Emergency contraception

Overview

Most to least effective

1. Copper IUD
2. Ulipristal (Ella)
3. Progestin-only regimen
4. Combination estrogen-progestin regimen

Copper IUD

• Copper intrauterine device (Paragard) can be used as emergency contraception up to 120 hours after unprotected sex
• Advantages:
  • More effective than oral regimens (>99% vs ~88%)
  • Serves as long-acting reversible contraception for up to 12 years after insertion
• Disadvantages:
  • Contraindicated in patients with PID or active gonorrhea/chlamydia: STD screening recommended prior to insertion
  • Not a very feasible method in the ED

Ulipristal (Ella)

• Progesterone-receptor modulator, effective up to 120 hours after unprotected sex
• May be more effective than levonorgestrel in overweight patients
• 30 mg PO in single dose
• Safe in breast feeding women, but FDA recommends discarding breast milk for 24 hrs after taking
• Adverse effects: Nausea (~13%), abdominal pain (8-15%), headache (19%)
• Disadvantages:
  • Not available from many hospital pharmacies, so patient often cannot get dose immediately, increasing the risk that they never receive therapy if unable to obtain at outside pharmacy.
  • More expensive than other therapies

Progestin-only Regimen

General

• First dose within 48 hours after unprotected intercourse followed by second dose 12 hours later
  • May also be taken as single dose (double dose)
• Relative risk reduction of pregnancy = 89% (1% with vs 8% without)
  • Effectiveness may be reduced in obese patients; some emerging evidence suggests doubling dose for obese patients
• Adverse effects: Nausea (23%), vomiting (6%)

Dosing

• Plan B (marketed specifically for emergency contraception) - levonorgestrel 0.75mg PO per pill
  • Should be given as soon as possible after intercourse; labeled for use up to 72 hours post-coitus, however may still be moderately effective up to 5 days after
  • Levonorgestrel (Plan B and generics) 0.75mg PO Q12H x2 doses
• May also be taken as one-time dose of levonorgestrel 1.5mg PO once

Combination OCPs (AKA Yuzpe Regimen)

General

• First dose within 72 hours after unprotected intercourse followed by second dose 12 hours later
• May be given up to 120 hours later (but efficacy reduced)
• Reduces risk of pregnancy by 75% (2% with vs 8% without)
• Adverse effects: Nausea (50%), vomiting (20%)

FDA approved regimens

• Ovral, Ogestrel - 2 pills (100 ug ethiny estradiol/0.5mg levonorgestrel) per dose; repeat in 12h
• Alesse, Aviane, Levlite - 5 pills (100 ug ethiny estradiol/0.5mg levonorgestrel) per dose; repeat in 12h
• Levlen, Levora, Lo/Ovral, Low-Ogestrel - 4 pills (120 ug ethiny estradiol/0.6mg levonorgestrel) per dose; repeat in 12h
• Triphasil, Tri-Levlen, Trivora - 4 pills (120 ug ethiny estradiol/0.5mg levonorgestrel) per dose; repeat in 12h

See Also

• Sexual assault