Postcoital contraception with dl-norgestrel/ethinyl estradiol combination: six years experience in a student medical clinic

Emergency Contraception

Despite significant declines over the past 2 decades, the United States continues to experience birth rates among teenagers that are significantly higher than other high-income nations. Use of emergency contraception (EC) within 120 hours after unprotected or underprotected intercourse can reduce the risk of pregnancy. Emergency contraceptive methods include oral medications labeled and dedicated for use as EC by the US Food and Drug Administration (ulipristal and levonorgestrel), the "off-label" use of combined oral contraceptives, and insertion of a copper intrauterine device. Indications for the use of EC include intercourse without use of contraception; condom breakage or slippage; missed or late doses of contraceptives, including the oral contraceptive pill, contraceptive patch, contraceptive ring, and injectable contraception; vomiting after use of oral contraceptives; and sexual assault. Our aim in this updated policy statement is to (1) educate pediatricians and other physicians on available emergency contraceptive methods; (2) provide current data on the safety, efficacy, and use of EC in teenagers; and (3) encourage routine counseling and advance EC prescription as 1 public health strategy to reduce teenaged pregnancy.

Safety data for levonorgestrel, ulipristal acetate and Yuzpe regimens for emergency contraception

The World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) provide recommendations for use of emergency contraceptive pills (ECPs), including levonorgestrel (LNG) and combined oral contraceptives (COCs). A new ECP formulation, ulipristal acetate (UPA), is now available worldwide. To determine whether LNG, UPA or COC (Yuzpe) ECPs are safe for women with certain characteristics or medical conditions, we searched the PubMed and Cochrane databases for articles published from date of inception until May 2015 pertaining to the safety of LNG, UPA or Yuzpe ECP use. For direct evidence, we considered studies that looked at safety outcomes among women with certain medical conditions or characteristics taking ECPs compared with women not taking ECPs. For indirect evidence, we considered studies that reported pharmacokinetic (PK) data for ECP use among women with certain medical conditions or characteristics and studies that reported safety outcomes among healthy women taking ECPs. Five studies provided direct evidence; of these five studies, four examined LNG or Yuzpe use among pregnant or breastfeeding women, and one reported risk of ectopic pregnancy among women repeatedly using LNG ECPs. Poor pregnancy outcomes were rare among pregnant women who used LNG or Yuzpe ECPs during the conception cycle or early pregnancy. Breastfeeding outcomes did not differ between women exposed to LNG ECP and those unexposed, and there was no increased risk of ectopic pregnancy versus intrauterine pregnancy after repeated use of LNG ECPs compared with nonuse. Forty-five studies provided indirect evidence. One PK study demonstrated that LNG passes into breastmilk but in minimal quantities. In addition, nine studies examined pregnancy outcomes following ECP failure among healthy women, and 35 articles reported adverse events. Studies suggest that serious adverse events are rare among women taking any of these ECP formulations.

IMPLICATIONS

Evidence on safety of ECPs among women with characteristics or medical conditions listed within WHO and CDC family planning guidance is limited. However, both direct and indirect evidence for our study question did not suggest any special safety concerns for the use of ECPs among women with particular medical conditions or personal characteristics, such as pregnancy, lactation or frequent ECP use.

Emergency contraception

Despite significant declines over the past 2 decades, the United States continues to have teen birth rates that are significantly higher than other industrialized nations. Use of emergency contraception can reduce the risk of pregnancy if used up to 120 hours after unprotected intercourse or contraceptive failure and is most effective if used in the first 24 hours. Indications for the use of emergency contraception include sexual assault, unprotected intercourse, condom breakage or slippage, and missed or late doses of hormonal contraceptives, including the oral contraceptive pill, contraceptive patch, contraceptive ring (ie, improper placement or loss/expulsion), and injectable contraception. Adolescents younger than 17 years must obtain a prescription from a physician to access emergency contraception in most states. In all states, both males and females 17 years or older can obtain emergency contraception without a prescription. Adolescents are more likely to use emergency contraception if it has been prescribed in advance of need. The aim of this updated policy statement is to (1) educate pediatricians and other physicians on available emergency contraceptive methods; (2) provide current data on safety, efficacy, and use of emergency contraception in teenagers; and (3) encourage routine counseling and advance emergency-contraception prescription as 1 part of a public health strategy to reduce teen pregnancy. This policy focuses on pharmacologic methods of emergency contraception used within 120 hours of unprotected or underprotected coitus for the prevention of unintended pregnancy. Emergency contraceptive medications include products labeled and dedicated for use as emergency contraception by the US Food and Drug Administration (levonorgestrel and ulipristal) and the "off-label" use of combination oral contraceptives.

Nonprescription Availability of Emergency Contraception in the United States: Current Status, Controversies, and Impact on Emergency Medicine Practice

In October 2004, the American College of Emergency Physicians Council joined more than 60 other health professional organizations in supporting the nonprescription availability of emergency contraception. This article reviews the history, efficacy, and safety of emergency contraception; the efforts toward making emergency contraception available without a prescription in the United States; the arguments for and against nonprescription availability of emergency contraception; and the potential impact nonprescription availability could have on the practice of emergency medicine in the United States.

Emergency contraception

Teen birth rates in the United States have declined during the last decade but remain much higher than rates in other developed countries. Reduction of unintended pregnancy during adolescence and the associated negative consequences of early pregnancy and early childbearing remain public health concerns. Emergency contraception has the potential to significantly reduce teen-pregnancy rates. This policy statement provides pediatricians with a review of emergency contraception, including a definition of emergency contraception, formulations and potential adverse effects, efficacy and mechanisms of action, typical use, and safety issues, including contraindications. This review includes teens' and young adults' reported knowledge and attitudes about hormonal emergency contraception and issues of access and availability. The American Academy of Pediatrics, as well as other professional organizations, supports over-the-counter availability of emergency contraception. In previous publications, the American Academy of Pediatrics has addressed the issues of adolescent pregnancy and other methods of contraception.

Emergency contraception pills (ECPs): current trends in United States college health centers

Access to emergency contraception pills (ECPs) could drastically reduce the high rates of unintended pregnancies in college women. In spring 2001, a survey was distributed to 139 US college health centers to assess availability of ECPs. Those that prescribed ECPs provided additional information about health center distribution policies and procedures, provider practice patterns, advertising and staff attitudes. Those that did not offer ECPs were asked to state reasons for not providing this service and whether FDA approval of dedicated emergency contraception products might promote availability. The majority of campuses (66.9%) prescribe ECPs; however, many barriers exist to access. Campuses not prescribing ECPs cited moral conviction (56.5%) as a main reason for not providing this service. Staff and administration attitudes appear to play a major role in whether campuses make ECPs available to their students. Despite recent advances leading to increased availability of ECPs among college health centers, a number of campuses still do not prescribe ECPs.

Effectiveness of the Yuzpe regimen of emergency contraception by cycle day of intercourse: implications for mechanism of action

OBJECTIVE

The purpose of this study was to provide evidence about the mechanism of action of the Yuzpe method of emergency contraception by examining effectiveness by cycle day of intercourse relative to ovulation.

METHODS

Through a literature search, we identified eight studies that present the number of women treated and outcome of treatment by cycle day of unprotected intercourse relative to expected day of ovulation. Using five sets of external estimates of conception probabilities by cycle day of intercourse among women not using contraception, we assessed and compared the effectiveness of the Yuzpe regimen by whether intercourse occurred on or before the second day before ovulation or afterward, and whether intercourse occurred on or before the first day before ovulation or afterward.

RESULTS

In 36 of the 45 pairs of estimates of effectiveness, based on eight separate studies and the eight studies combined and five different sets of conception probabilities by cycle day, effectiveness was higher-and in most cases substantially higher-when intercourse occurred on or before the second day before ovulation (day -2) than when it occurred later. When data were stratified by whether intercourse occurred on or before the day before ovulation (day -1), effectiveness was greater when intercourse occurred early in 43 of 45 pairs.

CONCLUSIONS

These results suggest that one hypothesized mechanism of action of the Yuzpe method, inhibiting implantation of a fertilized egg, is unlikely to be the primary mechanism of action.

Postfertilization effect of hormonal emergency contraception

OBJECTIVE

To assess the possibility of a postfertilization effect in regard to the most common types of hormonal emergency contraception (EC) used in the US and to explore the ethical impact of this possibility.

DATA SOURCES AND STUDY SELECTION

A MEDLINE search (1966-November 2001) was done to identify all pertinent English-language journal articles. A review of reference sections of the major review articles was performed to identify additional articles. Search terms included emergency contraception, postcoital contraception, postfertilization effect, Yuzpe regimen, levonorgestrel, mechanism of action, Plan B.

DATA SYNTHESIS

The 2 most common types of hormonal EC used in the US are the Yuzpe regimen (high-dose ethinyl estradiol with high-dose levonorgestrel) and Plan B (high-dose levonorgestrel alone). Although both methods sometimes stop ovulation, they may also act by reducing the probability of implantation, due to their adverse effect on the endometrium (a postfertilization effect). The available evidence for a postfertilization effect is moderately strong, whether hormonal EC is used in the preovulatory, ovulatory, or postovulatory phase of the menstrual cycle.

CONCLUSIONS

Based on the present theoretical and empirical evidence, both the Yuzpe regimen and Plan B likely act at times by causing a postfertilization effect, regardless of when in the menstrual cycle they are used. These findings have potential implications in such areas as informed consent, emergency department protocols, and conscience clauses.

Updated estimates of the effectiveness of the Yuzpe regimen of emergency contraception

The purpose of this study was to provide revised estimates of the effectiveness of the Yuzpe method of emergency contraception. Through a literature search, we identified eight studies that present the number of women treated and outcome of treatment by cycle day of unprotected intercourse relative to expected day of ovulation. Using five sets of external estimates of conception probabilities by cycle day of intercourse among women not using contraception, we assessed the effectiveness of the Yuzpe regimen. The 45 estimates of effectiveness, based on eight separate studies and the eight studies combined and five different sets of conception probabilities by cycle day, ranged from a low of 56.4% to a high of 89.3%. Our preferred point estimate is that the Yuzpe regimen reduces the risk of pregnancy by 74.1%, with a 95% confidence interval extending from 62.9% to 79.2%. True effectiveness is likely to be > 74% because treatment failures (observed pregnancies) include women who were already pregnant when treated and women who became pregnant after being treated.

Safety and effectiveness of hormonal postcoital contraception: a prospective study

OBJECTIVE

The aim of this study was to evaluate the demographic characteristics of the population attending our hospital requesting postcoital contraception and to determine the effectiveness of the method and its side-effects.

METHODS

A total of 503 women asking for postcoital contraception were included in a prospective open trial. After filling in a questionnaire dealing with demographic and contraceptive data, we prescribed an ethinylestradiol-levonorgestrel combination (100 micrograms/500 mg for two doses 12 h apart).

RESULTS

Only 487 women were available for analysis of demographic data. A further 77 were excluded because they presented irregular menstrual cycles and 55 cases were lost for follow-up. Mean age was 22.6 +/- 5.25 years and 35.9% of cases came to the center within the first 5 h after unprotected intercourse. Only 18.8% had previously asked for postcoital contraception. Breakage of condom was the most common reason for request (81.9%). Two pregnancies occurred in the remaining 355 women. According to Dixon's method 15.5 pregnancies should be expected being the overall efficacy of 87.14%. There were no serious adverse effects. Nausea and vomiting (16.33%) were the most prevalent and 59% of the users menstruated at the expected time whilst menses were delayed in 6% of the cases.

CONCLUSION

The combination of ethinylestradiol and levonorgestrel in low doses is an effective and safe method of postcoital contraception.

New estimates of the effectiveness of the Yuzpe regimen of emergency contraception

The purpose of this study was to provide new estimates of the effectiveness of the Yuzpe method of emergency contraception and to offer correctly computed estimates of the confidence intervals for estimated effectiveness rates. Through a literature search, seven studies that present the number of women treated and outcome of treatment by cycle day of unprotected intercourse relative to expected day of ovulation were identified. Probabilities of conception by cycle day of intercourse among women not using contraception and the associated variance-covariance matrix from five other datasets were estimated, and these external estimates were used to assess the effectiveness of the Yuzpe regimen. The 40 estimates of effectiveness, based on seven separate studies and the seven studies combined and five different sets of conception probabilities by cycle day, ranged from a low of 44.2% to a high of 88.7%. The preferred point estimate is that emergency contraceptive pills reduce the risk of pregnancy by 75.4%, with a 95% confidence interval extending from 65.6% to 82.4%. True effectiveness is likely to be at least 75% because treatment failures (observed pregnancies) include women who were already pregnant when treated and women who became pregnant after being treated.

Emergency postcoital contraception

Of the estimated 3.5 million unintended pregnancies that occur each year in the United States, some 1.7 million are thought to be the result of contraceptive failure. The extremely high numbers of unintended pregnancies not only in the United States but also worldwide indicates that emergency contraception remains an important but underused method of pregnancy prevention. Emergency postcoital contraception via mechanical or pharmacological means inhibits fertilization and/or implantation from unprotected sexual intercourse. Although emergency contraception has been used primarily in victims of sexual assault, it offers a low-cost, highly effective method to reduce the incidence of unintended pregnancy. Emergency contraception decreases the costs and emotional and physical risks to women who have had unprotected intercourse. Emergency contraception also increases the latitude women have to make reproductive decisions by offering an alternative to abortion and childbearing. The heart of the problem with emergency contraception is not the failure rate or side effects of specific methods but the fact that so few women and adolescents who have had unprotected intercourse know the option exists, and their providers may be reluctant to prescribe the method.

Feasibility of a telephone follow-up on use of emergency contraceptive pills in a college health center

The authors examined the feasibility and effectiveness of a telephone follow-up procedure on use of emergency contraceptive pills (ECP) at a college health center. They made 264 telephone calls to the 97 women who had received ECPs during one 16-week academic semester and were successful in reaching 65 (67%) of the women, who responded with information about their experiences with ECPs. The women demonstrated a high rate of adherence to the medical regimen and reported very few side effects from ECPs; a majority said that ECPs did not affect their ability to carry out daily activities. On weighing the relative absence of problems following ECP distribution against the time, effort, and cost required to reach just over two thirds of the women, the researchers concluded that an ECP telephone follow-up procedure was neither cost-effective nor particularly useful.

Emergency contraceptive pills: a survey of use and experiences at College Health Centers in the mid-Atlantic United States

The authors conducted a telephone survey to investigate the availability of the emergency contraceptive pill (ECP) at college health centers in the mid-Atlantic region of the United States. Related issues, such as distribution procedure, existence of an ECPs protocol, personnel involved, contraindications, follow-up procedures, methods of advertising, and staff attitudes were examined. Of the 124 completed responses, 43 schools (35%) reported distributing ECPs. The major reasons the schools listed for not distributing ECPs (n = 81, 65%) were inadequate staffing, religious convictions, no perceived need, and the service was available from a source in the local community.

The emergency contraceptive pill: a survey of knowledge and attitudes among students at Princeton University

OBJECTIVE

Our purpose was to measure and analyze knowledge and attitudes about emergency contraceptive pills. The hypothesis we tested was that more accurate knowledge about the regimen would be associated with favorable attitudes towards its use.

STUDY DESIGN

We conducted a random sample telephone survey and a series of focus group discussions at Princeton University (results for 11 focus groups are presented elsewhere) A total of 550 undergraduate and graduate students were selected randomly for participation in the survey, and the response rate was 82%. The study's primary outcome measure was attitudes toward the emergency contraceptive pill as a method of fertility control. We used multivariate regression analysis with ordered logit models to test the hypothesized association between knowledge and attitudes.

RESULTS

Basic awareness and approval of the emergency contraceptive pill were widespread, yet students lacked detailed knowledge, which did contribute to health and ethical misgivings about the regimen. Students with accurate information, especially those students who knew that the therapy is a large dose of regular oral contraceptives and that side effects are generally minor, were significantly more likely than others to report favorable attitudes. Many students confused the pills dispensed by the university health services (Oral, Wyeth-Ayerst, Philadelphia) with the abortifacient RU 486. Students noted discussion of the method is rare, and many wanted to know more about it. Statistical results are reported with a 95% confidence level.

CONCLUSIONS

Educational efforts should offer specific information about the composition of emergency contraceptive pills, the side effects, and how the regimen works.

Endometrial suction in luteal phase as a method of late postcoital contraception

In a pilot study group of 25 women presenting in our clinic after exposure at ovulation to undesired pregnancy, endometrial suction by means of a Pipelle catheter was performed. Sixteen of the 25 women had proven fertility and 9 had never tried to conceive. The women were aged 18 to 38 years. Pathological dating of endometrial sampling verified that the patients were actually post-ovulation in all cases studied. hCG tests were performed 10 to 14 days after endometrial suction and all were negative. We conclude that endometrial suction in the luteal phase is a possible means of postcoital non-hormonal contraception, and we are currently expanding our study.

Comparison of Yuzpe regimen, danazol, and mifepristone (RU486) in oral postcoital contraception

OBJECTIVE

To compare the effectiveness and acceptability of three regimens of postcoital contraception.

DESIGN

Randomised group comparison of ethinyloestradiol 100 micrograms plus levonorgestrel 500 micrograms repeated after 12 hours (Yuzpe method); danazol 600 mg repeated after 12 hours; and mifepristone 600 mg single dose.

SETTING

Community family planning clinic.

SUBJECTS

616 consecutive women with regular cycles aged 16 to 45 years.

MAIN OUTCOME MEASURES

Number of pregnancies, incidence of side effects, and timing of next period.

RESULTS

The raw pregnancy rates (with 95% confidence intervals) for the Yuzpe, danazol, and mifepristone groups were 2.62% (0.86% to 6.00%), 4.66% (2.15% to 8.67%), and 0% (0% to 1.87%) respectively. Overall, these rates differed significantly (chi 2 = 8.988, df = 2; p = 0.011). The differences between the mifepristone and Yuzpe groups and between the mifepristone and danazol groups were also significant. Side effects were more common and more severe in the Yuzpe group (133 women (70%)) than in either the danazol group (58 (30%)) or the mifepristone group (72 (37%)). The Yuzpe regimen tended to induce bleeding early but mifepristone prolonged the cycle. Three women bled more than seven days late in the Yuzpe group compared with 49 in the mifepristone group.

CONCLUSIONS

Mifepristone was effective in reducing expected pregnancy rates and the Yuzpe method also had a clinical effect. Danazol had little or no effect. A further multicentre trial is needed.

The medical evaluation of the sexually abused child

The diagnosis of suspected sexual abuse is nearly always based on a description of abuse provided by the child. The physician should invite a child to describe his or her sexual victimization in detail if such a "disclosure" interview has not already occurred, if the child seems ready to describe the abuse, and if a child protective services worker has not yet been notified of the suspected abuse. If an allegedly abused child has already been carefully interviewed, however, the physician should instead obtain information from the child's parents or other appropriate adults to determine how best to address the questions being raised. Nonspecific behavioral or somatic complaints unaccompanied by a specific description of sexual abuse should generate a differential diagnosis for further investigation. The goals of the physical examination of the sexually abused child are to identify abnormalities that warrant further diagnostic efforts or treatment, to obtain specimens to screen the patient for sexually transmitted infections, and to make observations and take specimens that may corroborate the patient's history of victimization. These goals should be met in the context of a standard, complete physical examination. The advisability of postcoital contraception should be discussed with every postmenarcheal victim seen within 72 hours after a rape. Because gonorrhea and chlamydial infections are the most prevalent STDs seen after sexual abuse and are often asymptomatic, universal screening for these infections is recommended. Parents of all abused children should be given an opportunity to make an informed choice about HIV screening. Because the risk of acquiring STDs is low, routine antibiotic prophylaxis is not recommended for sexually abused children. Physicians must report all cases of suspected sexual abuse to states' child protective services agencies. Failure to do so can incur legal penalties. Reporting sexual assaults of children to local law enforcement officials is strongly advised. The long-term impact of sexual abuse on children's psychological adjustment is unpredictable. In the short term, children's circumstances vary widely. Some show no evidence of psychological distress. Others have severe, pervasive difficulty. Office counseling by the empathetic and knowledgeable primary care physician, short-term crisis counseling, a more formal psychological evaluation, and longer-term psychotherapy may be recommended for individual children, depending on the nature and severity of each child's symptoms, his or her parents' preference, and the availability of services in the child's community.

Post-coital contraception: an overview of published studies

Information from published studies testing the effect of hormonal and mechanical interceptive methods in post-coital contraception was pooled with the aim of assessing the efficacy of various regimens. The pooled failure rates were 0.6% (19/3168 based on four studies) for high-dosage ethinylestradiol, 1.1% (11/975, based on two studies) for other high-dose estrogens, 1.8% (69/3802 based on 11 studies) for combined estro-progestin preparations, 2.0% (20/998 based on three studies) for danazol and 0.1% (1/879 based on nine studies) for intra-uterine devices (IUD). Although this overview has several limitations in terms of over-representation of optimistic results in the literature or absence of direct comparison between treatments in several studies, it suggests that IUD and high-dose ethinylestradiol are more efficacious forms of post-coital contraception than danazol or combined contraceptives.

Postcoital contraception: some characteristics of women who use this method

This paper describes some of the characteristics of the women who attended a medical clinic requesting postcoital contraception. The information is derived from 871 observations in 653 women who requested this contraception. The mean age of women at the time of first request for this method was older than expected (21.9 years) and the mean time from first coitus to first request for the method was longer than expected (2.7 years). Previous pregnancy with therapeutic abortion was reported by 11.3% of the women. Multiple users of the method were younger at their first visit, and more likely to report a previous pregnancy. The method of contraception used before and after the need for postcoital contraception tended to be the same. Barrier method users have need of this method either for use when they fail to use their barrier method or for use when their barrier method fails. The need for more general availability of this method is discussed.