POTD: Emergency Contraception

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I wanted to touch on emergency contraception and the modalities available to emergency physicians. It’s been surprising to me that this request has not come up more often in residency. Remember, you want to initiate emergency contraception as soon as possible for higher efficacy.

What does “emergency contraception” mean?

Emergency contraception refers to the products that prevent pregnancy from occurring after an episode of unprotected intercourse or a failure of alternate forms of contraception.

Emergency contraception can be in the form of oral medications or IUDs.

Oral medications:

Technically, the FDA has only approved two forms of emergency contraception: oral levonorgestrel and oral ulipristal acetate.


Oral levonorgestrel – 1.5mg PO (one dose)

  • Must be initiated within 72 hours, maximum up to 5 days for moderate efficacy

  • Relative risk reduction (RRR) of pregnancy: 89% if initiated within 48h

  • Brand names: Plan B, Plan B One Step, My Way, Next Choice

  • Mechanism of action: progestin (aka synthetic progesterone)

  • prevents fertilization by inhibiting ovulation, and it thickens cervical mucus

  • Side effects: heavy/irregular vaginal bleeding, GI symptoms

  • Available OTC for ~$40 out of pocket, (or $10 with GoodRx)

  • Not recommended if patient’s BMI > 25

  • There is a long list of drug interactions

Oral ulipristal acetate – 30 mg (one dose)

  • Must be initiated within 5 days

  • May be more effective for overweight patients

  • Brand name: Ella

  • Mechanism of action: progestin

  • Delays or inhibits ovulation and prevents implantation by altering the endometrium

  • Recommended to discard breast milk x 24 hours after ingestion

  • Side effects: GI symptoms, headache

  • Available OTC for ~$50 out of pocket, (or $40 with GoodRx)

IUDs:

  • IUDs are the most effective forms of emergency contraception

  • They must be inserted within 5 days of unprotected intercourse

  • 99+% RRR of pregnancy

  • No weight limit!

  • Traditionally, the copper IUD (e.g. ParaGard) was considered the gold standard.

  • However, recent literature shows that hormonal IUDs (e.g. Mirena, Liletta), are just as effective forms for emergency contraception. (See the NEJM study below.) Personally, I think this is a game changer.

  • Emergency contraceptive users have an incidence of ~10% of pregnancy within 1 year

  • Contraindicated in patients with PID or with active gonorrhea/chlamydia

  • Consider an OB/GYN consult if you think an IUD might be the best option for your patient.

Yuzpe Method:

  • Lastly, in lower-resource areas where access is a concern, you can consider the “Yuzpe” method, which is a combination estrogen/progesterone treatment.

  • 100mcg ethinyl estradiol (aka synthetic estrogen) + 0.5 mg levonorgestrel Q12h for one day

  • RRR of pregnancy is ~75%

  • Recommended within 5 days

Should you find yourself in a pickle overseas, this Wikipedia article has information regarding EC availability by country. I thought it was interesting!

https://en.wikipedia.org/wiki/Emergency_contraceptive_availability_by_country

Resources:

  1. https://www.uptodate.com/contents/emergency-contraception?search=emergency%20contraception&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

  2. https://wikem.org/wiki/Emergency_contraception

  3. https://www.nejm.org/doi/full/10.1056/NEJMoa2022141 https://www.mayoclinic.org/drugs-supplements/levonorgestrel-oral-route/before-using/drg-20074413


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