[Emergency contraception]

Emergency contraception is indicated when no birth control is used or in case of contraception failure. To day, two methods of emergency contraception are available. The hormonal method consists in taking a tablet of levonorgestrel 1.5 mg (NorLevo), as soon as possible following the contraceptive failure since its efficiency decreases rapidly as time goes by. No contraindication is associated with this contraceptive; however, it cannot be used as a regular contraception method since it is not 100% efficient (from 95.5 to 89% according to the authors). Apparently, this contraceptive acts by delaying ovulation. Mechanical contraceptives, such as intra-uterine devices, are extremely efficient (99.5%) and can be used up to 5 days after the estimated ovulation date. However, surveys conducted by the Inserm have revealed that in France, women are not aware of or lack of knowledge about emergency contraception and have many misconceptions. Moreover, many of them do not use emergency contraception since they do not feel concerned by the risk of pregnancy following contraception failure.

Current issues in emergency contraception: an overview for providers

Emergency contraception has the potential to greatly reduce the number of unintended pregnancies occurring each year in the United States. Emergency contraception is a safe and effective intervention to which all women should have easy access in the event of an act of unprotected intercourse. Methods of emergency contraception include combined hormone oral contraceptive pills, progestin-only oral contraceptive pills, a dedicated progestin-only emergency contraceptive product, and insertion of a copper intrauterine device. Barriers exist to the increased use of emergency contraception, including the prescription-only status of all of the methods and lack of accurate knowledge on the part of health care providers and consumers. This article provides an overview of the clinical management of emergency contraception.

Access to emergency hormonal contraception from community pharmacies and family planning clinics

AIMS

To evaluate differences in the time taken to access progestogen-only emergency hormonal contraception (EHC) by young women from family planning (FP) or community pharmacy settings.

METHODS

An observational study of 203 women requesting EHC from FP clinics and community pharmacies in South-west Kent Primary Care Trust (PCT) from December 2002 to October 2003.

RESULTS

Access to EHC from community pharmacy was significantly faster than from FP clinics (16 h vs. 41 h, P<0.001). Older teenagers tended to seek EHC more quickly and were more likely to have had a contraceptive failure rather than have used no contraception at all.

CONCLUSION

The results provide further support for pharmacist involvement in the supply of EHC.

A qualitative study of pharmacists' perspectives on the supply of emergency hormonal contraception via patient group direction in the UK

AIM

To investigate pharmacists' views and experiences of supplying emergency hormonal contraception (EHC) via a group prescribing protocol in community pharmacies in the UK.

DESIGN

Qualitative study using depth interviews.

SETTING

Community pharmacists in Manchester, Salford and Trafford (Greater Manchester), and Lambeth, Southwark and Lewisham (London) Health Action Zones in the UK.

PARTICIPANTS

Forty-four community pharmacists supplying EHC in Manchester, Salford and Trafford, and Lambeth, Southwark and Lewisham (London).

RESULTS

Pharmacists were broadly very positive about their experiences supplying EHC via the group prescribing protocol. Pharmacists identified many benefits of the EHC schemes for clients, in particular, improved access to EHC at no cost to clients. The confidential nature of the scheme was also seen as an advantage as was the scope for referral to other service providers. Pharmacists also believed that the scheme had benefits for the profession in terms of enhanced professional standing. However, their concerns included the extent of repeated use of EHC, the possible impact on contraceptive behaviors and sexually transmitted infections and its impact on male coercive sexual behavior.

CONCLUSIONS

Although pharmacy supply of EHC may improve access for some clients and is perceived as a popular service, research into the implications of the schemes as identified in this study need to be conducted.

Effects of making emergency contraception available without a physician's prescription: a population-based study

BACKGROUND

Timely access to emergency contraception has the potential to reduce the number of unwanted pregnancies and subsequent abortions. A public health policy initiative in British Columbia beginning in December 2000 allowed pharmacists to provide emergency contraceptives (ECs) without a prescription. We sought to determine changes in EC use after the policy was introduced and to analyze EC use with data generated by the policy.

METHODS

All Ovral, Preven and Plan B EC prescriptions from Jan. 1, 1996, to Dec. 31, 2003, were identified through the BC PharmaNet and Medical Services Plan administrative databases and the data analyzed to determine changes between 1996 and 2002. Changes over time were determined in the frequency of EC provision, choice of EC agent, frequency of EC use by age group, repeat use and geographic distribution of EC prescription for the pre- and post-policy periods. Anonymized patient-specific data from treatment consent forms were used to describe the reason for EC use, interval between unprotected intercourse and EC prescription, proportion prescribed for immediate or future use, referrals for regular birth control and STD screening and concomitant antiemetic use. Consent data also provided the time in the menstrual cycle that the EC was requested.

RESULTS

The number of EC prescriptions increased from a pre-policy mean of 8805 (99% confidence interval 7823-9787) in the years 1996 to 2000 to a post-policy total in 2002 of 17 794. Physicians prescribed the levonorgestrel regimen (Plan B) less frequently than did pharmacists. The frequency of EC use was highest among women aged 20-24 years across all study years, and all age groups demonstrated a post-policy increase in use. On average, 2.1% of the women received an EC 3 or more times a year over the period of the study. More women in urban regions received ECs than women in more rural areas of the province. Analysis of pharmacist treatment consent forms used in 2001 and 2002 showed that 56.2% of women receiving an EC reported using a method of birth control that had failed, 55.7% of pharmacist-provided ECs were obtained within 24 hours after unprotected intercourse, 1.1% of ECs were obtained for future use, antiemetics were provided to 57.7% of women receiving the Yuzpe regimen (Ovral, Preven) and to 20.5% of women receiving levonorgestrel, and women tended to seek ECs when unprotected intercourse occurred at the time of highest risk of pregnancy in their menstrual cycle. Women in greatest financial need obtained ECs more frequently from physicians than from pharmacists.

INTERPRETATION

The policy change that granted pharmacists authority to provide ECs to women without a physician's prescription did not simply expand EC availability but was associated with an overall increase in EC use in the province.

Emergency contraception--clinical and ethical aspects

Emergency contraception (EC) consists of either 1.5 mg of levonorgestrel (LNG) in one or two doses, or a combination of LNG with ethinylestradiol, administered for up to 5 days after unprotected intercourse. Clinical studies indicate that LNG alone is more effective and has less side effects. Its effectiveness decreases the longer after coitus it is taken. EC is indicated when there is non-compliance or accidents with the use of regular methods of contraception, or when women have had voluntary or imposed unprotected intercourse. The ethics of providing EC has been questioned by some, arguing that it acts by preventing implantation. Scientific evidence does not support this concept, but shows that EC acts mostly before fertilization. Placing obstacles to the access of EC is unethical as it transgresses the ethical principles of autonomy, non-maleficence beneficence and justice. Far from inducing abortions, EC reduces unwanted pregnancies and prevents abortion.

Ectopic pregnancies following emergency levonorgestrel contraception

There are little or no data on the risk of ectopic pregnancy following levonorgestrel treatment as an emergency contraception. We encountered three cases of ectopic pregnancy following the use of levonorgestrel administered peri- or postovulation. Here we report these cases and discuss the clinical and epidemiologic implications of this association. Health providers should be alert to the possibility of an ectopic pregnancy in women who become pregnant or complain of lower abdominal pain after taking levonorgestrel.

Surfing on the morning after: analysis of an emergency contraception website

The introduction of widespread nonprescription delivery of hormonal emergency contraception (EC) calls for development of innovative tools to provide information to and gather feedback from EC users. Individuals seeking confidential information on sexual health and contraception are increasingly turning to the Internet as the resource of choice. This study employed analytical software and manual content analysis to examine the use of a website dedicated to an EC product (www.norlevo.com) over the course of 2 years. Frequency of visits to and pageviews of the site increased consistently over the 2-year time period, and the bulk of the visitors to the site were EC users seeking responses to frequently asked questions. The most common concern raised by users was the occurrence of spotting and menstrual bleeding following EC use. This analysis reveals that within the context of nonprescription access to hormonal EC, a website can constitute a potent educational tool for health professionals and EC users and provide a valuable source of post-marketing feedback on product use.

[Who are the users of emergency contraception?]

INTRODUCTION

A user profile is necessary in order to direct future campaigns for emergency contraception (EC).

MATERIAL AND METHODS

Over a three-month period, 423 women with prescriptions for EC were consecutively entered in the study, which was carried out in four inner-city pharmacies in Copenhagen, Denmark.

RESULTS

The median age was 24 years (range 13-50 years). Most women (73%) were first-time users of EC. The reason for the current need for EC was most often condom failure (54%) or non-use of any contraceptive method (41%). Only six women (1.4%) reported non-use of contraception because of their knowledge of EC and only four women (0.9%) reported EC as the usual method of contraception. Knowledge about EC more often came from family or friends (51%) and advertising (47%), than from general practitioners (26%) or through sex education in schools (3%). Altogether 282 women (69%) received EC from a doctor in the medical emergency service or a casualty ward.

DISCUSSION

Overall, EC is used as recommended. Its availability does not seem to reduce the use of safer contraceptive methods. The mandatory sex education in school should include information on EC.

Knowledge, use and attitudes towards emergency contraceptive pills among Swedish women presenting for induced abortion

OBJECTIVE

To investigate the knowledge, experiences and attitudes towards emergency contraceptive pills (ECP) among women presenting for induced abortion.

DESIGN

Survey by self-administered waiting room questionnaires.

SETTING

Three large hospitals in the cities of Uppsala, Västerås and Orebro in Sweden.

POPULATION

591 Swedish-speaking women consecutively attending the clinics for an induced abortion during a four-month period in 2000.

RESULTS

The response rate was 88% (n = 518). As many as 43% had a history of one or more previous abortions and 43% were daily smokers. Four out of five women, 83%, were aware of ECP, but only 15 women used it to prevent this pregnancy. Fewer, 38%, knew the recommended timeframes for use and 54% had knowledge of the mode of action. The two most common sources of information about ECP were media and friends. One out of five, 22%, had previously used the method, and at the time of conception, 55% would have taken ECP if it had been available at home, and 52% were positive to having ECP available over the counter.

CONCLUSIONS

Emergency contraception is well known but is still underused. Lack of awareness of pregnancy risk may be one limiting factor for its use. Making ECP available over the counter may be an important measure towards better availability. Information strategies to the public are needed before ECP will be a widely used back-up method.

The role of matching menstrual data with hormonal measurements in evaluating effectiveness of postcoital contraception

The effectiveness of postcoital contraception can only be estimated. The most commonly used method of calculation compares the expected pregnancy rate in the exposed population to the resultant pregnancies after treatment. Estimation of the fertile period and the day of ovulation are critical to calculate the expected pregnancies. The aim of this study was to improve the accuracy of calculations by evaluating the hormonal status on the day of contraceptive treatment. A total of 483 consecutive women requesting postcoital contraception was included in a prospective observational trial. A blood sample was obtained at the moment of consultation to measure serum luteinizing hormone, estradiol, and progesterone concentrations. An ethinylestradiol-levonorgestrel combination (100 micrograms/500 mg for two doses, 12 h apart) was then prescribed. The fertile period was estimated according to previous hormonal studies in the normal cycling population. Of 483 women, 64 (13.25%) women were excluded because they presented irregular menstrual cycles and 37 (7.6%) women were lost to follow-up. Two pregnancies occurred in the remaining 382 women. Following Wilcox's and Trussell's methods, 21.1 and 17.75 pregnancies should be expected, yielding an overall treatment effectiveness of 90.52% (95% confidence interval [CI] 62.58%-97.6%) and 88.73% (95% CI 55.93%-97.12%), respectively. Hormonal data were available in 356 women; 303 of whom presented with regular cycles. Hormonal information in this group restricted the number of exposed cases to 88 women. Of the women included in Trussell's method of analysis, only 51 (51.5%; p < 0.05) were at risk using hormonal data. Fifty-six percent (95% CI 34.9%-75.6%) of women with luteinizing hormone levels > 20 IU/L were not between days-1 and +1 of the cycle. Hormonal studies suggest that methods based on pregnancy risk calculated by cycle day do not faithfully reflect the real exposure.

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.

A reassessment of efficacy of the Yuzpe regimen of emergency contraception

This review discusses the available data reporting the efficacy of emergency contraceptive treatment with the Yuzpe regimen (0.2 mg of ethinyl oestradiol in combination with either 2.0 mg of norgestrel or 1.0 mg of levonorgestrel) and evaluates the true effectiveness in preventing pregnancy. A literature review was completed for reports including women treated with the Yuzpe using a MEDLINE search for articles published since 1970 and by reviewing the secondary reference lists of these manuscripts. Expected pregnancy rates for each study population were calculated using published conception rate estimates. Seven published studies provided adequate data to assess accurately efficacy of the Yuzpe regimen in preventing pregnancy after unprotected intercourse. Of 2871 women treated, 54 (1.9%, 95% confidence intervals (CI) 1.4-2.4) became pregnant. By calculating the expected pregnancy rates using two different methodologies, the Yuzpe regimen decreased the observed number of pregnancies by 70.0% (95% CI 63.3-76.7) and 77.2% (95% CI 71.5-82.8). Emergency contraception with the Yuzpe regimen is an effective form of contraception to prevent unwanted pregnancy after unprotected intercourse.

Ethinyl oestradiol plus dl-norgestrel or levonorgestrel in the Yuzpe method for post-coital contraception: results of an observational study

This observational study compares the efficacy and incidence of side-effects between dl-norgestrel (2 mg) and levonorgestrel (1 mg) associated with ethinyl oestradiol (200 micrograms) given in two doses 12 h apart for emergency post-coital contraception. A total of 117 consecutive women were given dl-norgestrel in combination with the oestrogen (dl-norgestrel group) while 423 consecutive subjects received the combination ethinyl oestradiol/levonorgestrel (levonorgestrel group). Overall, four (0.8%) pregnancies occurred in the 540 treated women, one (0.9%) in the dl-norgestrel group and three (0.7%) in the levonorgestrel group. In addition to this similar high contraceptive efficacy between both study groups, women in the levonorgestrel group had a significantly lower incidence of side-effects (23.5%) and better timing of the next menstruation after treatment (75% had bleeding on time) than those in the dl-norgestrel group (corresponding figures were 50.5 and 62.6% respectively). It is concluded that levonorgestrel should be used in preference to dl-norgestrel for post-coital contraception in the Yuzpe regimen.

Provision of emergency contraception by nurses: a way forward to increased access

OBJECTIVES

The objectives of the study were to assess the suitability of a service for provision of emergency hormonal contraception by nurses.

METHODS

Retrospective analysis was carried out of data obtained from the case records of 500 consecutive women who attended ABACUS (a city center-based family planning clinic in Liverpool, UK) for emergency contraception during the 7th and 9th months of the first year (1994) of the service. Similar data were collected for 100 consecutive women during 1 month of the third year (June 1996). The number of women who received emergency hormonal contraception was noted. In particular, details pertaining to the reasons for referral to the doctor and the trend of referrals were noted.

RESULTS

The results indicate that during the first year the nurses independently issued emergency hormonal contraception to 37% of the women. They referred the remaining 63% to the medical staff. One-third of referrals were for ongoing contraception, especially oral contraception. Another third of referrals appeared to be due to 'nurse anxiety', as no medical or other cause was found for these referrals. During the third year, nurses dispensed emergency hormonal contraception to 64% of women. Among the remaining 36% of women who were referred to the doctor, 19% needed hormonal contraception. Referral reflecting 'nurse anxiety' significantly declined (1%) compared to the first year of service.

CONCLUSIONS

Ongoing contraception, particularly initiation of oral contraception, was one of the main reasons for referral during the first year. Referral due to 'nurse anxiety' significantly declined with continued experience and may have reflected initial anxiety and the learning curve. With increased experience over the first 2 years, the outcome of this service showed encouraging improvement. The nurses now dispense emergency hormonal contraception to a majority of women.

Emergency contraception, a method whose time has come: an update

Unplanned pregnancy is a major public health problem in the United States. Emergency contraception has the potential to significantly decrease the incidence. The Yuzpe regimen is highly effective but woefully underutilized. Mechanisms of action of hormonal emergency contraception will be discussed as well as appropriate indications for use, patient counseling issues, and future methods.

7 alpha-Methyl-19-nortestosterone: an ideal androgen for replacement therapy

MENT is a synthetic androgen which cannot be 5 alpha-reduced. Therefore, relative to T, its stimulatory action on the prostate is lower than that on the muscle and pituitary. Like T, MENT undergoes enzymatic aromatization to an estrogen. We conclude that the use of MENT instead of T for androgen replacement therapy could have health-promoting effects by reducing the occurrence of prostate disease.

[Initial experiences with a levonorgestrel-ethinyl estradiol combination for interception]

Several authors have reported on reliable postcoital contraception, using an estrogen/gestagen combination. These studies in more than a hundred women showed, that the unprotected intercourse in less than 50% took place around ovulation. Pregnancy rates from 0.7 to 2.6% were observed. From October 1987 to July 88, 50 women after unprotected intercourse around ovulation were included in our study. From one to 44 hours after intercourse, 0.5 mg levonorgestrel + 0.1 mg ethinylestradiol (Tetragynon) were administered orally. The same dose was repeated 12 hours later. Cervical secretion, LH- and E2 and P-serum levels at the time of the first administration were determined and side effects and bleeding patterns were registered. In one third of the women, we observed slight side effects. The bleeding resulted 5 to 29 days after the first tablet administration. Shortened menstruation cycles were seen more often than prolonged cycles. Bleeding duration was only slightly prolonged. Two pregnancies occurred - both women vomited immediately after the first medication and disregarded the order to visit our department again as quickly as possible. Tetragynon is not appropriate for regular contraception and should only be used in emergency situations.

Ethinyl oestradiol and D-norgestrel is an effective emergency postcoital contraceptive: a report of its use in 1,200 patients in a family planning clinic

We describe a prospective study of 1,200 patients using the Yuzpe regimen of hormonal postcoital contraception. There was an 85% follow-up rate, and of the 1,015 patients followed there were 13 pregnancies, giving a pregnancy rate of 1.3%. The number of expected pregnancies at mid-cycle was reduced by 83%; 12 of the 13 pregnancies went on to abortion. The patients were young: 86% were under 25, and 10% were under 15. The most frequent reason for presentation was that no contraception had been used (57%). All patients received an antiemetic; 57% experienced no side-effects, 28% had some nausea and 9.6% some vomiting. It is concluded that this is a safe form of emergency contraception, which is an effective way of reducing the number of unwanted pregnancies, especially in the very young.