Emergency contraception (EC) 
  • The use of a drug or device to prevent unplanned pregnancy that may occur after unprotected sexual intercourse (UPSI) which may include contraceptive failure or imperfect use.
  • Intended for occasional use & is not recommended as a primary contraceptive method – less effective than regular hormonal contraception for this purpose
  • Situations that may warrant the use of emergency contraception include:
    • No contraceptive method used
    • Condom slip or breakage
    • Displacement of cervical cap or diaphragm
    • Removal, displacement, or missing IUD
    • Incorrect use of regular contraceptive method
      • missed combined oral contraceptives (see individual product monographs)
      • >27 hours since last progestin only contraceptive  
        • Decreased absorption is a concern if vomiting and/or diarrhea for > 48 h with oral contraceptives 
      • Removed intravaginal contraceptive ring for >3 hours during an in-ring week
      • Removed transdermal contraceptive patch for >24 hours during a patch week
      • > 13-week interval between depo-medroxyprogesterone injections
    • Ejaculation on external genitalia
    • Sexual assault
  • Ovulation times can vary between women, as well as between cycles in an individual woman
    • Any UPSI has some risk of pregnancy

Note: there are no absolute medical contraindications for emergency contraception (EC) other than allergy to components of EC products

  • Hormonal emergency contraceptives may be used in women with contraindications to daily oral contraceptives, including:
    • cardiovascular disease
    • migraines
    • liver disease
    • current breastfeeding
  • If menstrual period is overdue, recommend a pregnancy test; if positive refer
  • If patient chooses a copper-IUD for EC after being informed about various EC methods, refer. If uncertain patient will be able to have the IUD inserted within 7 days of UPSI, provide oral EC

Selection of an EC agent is often driven by patient preference, however, consideration must be also given to patient characteristics, characteristics of each method, availability & cost.

1) Devices for EC

  • Copper IUD
    • Most effective form of emergency contraception- 99.9%
    • Can be considered up to 7 days after UPSI
    • Effective the day of & even after ovulation 
    • Works regardless of weight or BMI
    • Various brands, sizes, costs; see details
    • Provides the additional benefit of ongoing contraception 
    • Levonorgestrel IUDs not recommended - have not been evaluated for EC
    • Patient may wish to get oral EC agent in addition to Copper IUD if they're not sure they can get it inserted within the time frame
    • Insertion in medical clinic, family planning clinic
      • Find out where in your community people can be referred to 

2) Pharmacologic Agents for EC

A) Levonorgestrel (LNG)

  • In Saskatchewan, Schedule III status (available OTC) as of February 2020
  • Mechanism of Action: Works in the preovulatory stage
    • Prevents the luteinizing hormone surge that triggers ovulation
    • Delays ovulation
    • Not effective the day before ovulation or after ovulation has occurred
  • Dose: 1.5 mg PO stat within 5 days of UPSI (although efficacy decreases further on days 4 & 5 & UPA is shown to be more effective) 
  • Most effective if taken within 24hrs of UPSI
  • When used within 5 days of UPSI, rates of pregnancy are found to be 2.2%. However, there are many factors to take into consideration that may change its effectiveness, including weight or BMI, as well as timing in relation to where in the cycle it is used. 
  • Hormonal contraception (oral, patch, ring, etc)  can be started the day of or the day after LNG; abstinence or barrier method of contraception is required for the next 7 days
  • Effect may be dependent on patient weight or BMI
    • Possible lowered effect if BMI 25–29 OR Wt > 75 to 80 kg
    • May be ineffective if BMI > 30  OR Wt > 80 kg
    • If patient wishes to receive, do not withhold treatment but ensure patients with BMIs > 25 are aware of the increased risk and alternative EC options.
  • Can be repeated as required for UPSI incidents, although a regular contraceptive method may be preferred
  • Hormonal emergency contraceptives may be used in women with contraindications to daily oral contraceptives, including:
    • cardiovascular disease
    • migraines
    • liver disease
    • current breastfeeding 

 B) Ulipristal Acetate

  • Schedule I, may be prescribed by a pharmacist
  • Mechanism of action: progesterone receptor modulator
    • Delays ovulation  
    • Direct inhibitory effect on follicular rupture, even when given shortly before ovulation
    • Works in preovulatory stage,(before & during the LH surge) but is not effective if ovulation has occurred
  • Dose: 30 mg PO stat within 5 days of UPSI
    • Not recommended for use more than once during same menstrual cycle
    • Effectiveness remains relatively consistent over 5 day window
  • When used within 5 days of UPSI, rates of pregnancy are found to be 1.3%. However, there are many factors to take into consideration that may change its effectiveness, including weight or BMI, as well as timing in relation to where in the cycle it is used. 
  • More effective than LNG, especially days 4 & 5 post-UPSI
  • More effective than LNG in overweight and obese women (although some studies indicate reduced effect compared with normal weight women); no information on effectiveness in patients with BMI >35. 
  • Theoretical interaction with hormonal contraceptives: preferably avoid in women who have used hormonal contraception in the past 7 days. 
  • Do not initiate or resume hormonal contraception for at least 5 days after taking ulipristal; abstinence or barrier method of contraception is required for 14 days after starting the hormonal contraception  

 C) Yuzpe Method

  • Older method, not widely used any more
  • Less effective that LNG or UPA
  • Higher incidence of side effects due to estrogen component (nausea & vomiting)
  • May recommend pre-dosing with an antinauseant (ie/dimenhydrinate)
  • Two doses (q 12 hours) of various combined oral contraceptives (See Table 1 below)
  • Similar concerns as with levonorgestrel EC in regards to reduced effectiveness in overweight women

Table 1: Yuzpe method dosing
Product Tabs / dose Ethinyl estradiol / levonorgestrel 
mcg/dose

Alesse®,  Alysena®, Aviane®

5 100/500

Triquilar®

4 yellow 120/500

Min-Ovral®, Portia®, Ovima®

4 120/600

 

 3) EC Drug Interactions:

  • Hormonal contraception (HC)
    • Levonorgestrel: HC can be started the day of or the day after EC; abstinence or barrier method of contraception required for 7 days 
    • Ulipristal acetate: Wait 5 or more days before starting HC; abstinence or barrier method of contraception required for 14 days or until next period (whichever occurs first)
    • Ulipristal acetate + levonorgestrel (and Yuzpe products)
      • Theoretical antagonism of effect. Not recommended for use together or within same menstrual cycle
  • Enzyme inducing drugs &  natural products such as carbamazepine, modafinil, phenytoin, protease inhibitors, phenobarbital, St. John's wort, topiramate
    • Decreased efficacy of levonorgestrel, Yuzpe regimen, ulipristal acetate
    • Copper IUD is method of choice: not affected by interaction
    • Do not withhold hormonal EC but recommend patients consider the copper IUD in addition to oral EC 
    • Some experts suggest a 3mg (2x1.5mg) dose of levonorgestrel, however, effectiveness is unknown in this situation. 

4) Adverse Effects:

Oral EC Agents:
  • Nausea and vomiting
    • Higher incidence with Yuzpe method products; incidence lower with levonorgestrel and ulipristal acetate
    • Dose should be repeated if patient vomits within 2 hours for LNG or Yuzpe, or within 3 hours if UPA
    • If using Yuzpe regimen, recommend dimenhydrinate prior to dose of EC
  • Dizziness
  • Fatigue
  • Headache
  • Breast tenderness
  • Lower abdominal pain
  • Spotting, breakthrough bleeding
  • Effects usually resolve within 24 hours

Copper IUD:

  • Insertion Pain
  • Cramping
  • Heavier menstrual periods

5) Lactation

  • Levonorgestrel 1.5 mg is oral EC of choice
    • No interruption of breastfeeding required 
  • Ulipristal acetate
    • No information is available on use during breastfeeding
    • Pump and dump for 1 week (WHO) after ulipristal acetate administration

 

  • Education:
    • Mechanism of action
      • EC will not terminate a pregnacy that has already occured
    • Effectiveness
      • Copper IUD most effective method at any time during cycle
    • Does not protect against sexually transmitted infections
      • If symptomatic or symptoms emerge, advise visit to STI clinic, MD or NP
    • Oral emergency contraceptives do not provide ongoing protection against pregnancy
      • Abstinence or use of barrier methods required
      • Are effective for a single act of UPSI. Patients with multiple episodes of UPSI in the same cycle are at highest risk for pregnancy 
      • Discuss regular contraceptive methods and provide or refer as appropriate
  • Menstruation should occur within 21 days
    • Pregnancy test and/or refer if > than 21 days
  • Administration instructions
    • When to start / continue regular hormonal contraceptive
    • How long to use alternate contraceptive methods (abstinence, barrier methods)   
      • Levonorgestrel: HC can be started the day of or the day after EC; abstinence or barrier method of contraception required for 7 days 
      • Ulipristal acetate: Wait 5 or more days before starting HC; abstinence or barrier method of contraception required for 14 days or until next period (whichever occurs first)
  • Adverse effects management
    • Nausea: Take with food, or take dimenhydrinate as pre-med (with Yuzpe regimen)
    • Vomiting: Repeat dose if vomit within 2 hours for LNG or Yuzpe; 3 hours for UPA
    • If adverse effects occur, generally mild and will subside within 24 hours
  • Follow-up not usually required

Detailed information on contraindications, cautions, adverse effects and interactions is available in individual drug monographs in the RxTx - CPS from CPhA, RxTx (Internet), Lexi-Comp, AHFS, www.drugs.com or other reliable drug monograph references. For comprehensive drug comparisons, see RxFiles charts (www.rxfiles.ca). This information should be routinely consulted before prescribing.

Ingredient

Dosage

Levonorgestrel

1.5mg STAT

Ulipristal acetate*

30mg stat

Yuzpe method

See treatment table

* Not a listed benefit of the Saskatchewan Drug Plan Formulary.

  • Important prescribing fee billing update, effective November 1st:
    • A minor ailment prescribing fee can ONLY be billed if ulipristal acetate is prescribed
    • For levonorgestrel, the former system of billing is phased out. Levonorgestrel is Schedule III in Saskatchewan, therefore, the SK Drug Plan will not reimburse the assessment fee. Pharmacists can prescribe and charge the fee to the patient or the product can be provided without a prescription.

  • Fee pseudoDIN 00951319; maximum of two claims per year

  • NIHB will not pay assessment fees for ECP products; pharmacies can charge the fee to the patient but must advise the client that if they get the prescription from a doctor or nurse practitioner, they would not have to pay this fee.

  • Only products with an official indication from Health Canada for emergency contraception and/or those recommended by reputable and reliable guidelines are considered for these guidelines.  Only the active ingredients in the "products" section are approved for pharmacist prescribing. 
  1. Graves G. Contraception. In RxTx - CTC online. Available at www.e-therapeutics.ca (by subscription). Available in Saskatchewan through SHIRP (www.shirp.ca).
  2. Whelan A.  Contraception. In RxTx - CTMA. Available at www.e-therapeutics.ca  (by subscription). Available in Saskatchewan through SHIRP (www.shirp.ca).
  3. Black A, Guilbert A. Canadian Contraception Consensus (Part 1 of 4). J Obstet Gynaecol Can 2015;37(10):S1–S28
  4. Wang L. A clinician’s guide to emergency contraception. In Medscape. Free access at http://www.medscape.com/viewarticle/831720_2.
  5. Ziemen M. Emergency contraception. In UpToDate online. Available at  www.uptodate.com (by subscription).
  6. Emergency Contraception.  In Dynamed online. Available at www.dynamed.com  (by subscription).
  7. Bullock H. Salcedo J. Emergency Contraception. Obstetrics and Gynecology Clinics 2015;42:699-712
  8. Jensen J. Emergency Contraception.Ob/Gyn Clinical Alert 2014;30:81-88. Available at  http://www.ctcfp.org/wp-content/uploads/OBGYN-Clinical-Alert-3-2014.pdf.     

No part of this work may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the copyright holder. For copyright permission requests, please contact druginfo@usask.ca.

Written by medSask
Posted Nov 2017; Updated Nov 2018