Ectopic pregnancies following emergency levonorgestrel contraception

Over-the-counter emergency contraception in Italy: ethical reflections and medico-legal issues

Although more than ten years have passed since the marketing of Ulipristal acetate in Europe, emergency contraception remains a complex issue with many scientific, legal, ethical and social implications. The topic is an example of the differences that can exist between scientific evidence, the certainties on which law is based, and social implications. This paper shows the incompleteness of the scientific reconstruction on the effects of emergency hormonal contraceptives and the dangerousness of the decision to alienate the supply of over-the-counter drugs from the general rules of health care. This report shows the incompleteness of the scientific reconstruction on the effects of emergency hormonal contraceptives and the dangerousness of the decision to alienate the supply of over-the-counter drugs from the general rules of health care. Various ethical and medico-legal issues will be addressed, also focusing attention on underage women whose sexual and reproductive health requires not abandoning them, but actually taking charge of them without medicalizing their choices.

A systematic review and meta-analysis of the prevalence and association between levonorgestrel and ectopic pregnancy

BACKGROUND

The use of levonorgestrel emergency oral contraceptives (EOCs) is one of the factors that may be associated with ectopic pregnancy. We aimed to investigate the incidence of ectopic pregnancy in EOC users and the association between EOCs and ectopic pregnancy.

RESEARCH DESIGN AND METHODS

We searched for articles that provided the incidence of and the association between levonorgestrel EOCs and ectopic pregnancy in women of reproductive ages in CINAHL Complete, Medline, OpenDissertations, Scopus, Science Direct, and Thai Journal Online. The risk of bias was assessed by Risk Of Bias In Non-randomized Studies or Risk of Bias 2. A meta-analysis was conducted using the random-effects model.

RESULTS

We retrieved 1839 nonredundant articles from the systematic search. The meta-analysis showed that the prevalence of ectopic pregnancy was not statistically different from zero (pooled prevalence estimate = 0.029%; 95%CI: -0.006, 0.065; N = 9; I2 = 0) and rare. In addition, levonorgestrel EOCs increased the risk of ectopic pregnancy (OR = 6.17; 95%CI: 3.78, 10.08; N = 5; I2 = 43%).

CONCLUSIONS

Women with extrauterine or ectopic pregnancy had higher odds of using levonorgestrel emergency oral contraceptives than those with intrauterine pregnancy. However, the prevalence of ectopic pregnancy is rare.

Ectopic Pregnancy Following Levonorgestrel Emergency Contraception: Report of Two Cases

Abstract Ectopic pregnancy (EP) is likely to occur as an unwanted complication after unprotected intercourse in spite of levonorgestrel emergency contraception (LNG-EC).   Its incidence has been increasing recently. We present 2 cases of tubal EP  after the oral use of levonorgestrel, treated by  laparoscopy.The first unruptured EP with unclear ultrasound findings, because of   uterine ventrofixation  after the caesarean section (CS) . The second case is a ruptured EP after LNG –EC   on day 24 of the period  with mild  haemoperitoneum with severe peritoneal irritation. The fundamental question is whether levonorgestrel participates in the etiology of EP. The etiology of EP involves many factors. Levonorgestrel mechanisms of action give us grounds to believe theoretically that it increases the risk of EP and participates as an etiological factor.  

The role of SK3 in progesterone-induced inhibition of human fallopian tubal contraction

BACKGROUND

Normal motor activity of the fallopian tube is critical for human reproduction, and abnormal tubal activity may lead to ectopic pregnancy (EP) or infertility. Progesterone has an inhibitory effect on tubal contraction; however, the underlying mechanisms remain unclear. Small-conductance calcium-activated K⁺ channel 3 (SK3) is abundantly expressed in platelet-derived growth factor receptor α positive (PDGFRα+) cells and was reported to be important for the relaxation of smooth muscle. The present study aims to explore the expression of SK3 in the human fallopian tube and its role in progesterone-induced inhibition of tubal contraction.

METHODS

We collected specimens of fallopian tubes from patients treated by salpingectomy for EP (EP group) and other benign gynecological diseases (Non-EP group). The expression of SK3 was detected by quantitative real-time polymerase chain reaction, western blot, immunocytochemistry, and immunohistochemistry analyses. Isometric tension experiments were performed to investigate the role of SK3 in progesterone-induced inhibition of tubal contraction.

RESULTS

The baseline amplitude and frequency of human fallopian tube contraction were both statistically lower in the EP group compared with the non-EP group. The expression levels of SK3 in different portions of fallopian tubes from the non-EP group were significantly higher than in those from the EP group. Progesterone had an inhibitory effect on tubal contraction, mainly on the amplitude, in both groups, and SK3 as well as other calcium-activated K⁺ channels may be involved. SK3-expressing PDGFRα (+) cells were detected in the human fallopian tube.

CONCLUSIONS

The expression of SK3 is lower in the EP group, and SK3 is involved in the progesterone-induced inhibition of human fallopian tube contraction.

A Systematic Review and Meta-analysis of the Adverse Effects of Levonorgestrel Emergency Oral Contraceptive

INTRODUCTION

The levonorgestrel oral emergency contraceptive is well tolerated and effective, however its use is still limited, mainly due to safety concerns.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize current evidence regarding the adverse events, and their prevalence, reported during the use of oral levonorgestrel emergency contraceptives.

METHODS

Four electronic databases and the US FDA Adverse Event Reporting System (FAERS) Public Dashboard were searched. Studies that reported or investigated safety outcomes or adverse reactions during the use of levonorgestrel as an emergency oral contraceptive were included. Data on study design, demographics of levonorgestrel and the control cohort, and reported adverse effects were extracted.

RESULTS

A total of 47 articles were included in this systematic review, from which it was shown that most of the adverse reactions were common and not serious. Uncommon adverse reactions identified included anorexia, ectopic pregnancy, exanthema, chloasma, miscarriage, and weight gain. Multiple serious adverse events, including convulsion, ectopic pregnancy, febrile neutropenia, stroke, abdominal hernia, anaphylaxis, cancer, ovarian cyst rupture, serious infections, and suicidal ideation, were reported. In addition, the prevalence of adverse events after a levonorgestrel 0.75 mg two-dose regimen and a levonorgestrel 1.5 mg single-dose regimen were not statistically different (p > 0.05).

CONCLUSIONS

The most common adverse effects of levonorgestrel were not serious. This systematic review shows that data regarding the adverse reactions of repeated use of levonorgestrel are scarce. Studies on the multiple uses of levonorgestrel emergency contraception are still required to ensure its safety.

Critical ethnographic respect: womens' narratives, material conditions, and emergency contraception in India

Emergency Contraceptive Pills (ECPs) are increasingly available over the counter as a form of hormonal birth control in India. As use of ECPs is increasing over time, this paper draws on ethnographic research in Dehradun, in Uttarakhand (Northern State) to highlight the everyday material conditions under which women create narrative around choice and agency regarding these ECPs. Women viewed ECPs as better options than abortion, appreciated the sense of empowerment these provided them because they could be consumed in houses where women had limited 'space and privacy;' and finally that ECPs and their advertisements could act as 'agents of social change.' Feminist scholarship on reproduction demonstrates that choice is a form of agency that is enacted within certain constraints. Using this framework, the research here highlights how women create narratives about ideas of contraceptive choice and notions of 'empowerment' when talking about ECPs and their advertisements. In revisiting the dilemma about women's agency and choice, this paper builds on Rosalind Gill's concept of 'critical respect' to propose 'critical ethnographic respect' as an ethnographic tool to help read women's responses and respectfully contextualise the materiality from within which these narratives emerge.

Risk factors for ectopic pregnancy in a population of Cameroonian women: A case-control study

OBJECTIVE

To identify the risk factors for ectopic pregnancy (EP) in a population of Cameroonian women.

SAMPLE AND METHODS

We performed a matched case-control study; 88 women with diagnosed EP (cases), and 176 women with first trimester intrauterine pregnancy (IUP) (controls), who underwent questionnaires. Odds Ratio (OR) and 95% confidence intervals (CIs) were calculated and adjusted for potential confounding factors via multivariate logistic regression analysis.

RESULTS

Of the fifteen identified risk factors, 4 were independently associated with increased odds of EP: prior pelvic inflammatory disease (PID) (adjusted odds ratio [AOR] 13.18; 95% CI 6.19-27.42), followed by current use of levonorgestrel-only pills for emergency contraception (LNG-EC) (AOR 10.15; 95% CI 2.21-46.56), previous use of depot medroxyprogesterone acetate (DMPA) (AOR 3.01; 95% CI 1.04-8.69) and smoking at the time of conception (AOR 2.68; 95% CI 1.12-6.40).

CONCLUSION

The present study confirms the wide variety of EP's risk factors. Moreover, some new findings including current use of LNG-EC, previous use of DMPA, smoking at the time of conception are noteworthy. Thus, in our limited resources country where prevention remains the cornerstone for reducing EP chances of occurrence, clinicians should do enough counselling, especially to women with known risk factors. The necessity to facilitate access to more equipment to enable early diagnosis of EP is very crucial and should be seriously considered, in order to reduce the burden of EP in Cameroonian women.

Levonorgestrel only emergency contraceptive use and risk of ectopic pregnancy in Eldoret Kenya: a case-control study

INTRODUCTION

ectopic pregnancy is one of the causes of maternal morbidity and mortality in sub-Saharan Africa. Levonorgestrel (LNG) only emergency contraceptive pill is a well-established emergency contraceptive pill that is administered within 72 hours after unprotected intercourse. This study aimed at determining whether or not there is a significant association between levonorgestrel emergency contraceptive use and the occurrence of ectopic pregnancy.

METHODS

case-control (1:3) study among 79 women with ectopic pregnancy (cases) matched against 237 women without (controls) at Moi Teaching and Referral Hospital in Eldoret, Kenya; Sociodemographic and clinical data were collected using a questionnaire. Association between ectopic pregnancy and LNG-EC was assessed using Pearson chi-square test. The relationship between outcome and exposure (while adjusting for confounders) was assessed using logistic regression model.

RESULTS

The mean age was 27.15 years. Both cases and controls were similar by age (p = 0.990), educational level (p = 0.850), marital status (p = 0.559), employment status (p = 0.186) and parity (p = 0.999). Seventy-eight (24.7%) participants had a history of miscarriage. A higher proportion of the cases had history of using LNG-EC compared to the controls (32.9% vs. 7.2%, p < 0.001). The use of LNG-EC portended more than nine times increased odds of ectopic pregnancy compared to other contraceptive methods {OR = 9.34 (95% CI: 3.9 - 16.0)}.

CONCLUSION

levonorgestrel only emergency contraceptive use was associated with ectopic pregnancy. One of the limitations of this study is that we could not control for all confounders of ectopic pregnancy.

Ectopic pregnancy following oral levonorgestrel emergency contraception use

Levonorgestrel is used worldwide as an emergency oral contraceptive. There have been occasional reports of ectopic pregnancy after oral levonorgestrel use. We present a case of ectopic tubal pregnancy after the use of oral levonorgestrel as an emergency contraceptive in a 37-year-old woman with a history of treatment for Chlamydia trachomatis infection. She conceived after sexual intercourse on menstrual day 14 of the first menstrual cycle following a normal delivery. After salpingectomy for this right tubal pregnancy, her following pregnancy was an ectopic pregnancy in the contralateral tube, which was treated with laparoscopic salpingectomy. Histopathological examination revealed endometriosis. We should be aware of ectopic pregnancy even after emergency contraceptive use, especially in patients with risk factors, such as Chlamydia infection and endometriosis. Because the efficacy of levonorgestrel decreases after ovulation, we should check the stage of the cycle before prescription.

Association between levonorgestrel emergency contraception and the risk of ectopic pregnancy: a multicenter case-control study

Cases of ectopic pregnancy (EP) following levonorgestrel emergency contraception (LNG-EC) failure have been reported continuously, but whether there is an association between EP risk and LNG-EC is unclear. We concluded a case-control study to explore this association by recruiting 2,411 EP patients as case group, and 2,416 women with intrauterine pregnancy and 2,419 non-pregnant women as control groups. Odds ratios (ORs) and their 95% confidential intervals (CIs) were calculated and adjusted for potential confounding factors. Previous use of LNG-EC was not correlated with the EP. Compared to women who did not use contraceptives, current use of LNG-EC reduced the risk for intrauterine pregnancy (Adjusted OR [AOR] = 0.20, 95%CI: 0.14-0.27), but did not increase the risk for EP (AOR2 = 1.04, 95%CI: 0.76-1.42). Furthermore, compared to women who did not have further act of intercourse, women with unprotected further act of intercourse were at a higher risk of EP (AOR1 = 2.35, 95%CI: 1.17-4.71), and women with repeated use of LNG-EC for further intercourse during the same cycle was also associated with a higher risk for EP (AOR1 = 3.08, 95%CI: 1.09-8.71; AOR2 = 2.49, 95%CI: 1.00-6.19). A better understanding of the risk of EP following LNG-EC failure can optimize LNG-EC use and thus reduce the risk of EP.

Emergency contraceptive pill safety profile. Comparison of the results of a follow-up study to those coming from spontaneous reporting

BACKGROUND

The emergency contraceptive pill (ECP) containing levonorgestrel is dispensed without a prescription in Spain since 2009. An easy access could diminish unwanted pregnancies; however, there is a risk of misuse and, in any case, of developing some adverse events. The aim of the present study is to further learn the adverse effects of this ECP.

METHODS

An ad hoc follow-up study was carried out in three community pharmacies in a city of Central Spain; the sample was composed of those women asking for the ECP; they were interviewed by telephone after at least a month since the last menses. We completed the safety profile obtained with that coming from spontaneous reporting in Spain.

RESULTS

Out of 139 women surveyed, 113 developed any adverse event--two considered as severe; the most frequently reported events were menstrual disturbances, which accounted for 21% of all events. Through spontaneous reporting, 36 cases of whatever adverse events related to levonorgestrel as ECP were identified. Twenty-five cases were considered as severe. Both types of reaction and severity were significantly different in the follow-up study and in the spontaneous reporting. Some of the reactions identified, such as miscarriage, febrile neutropenia, and porphyria, are not included in the Summary of Product Characteristics.

CONCLUSIONS

Levonorgestrel as an ECP is mostly safe. Attention should be paid to some severe events and particularly to those risk factors for them to appear. Combining spontaneous reporting with an ad hoc follow-up study, the whole safety profile of a given medication can be obtained.

Emergency contraception: clinical outcomes

Emergency contraception (EC) is widely used to prevent unwanted pregnancy. This review considers the safety and efficacy of three commonly used methods -- levonorgestrel (LNG-EC), ulipristal acetate (UPA) and the copper intrauterine device. All are extremely safe, and side effects are minimal. Concerns about increased risks of ectopic pregnancy after EC use have proved unfounded, and possible teratogenic effects seem unlikely. Although the true effectiveness of EC is impossible to estimate, recent research suggests that LNG-EC prevents around 50% of expected pregnancies in women using the method within 72 h of intercourse, whereas UPA appeared to prevent almost two thirds of pregnancies. Emergency intrauterine device insertion probably prevents over 95% of pregnancies. However, although improved accessibility of EC has clearly led to increased use, it does not appear to have had any public health benefit in reducing unintended pregnancy rates. Most of the data on sexual behavior following improved access to EC do not show any detrimental effect on subsequent use of other more effective methods of contraception or on the incidence of unintended pregnancy or sexually transmitted infection. However, unless these other methods of contraception are also made easily available from pharmacies, improved access to EC risks unlinking its use with use of subsequent ongoing contraception.

Emergency contraception

OBJECTIVE

To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting.

OPTIONS

The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed.

OUTCOMES

Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception.

EVIDENCE

Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed.

VALUES

The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1).

BENEFITS, HARMS, AND COSTS

These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1. Hormonal emergency contraception may be effective if used up to 5 days after unprotected intercourse. (II-2) 2. The earlier hormonal emergency contraception is used, the more effective it is. (II-2) 3. A copper IUD can be effective emergency contraception if used within 7 days after intercourse. (II-2) 4. Levonorgestrel emergency contraception regimens are more effective and cause fewer side effects than the Yuzpe regimen. (I) 5. Levonorgestrel emergency contraception single dose (1.5 mg) and the 2-dose levonorgestrel regimen (0.75 mg 12 hours apart) have similar efficacy with no difference in side effects. (I) 6. Of the hormonal emergency contraception regimens available in Canada, levonorgestrel-only is the drug of choice. (I) 7. A pregnancy that results from failure of emergency contraception need not be terminated (I) Recommendations 1. Emergency contraception should be used as soon as possible after unprotected sexual intercourse. (II-2A) 2. Emergency contraception should be offered to women if unprotected intercourse has occurred within the time it is known to be effective (5 days for hormonal methods and up to 7 days for a copper IUD). (II-2B) 3. Women should be evaluated for pregnancy if menses have not begun within 21 days following emergency contraception treatment. (III-A) 4. During physician visits for periodic health examinations or reproductive health concerns, any woman in the reproductive age group who has not been sterilized may be counselled about emergency contraception in advance with detailed information about how and when to use it. (III-C).

Ectopic pregnancy after levonorgestrel emergency contraception

BACKGROUND

Although the possibility of ectopic pregnancy after intake of levonorgestrel (LNG) as an emergency contraceptive (EE) pill is well-known, the causality has not been well established.

CASE

A 27-year-old nulliparous woman with regular menstrual periods took 1.5-mg LNG EE midcyclic 5 h after an unprotected intercourse. She had prolonged vaginal bleeding at the expected time. She consulted the general practitioner because of continuous vaginal bleeding for 4 weeks and lower abdominal pain. The pregnancy test was positive, and her symptoms and clinical findings suggested an ectopic pregnancy. At emergency surgery, she was found to have a left tubal pregnancy.

CONCLUSION

The possible role of 1.5-mg LNG EE in causing ectopic pregnancy is discussed. A high serum LNG concentration decreases ciliary activity and tube motility, but further epidemiological studies are necessary to establish the risk of ectopic pregnancy following intake of LNG EE.

Ectopic pregnancy following levonorgestrel emergency contraception: a case report

Hormonal contraceptive pills containing 750 microgram levonorgestrel are the most commonly used postcoital contraceptive method because of their high efficacy and fewer side effects. Emergency contraceptive pills containing levonorgestrel present their effects by several mechanisms, including delayed tubal transport of the ovum. A delay of tubal transportation of an ovum is also one of the possible etiologic factors of tubal ectopic pregnancies. There are limited data on the risk of ectopic pregnancy following levonorgestrel treatment as an emergency contraception. Here, a case of tubal pregnancy associated with the use of levonorgestrel containing emergency contraceptive pills has been presented along with discussion of the relevant literature.

Ectopic pregnancy following levonorgestrel emergency contraception: a case report

Use of levonorgestrel as emergency contraception is a safe and effective measure to prevent unwanted pregnancy. However, ectopic gestation in case of failure is a known risk. Access to levonorgestrel without a prescription in many countries has made it impossible to estimate the exact incidence of this potential adverse event. Thus, spontaneous reporting of cases serves to alert physicians to this possibility. We present a case of ectopic pregnancy following use of levonorgestrel emergency contraception. To our knowledge, this is the first case report from India following introduction of levonorgestrel emergency contraception in 2001.

Regulation of muscular contractions in the human Fallopian tube through prostaglandins and progestagens

BACKGROUND

Transport of gametes and embryos is an important function of the Fallopian tube. Both muscular contractions and cilia activity are involved in the transportation. Prostaglandins (PGs) are known mediators of muscular contractility. PG receptors have previously been demonstrated in the human Fallopian tube. The aim was to study the effect of PGs and progestagens, antiprogestin, hCG and oxytocin on muscular contractions in the human Fallopian tube, and the hormonal regulation of PG receptors.

METHODS

Twenty-two healthy women operated for benign causes were included in the study. The ampullary-isthmic junction of the Fallopian tubes was excised and used for in vitro contractility studies. The effect of PGE(1), PGE(2), PGF(2alpha), progesterone, mifepristone, levonorgestrel, oxytocin and hCG on contractility was studied. Explants of Fallopian tubes were cultured for 24 h to study the effect of progestagens and hCG on the expression of PG receptors using immunohistochemistry and real-time PCR.

RESULTS

Muscular contractions increased after treatment with PGF(2alpha) and PGE(2) (P < 0.05). The contractions decreased after PGE(1), progesterone, levonorgestrel, mifepristone, oxytocin and hCG (P < 0.05). In tubal explant studies, relative mRNA expression of EP1, EP2, EP3 and FP increased after levonorgestrel treatment (P < 0.05). Mifepristone and levonorgestrel treatment increased immunostaining intensity of EP1 and EP2 protein, in lumen, muscle and vessels. Progesterone and mifepristone increased immunostaining of FP in vessels.

CONCLUSIONS

These data suggest that the transport of gametes and embryos involves the action of PGs, progesterone, oxytocin and hCG on muscular contractility.

Ectopic pregnancy following emergency contraception with ethinyloestradiol-levonorgestrel: a case report

BACKGROUND

Emergency contraception with ethinyloestradiol-levonorgestrel is effective, and ectopic pregnancy following its failure is rare.

CASE

A 21-year-old nulligravid Japanese woman with regular menstrual periods took ethinyloestradiol-levonorgestrel pills for emergency contraception (EC) 36 and 48 hours after a coitus complicated by retention of the condom in the vagina. She started bleeding vaginally 24 days after that intercourse. As the bleeding continued for three weeks she consulted a gynaecologist. The pregnancy test was positive. Two weeks later she complained of lower abdominal pain, and transvaginal ultrasonography suggested a pelvic blood collection. At emergency surgery, she was found to have a left tubal pregnancy.

CONCLUSION

Although ectopic pregnancy after failure of EC is rare, one should be alert to its possible occurrence.

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.

Failure of the emergency contraceptive levonorgestrel and the risk of adverse effects in pregnancy and on fetal development: an observational cohort study

OBJECTIVE

To determine pregnancy and neonatal outcome after the failure of levonorgestrel as an emergency contraceptive.

DESIGN

A retrospective observational cohort study.

SETTING

Telephone consultations concerning reproductive risk factors conducted by Telefono Rosso-Teratology Information Service, Catholic University of Sacred Heart, Rome, Italy.

PATIENT(S)

Women exposed to levonorgestrel (36 cases) compared with a control group (80 cases).

INTERVENTION(S)

Teratological counseling.

MAIN OUTCOME MEASURE(S)

The rate of congenital anomalies, the prepartum or peripartum complications, and the pregnancy outcomes.

RESULT(S)

Twenty-five exposed newborns with length and weight identical to that of the control group were shown to be without increased risk of congenital malformation. No statistical differences were observed in terms of spontaneous or legal abortion and pregnancy and neonatal complications, and there was no ectopic pregnancy in either group.

CONCLUSION(S)

Although the sample size was small, in our experience, the failure of levonorgestrel as an emergency contraceptive was not associated with an increased risk of major congenital malformations, prepartum or peripartum complications, or an adverse pregnancy outcome.

A randomized trial to compare 24 h versus 12 h double dose regimen of levonorgestrel for emergency contraception

BACKGROUND

Levonorgestrel (0.75 mg given for two doses 12 h apart) has been proven to be an effective regimen for emergency contraception when the first dose is given within 72 h of unprotected coitus. However, the dosing interval is inconvenient for those taking the first dose in the afternoon. We conducted a randomized study to evaluate two levonorgestrel dosing regimens for emergency contraception. Two doses of levonorgestrel 0.75 mg were administered with the first dose given up to 120 h after unprotected intercourse. The second dose was given 12 h later in the first regimen and 24 h later in the second regimen.

METHODS

We conducted a double-blind, randomized trial between 1997 and 2003 at five centres in China. A total of 2071 women requesting emergency contraception within 120 h of unprotected intercourse were recruited. They were randomized to receive two doses of 0.75 mg of levonorgestrel, given either 24 h apart or 12 h apart.

RESULTS

Outcome was unknown for 53 women (24 in the 24 h group and 29 in the 12 h group). Among the remaining 2018 women, the crude pregnancy rate was 1.9% in the 24 h group [95% confidence interval (CI) 1.17-2.94] and 2.0% in the 12 h group (95% CI 1.19-2.99). The proportion of pregnancies prevented was estimated to be 72% in the 24 h group and 75% in the 12 h group. Side-effects were mild in both groups. The efficacy of the 12 h regimen declined significantly when there were further acts of intercourse after treatment (5.0 versus 1.0%, P<0.01). This was not observed in the 24 h group.

CONCLUSIONS

Two doses of 0.75 mg levonorgestrel given either 24 or 12 h apart are effective for emergency contraception up to 120 h after unprotected intercourse. Further research to investigative more effective methods of emergency contraception is warranted.

Emergency contraceptive pills: a review of the recent literature

PURPOSE OF REVIEW

The purpose of this review is to inform the reader of new information published since early 2003 about emergency contraception, with a particular focus on issues of access.

RECENT FINDINGS

Research continues to document low but increasing levels of knowledge about emergency contraception, increasing use, and more positive attitudes towards emergency contraception by both patients and healthcare providers. Additional information is available about efficacy and mechanisms of action. More reports of side-effects have been published, as have studies relating to the impact of emergency contraception on sexual and contracepting behaviors. Advance provision, provision by pharmacists, and over-the-counter status have been studied as ways to improve access to emergency contraception.

SUMMARY

Knowledge about the efficacy, safety, types and use of emergency contraception continues to increase. Although patients have greater awareness of and more access to emergency contraception, there are still numerous barriers to its use even in countries where it is available over the counter. Healthcare providers must continue to educate themselves and their patients about emergency contraception even when it becomes available over the counter. In countries where emergency contraception is only available by prescription, providers should offer an advance prescription or supply (where available), and use newer dosing regimens for levonorgestrel-only emergency contraception to increase adherence and efficacy. Developing collaborative practice agreements with pharmacists to increase access is also recommended. Patients should be counseled to seek follow-up if no menses occurs within 3 weeks of taking emergency contraception or if symptoms such as lower abdominal pain occur after the use of emergency contraception.