective in obese
women.
IUDs: Instructions for Use as
Emergency Contraception
• Step 1: Insert IUD within 5 days of
unprotected intercourse.
• Step 2: If no menses (vaginal bleeding)
within 3 weeks, the client should consult
the clinic or service provider to check for
possible pregnancy.
• Step 3: If pregnancy not prevented,
counsel client regarding options.
ANTIPROGESTINS
• Different action from its use in medical abortion,
same dose
• A single 600mg dose of Mifepristone (RU-486)
within 72 hrs after unprotected intercourse is
highly effective
• Fewer side-effects than Yuzpe
• 10mg dose may be equally effective
Emergency Contraception:
Limitations
• COCs are effective only if used within 72 hours of
unprotected intercourse.
• COCs cause nausea and vomiting.
• POPs must be used within 72 hours of
unprotected intercourse but cause much less
nausea than COCs.
• IUDs are effective only if inserted within 5 days of
unprotected intercourse.
• IUD insertion requires minor procedure performed
by a trained provider.
• IUDs are not best choice for women at risk for
STDs (e.g., HBV, HIV/AIDS).
 FINAL WORDS….
Emergency contraception is using a drug or copper intrauterine device (Cu-
IUD) to prevent pregnancy after unprotected sex. This is for backup, not regular
contraception. Mifepristone and levonorgestrel are very effective with few
adverse effects, and are preferred to oestrogen and progestogen combined.
Levonorgestrel could be used in a single dose (1.5 mg) instead of two split
doses (0.75 mg) 12 hours apart. Another effective method for emergency
contraception is Cu-IUD and it can be kept for ongoing contraception.