Emergency contraception: clinical outcomes

doi:10.1016/j.contraception.2012.08.027

Contraception

Volume 87, Issue 3, March 2013, Pages 309-313

https://doi.org/10.1016/j.contraception.2012.08.027 Get rights and content

Abstract

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.

Introduction

Emergency contraception (EC) is used after intercourse to prevent unintended pregnancy either when no contraceptive method has been used or when an error in contraceptive use has been recognized — resulting, either way, in unprotected sexual intercourse. A number of methods of EC exist. Because each raises slightly different issues to do with effectiveness, accessibility and ease of use, this paper will discuss the clinical outcomes of the most commonly used oral method [levonorgestrel (LNG)], the newest oral method [ulipristal acetate (UPA)] and the most effective method [the copper intrauterine device (Cu-IUD)].

For treatment modalities for all conditions, the key questions relate to safety and efficacy, and one without the other is worthless. Side effects of any treatment are important for its acceptability but arguably much less important for a drug used as a one-off medication by someone highly motivated to prevent an unintended pregnancy with no other options for doing so at this time.

Section snippets

Safety and side effects

All methods of EC appear to be extremely safe.

Efficacy

There has never been a placebo-controlled trial of the efficacy of EC. Efficacy is estimated based on comparing the actual number of pregnancies occurring in a cohort of women using a method of EC with the number that might have been expected without EC use [11]. The expected number of pregnancies can only be a rough guess because it is based on estimating the risk of conception for each woman in the cohort on the reported cycle day of exposure (i.e., unprotected intercourse) related to her

Pregnancy rates with EC use

Whatever the exact number of pregnancies prevented, there can be little doubt that both oral LNG-EC and UPA and the Cu-IUD prevent some pregnancies in individual women. What has yet to be demonstrated, however, is the public health benefit of EC in reducing the number and rates of unintended pregnancies and induced abortions, and this is even harder to do. Paradoxically, indirect measurements of the effect of EC use on unintended pregnancy rates so far suggest a lack of effect. In many

Effect on risk-taking behavior and subsequent contraceptive use

In the discussions in the UK, which led eventually to deregulation of EC, those against the concept argued that giving women easier access to EC would increase its use at the expense of other methods of contraception [26]. It was suggested that the decrease in use of more effective methods would result in an increase, rather than a fall, in unintended pregnancies and abortions, Furthermore, the expected decline in condom use would, it was argued, increase the prevalence of STI. Such

References (31)

G. Sheffer-Mimouni et al.
Ectopic pregnancies following emergency levonorgestrel contraception
Contraception
(2003)
H.B. Croxatto et al.
Mechanism of action of hormonal preparations used for emergency contraception: a review of the literature
Contraception
(2001)
D.A. Grimes et al.
Scott Jones B. Emergency contraception over-the counter: the medical and legal imperatives
Obstet Gynecol
(2001)
H. Von Hertzen et al.
Low dose mifepristone and two regimens of levonorgestrel for emergency contraception
Lancet
(2002)
A.F. Glasier et al.
Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis
Lancet
(2010)
R. Sitruk-Ware
Mifepristone and misoprostol sequential regimen side effects, complications and safety
Contraception
(2006)
J. Trussell et al.
Estimating the effectiveness of emergency contraceptive pills
Contraception
(2003)
H.B. Croxatto et al.
Pituitary–Ovarian function following the standard levonorgestrel emergency contraceptive dose or a single 0.75-mg dose given on the days preceding ovulation
Contraception
(2004)
K. Fairhurst et al.
Emergency contraception: why can't you give it away? Qualitative findings from an evaluation of advance provision of emergency contraception
Contraception
(2004)
C. Moreau et al.
The remaining barriers to the use of emergency contraception: perception of pregnancy risk by women undergoing induced abortions
Contraception
(2005)

E.G. Raymond et al.

Effect of an emergency contraceptive pill intervention on pregnancy risk behaviour

Contraception

(2008)

A. Glasier et al.

Community pharmacists providing emergency contraception give little advice about future contraceptive use: a mystery shopper study

Contraception

(2010)

Faculty of Family Planning & Reproductive Healthcare Clinical Effectiveness Unit Emergency Contraception Guidance April...

K. Cleland et al.

Ectopic pregnancy and emergency contraceptive pills. A systematic review

Obstet Gynecol

(2010)

U.S. Food and Drug Administration (FDA) COMMISSIONER STATEMENTStatement from FDA Commissioner Margaret Hamburg, M.D.,...

Cited by (35)

Knowledge of and Interest in the Copper Intrauterine Device Among Women Seeking Emergency Contraception
2018, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
The Cu-IUD offers several advantages over hormonal EC methods. It has a reported efficacy of 99% compared with 60% to 80% for hormonal EC pills.3–7 The efficacy of the Cu-IUD for EC is maintained in overweight and obese women, whereas there is evidence that hormonal EC pills are less effective in women with BMI greater than 25 kg/m2.8,9
Emergency contraception (EC) includes hormonal pills (levonorgestrel or ulipristal acetate) and the copper IUD (Cu-IUD). The Cu-IUD is more effective for EC than hormonal pills but remains underused, possibly because of lack of knowledge or interest. The objective of this study was to examine knowledge of and interest in the Cu-IUD for EC among Canadian women seeking EC.
The study used a cross-sectional convenience survey of English-speaking women presenting for EC at two sexual health clinics in Toronto. The anonymous paper-based survey was completed in the waiting room. The main outcome measures were women’s knowledge of and interest in the Cu-IUD for EC. Demographic and reproductive health data were also collected.
Between January and December 2013, 124 surveys were completed. Mean age of respondents was 26 years (SD ± 6.9). Most were single (85%), and over one half had completed postsecondary education. Overall, 77% had heard of the Cu-IUD, but only 21% were aware of its use for EC. Over 50% were aware that the Cu-IUD is hormone-free and may be used for long-term contraception. Women were less familiar with the window of administration of the Cu-IUD for EC (26%) and its efficacy (6%). In total, 23% (28 of 124) of women were interested in the Cu-IUD, including eight women scheduled to receive one that day.
Women presenting for EC were unaware of the Cu-IUD but were moderately interested in it once informed. Public education and routine counselling about the Cu-IUD at EC visits may increase the uptake of this method.
Les méthodes de contraception d’urgence (CU) courantes sont les comprimés d’hormones (lévonorgestrel ou acétate d’ulipristal) et le DIU de cuivre. Cette dernière méthode est plus efficace que les hormones, mais demeure sous-utilisée, possiblement en raison d’un manque de connaissances ou d’intérêt. Cette étude visait donc à examiner les connaissances et l’intérêt entourant l’utilisation du DIU de cuivre comme CU chez les femmes canadiennes souhaitant obtenir une CU.
Dans le cadre de l’étude, une enquête transversale a été menée auprès d’un échantillon de commodité constitué de femmes anglophones s’étant présentées dans deux cliniques de santé-sexualité de Toronto pour obtenir une CU. Les femmes ont répondu au questionnaire papier anonymement dans la salle d’attente. Les principaux résultats mesurés étaient les connaissances et l’intérêt relativement à l’utilisation du DIU de cuivre comme CU. Des données démographiques et de santé reproductive ont également été recueillies.
Entre janvier et décembre 2013, 124 sondages ont été remplis. L’âge moyen des répondantes était de 26 ans (écart-type : 6,9). La plupart (85 %) étaient célibataires, et plus de la moitié avait fait des études postsecondaires. En tout, 77 % avaient entendu parler du DIU de cuivre, mais 21 % seulement étaient au courant qu’il s’utilise en CU. Plus de 50 % savaient qu’il s’agit d’une méthode de contraception sans hormone pouvant être utilisée à long terme. Les répondantes étaient moins nombreuses à connaître la fenêtre d’administration du DIU aux fins de CU (26 %) et son efficacité (6 %). Au total, 23 % des femmes (28 sur 124) s’intéressaient au DIU de cuivre, dont huit devaient s’en faire poser un le jour de leur visite.
Les femmes se présentant en clinique pour une CU en savaient peu sur le DIU de cuivre, mais manifestaient un intérêt modéré pour cette méthode une fois qu’elle leur avait été présentée. Il serait possible de faire augmenter l’utilisation de cette méthode si le public en était informé et si elle était abordée systématiquement aux consultations pour une CU.
Emergency Contraception Algorithm and Guide for Clinicians
2017, Nursing for Women's Health
There are currently three forms of emergency contraception: oral levonorgestrel, oral ulipristal acetate, and the copper intrauterine device. The copper intrauterine device is the most effective, followed by ulipristal acetate and levonorgestrel, respectively. Although levonorgestrel is the least effective method, studies show that more prescribers are familiar with it and that is the most frequently used method. Clinicians should consider several factors when helping women make informed medical decisions regarding emergency contraception, including access to the products, a woman’s individual preference, timing since unprotected intercourse, body mass index or weight, and initiation or resumption of routine contraception. This article explains and summarizes these considerations and provides an algorithm to guide clinicians.
Emergency Contraception: Do Your Patients Have a Plan B?
2015, Obstetrics and Gynecology Clinics of North America
Citation Excerpt :
However, the endometrial effects of a single 30-mg dose are similar to placebo.30,56 No deaths or serious complications have been reported in association with UPA.1,57 Of pregnancies exposed to UPA, no increase in spontaneous abortion, poor pregnancy outcomes, or teratogenicity have been reported.24,58
Canadian Contraception Consensus Chapter 3 Emergency Contraception
2015, Journal of Obstetrics and Gynaecology Canada
C. Jamin in reply to the commentaries by the editorial board of Gynécologie Obstétrique & Fertilité on the article entitled: "Emergency contraceptions: Propositions of the Orthogenics Commission of the French National College of Gynecology and Obstetrics". Gynecol Obstet Fertil 2015;43(9)
2015, Gynecologie Obstetrique et Fertilite
Counseling for emergency contraception: Time for a tiered approach
2014, Contraception

View all citing articles on Scopus

View full text

Review articleEmergency contraception: clinical outcomes

Abstract

Introduction

Section snippets

Safety and side effects

Efficacy

Pregnancy rates with EC use

Effect on risk-taking behavior and subsequent contraceptive use

Contraception

Contraception

Obstet Gynecol

Lancet

Lancet

Contraception

Contraception

Contraception

Contraception

Contraception

Contraception

Contraception

Ectopic pregnancy and emergency contraceptive pills. A systematic review

Obstet Gynecol

Review article
Emergency contraception: clinical outcomes