Episode 129: Emergency Contraception

Episode 129: Emergency Contraception

Bailey describes the available methods of emergency contraception in the United States. 

Written by Bailey Corona, MS4, American University of the Caribbean. Editing by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Definition. 

Emergency contraception refers to therapy used after intercourse to prevent pregnancy. The need for emergency contraception can happen for many reasons, such as a condom breaking or failure to use contraception. More than 11% of sexually active women in the United States between ages 15 and 44 reports using emergency contraception at least once. With such high demand, a multitude of options has become available to meet these needs. With so many options on the market, it may be difficult to decide which option best fits the needs of each individual, which makes it important for providers to have a clear understanding of the risks and benefits associated with each method. 

Emergency contraception may be commonly used by young patients as their main contraception method. Let’s talk about the types of emergency contraception.

Levonorgestrel-only (Plan B®).

Levonorge’strel-only emergency contraception is the most popular option on the market today. More commonly known as “Plan-B”, this therapy works because of levonorgestrel’s similar make-up to progesterone. 

Mechanism of action.

High levels of progesterone delay follicular development so long as it is administered before the level of luteinizing hormone begin to rise. This gives contraceptive therapy of this class a therapeutic window of 72 hours which is the most limited window of all the methods discussed. Despite this shortcoming, Levonorgestrel contraception remains the most popular option because it can be purchased over the counter without the need of a physician and is available to women of all ages. Additionally, therapy includes only a single 1.5mg dose making noncompliance virtually non-existent. 

Side effects. 

Side effects include nausea in 12% of patients and headache in 19% of patients. According to one study, 16% of women reported self-resolving uterine bleeding within the first week after use.

Selective progesterone modulators (Ella®).

The second most commonly used form of emergency contraception are the selective progesterone receptor modulators or more widely known as Ella®. 

Mechanism of action.

Treatment includes a single 30mg dose of ulipristal acetate, which inhibits follicular rupture even after the luteinizing hormone has begun to rise. Due to this mechanism of action, selective progesterone receptor modulators have a wider therapeutic window of 5 days.

Side effects.

Side effects resemble that of progesterone-only therapy, significant for nausea and headache. Treatment has 2 major barriers preventing it from being the most widely used. Firstly, efficacy is decreased in women with a BMI greater than 35, and secondly, treatment requires a prescription from a medical professional. 

Estrogen-progesterone combination.

Estrogen-progesterone combination therapy is also a viable option for emergency contraception; however, it is no longer available as a dedicated product but can be made from a variety of oral contraceptives. Its decreased popularity is likely due to its increased incidence of nausea when compared to the other options available.

Copper IUD.

Lastly, Copper IUDs like Paragard can be used for emergency contraception despite not being FDA-approved for this purpose. Copper IUDs are highly effective if placed within 5 days of intercourse, but studies have shown therapy to be effective up to 10 days after. 

Mechanism of action.

Copper IUDs prevent fertilization by altering sperm viability and oocyte-endometrium interaction. This method is the most invasive as it requires placement by a physician and carries the rare risk of uterine perforation, occurring in around 1/1000 IUD placements. That said, copper IUD placement carries with it the added benefit of continued contraception for 10 years. It is contraindicated, however, in patients with a history of heavy menstrual bleeding. 

FAQs about emergency contraception:

1. Does increasing the availability of emergency contraception encourage risky sexual behavior?
   • No, according to a systematic review by Maria Rodrigues, there was no significant increase in sexually risky behavior correlated with increased availability of emergency contraception.
     • Rodriguez MI, et al.
2. What is the greatest barrier to emergency contraception use in the United States?
   • Education. A study by Abbott J, et al, interviewed adolescents receiving care in urban emergency rooms. The study showed that only 64% of patients had ever heard of emergency contraception. By educating patients of reproductive age on what options may be available to them it is expected that there would be a decrease in unplanned pregnancies. 
   • Additionally, studies like “knowledge of emergency contraception among women aged 18-44 in California” by Foster DG have gone further to establish that women of lower socioeconomic status, foreign birth, or who have not graduated high school also have suboptimal education in emergency contraception.
3. When should someone use emergency contraception?
   • Treatment should begin as soon as possible after unprotected intercourse in order to ensure maximum efficacy. 3 days for Plan B, 5 days for Ella, and 10 days for IUD.
4. How effective is emergency contraception?
   • The answer to this question differs based upon what method a patient decides to use
   • IUDs
     • A systematic review of 42 studies over a 35-year time period reports that pregnancy rates were between 0 and 2%.
       • The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience by Cleland K. et al. 
     • Oral regimens have been studied extensively and have shown that ulipristal acetate like Ella® are slightly more effective, showing a pregnancy rate of 1.4% and a rate of 2.2% in levonorgestrel-only pills like Plan B. 
       • Ulipristal acetate versus levonorgestrel for emergency contraception: a randomized non-inferiority trial and meta-analysis by Glacier AF.
5. Do patients require follow up after use of emergency contraception?
   • No. Only if there is a delay in the start of normal menses by greater than 1 week or if lower abdominal pain or persistent irregular bleeding develops.

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Conclusion: Now we conclude episode number 129 “Emergency Contraception.” Bailey explained that a pelvic exam is not needed in most cases before or after emergency contraception. Plan B® is available over the counter, while Ella® is available with a prescription. Copper IUD is not FDA-approved for emergency contraception, but evidence has shown it is an effective method. Dr. Arreaza suggested that, after learning more about emergency contraception, listeners can draw their own conclusions about the ethical dilemma of prescribing it to their patients. 

This week we thank Hector Arreaza and Bailey Corona. Audio editing by Adrianne Silva.

Even without trying, every night, you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you; send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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Sources:

1. Abbott J, Feldhaus KM, Houry D, Lowenstein SR. Emergency contraception: what do our patients know? Ann Emerg Med. 2004 Mar;43(3):376-81. doi: 10.1016/S019606440301120X. PMID: 14985666. https://pubmed.ncbi.nlm.nih.gov/14985666/.
2. Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod. 2012 Jul;27(7):1994-2000. doi: 10.1093/humrep/des140. Epub 2012 May 8. PMID: 22570193; PMCID: PMC3619968. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3619968/.
3. “Emergency Contraception.” ACOG, https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2015/09/emergency-contraception.
4. Foster DG, Harper CC, Bley JJ, Mikanda JJ, Induni M, Saviano EC, Stewart FH. Knowledge of emergency contraception among women aged 18 to 44 in California. Am J Obstet Gynecol. 2004 Jul;191(1):150-6. doi: 10.1016/j.ajog.2004.01.004. PMID: 15295356. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3619968/
5. Glasier AF, Cameron ST, Fine PM, Logan SJ, Casale W, Van Horn J, Sogor L, Blithe DL, Scherrer B, Mathe H, Jaspart A, Ulmann A, Gainer E. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010 Feb 13;375(9714):555-62. doi: 10.1016/S0140-6736(10)60101-8. Epub 2010 Jan 29. Erratum in: Lancet. 2014 Oct 25;384(9953):1504. PMID: 20116841.https://pubmed.ncbi.nlm.nih.gov/20116841/
6. Jayson, Sharon. “5.8M Women Have Used 'Morning after' Pill.” USA Today, Gannett Satellite Information Network, 14 Feb. 2013, https://www.usatoday.com/story/news/nation/2013/02/13/cdc-contraception-emergency-methods/1914673/. 
7. Rodriguez MI, Curtis KM, Gaffield ML, Jackson E, Kapp N. Advance supply of emergency contraception: a systematic review. Contraception. 2013 May;87(5):590-601. doi: 10.1016/j.contraception.2012.09.011. Epub 2012 Oct 4. PMID: 23040139. https://pubmed.ncbi.nlm.nih.gov/23040139/.
8. von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Bártfai G, Ng E, Gemzell-Danielsson K, Oyunbileg A, Wu S, Cheng W, Lüdicke F, Pretnar-Darovec A, Kirkman R, Mittal S, Khomassuridze A, Apter D, Peregoudov A; WHO Research Group on Post-ovulatory Methods of Fertility Regulation. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002 Dec 7;360(9348):1803-10. doi: 10.1016/S0140-6736(02)11767-3. PMID: 12480356. https://pubmed.ncbi.nlm.nih.gov/12480356/.
9. Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/