Emergency contraception 01-Sep-2017

Overview

g Emergency contraception is intended for occasional

use, to reduce the risk of pregnancy after unprotected sexual

intercourse. It does not replace effective regular

contraception.

Women who do not wish to conceive should be offered

emergency contraception after unprotected sexual

intercourse that has taken place on any day of a natural

menstrual cycle. Emergency contraception should also be

offered after unprotected intercourse from day 21 after

childbirth (unless the criteria for lactational amenorrhoea

are met), and from day 5 after abortion, miscarriage, ectopic

pregnancy or uterine evacuation for gestational

trophoblastic disease.

Emergency contraception should also be offered to women

if their regular contraception has been compromised or has

been used incorrectly. h

Emergency contraceptive methods

Copper intra–uterine devices

g Insertion of a copper intra-uterine device (see intrauterine contraceptive devices (copper) p. 802) is the most

effective form of emergency contraception and should be

offered (if appropriate) to all women who have had

unprotected sexual intercourse and do not want to conceive.

A copper intra-uterine contraceptive device can be inserted

up to 120 hours (5 days) after unprotected intercourse or up

to 5 days after the earliest likely calculated ovulation (i.e.

within the minimum period before implantation), regardless

of the number of episodes of unprotected intercourse earlier

in the cycle. Antibacterial cover should be considered for

copper intra-uterine contraceptive device insertion if there

is a significant risk of sexually transmitted infection that

could be associated with ascending pelvic infection.

A copper intra-uterine device is not known to be affected

by body mass index (BMI) or body-weight or by other drugs.

h

Hormonal methods

g Hormonal emergency contraceptives (includes

levonorgestrel p. 806 and ulipristal acetate p. 804) should be

offered as soon as possible after unprotected intercourse if a

copper intra-uterine device is not appropriate or is not

acceptable to the patient; either drug should be taken as

soon as possible after unprotected intercourse to increase

efficacy. Hormonal emergency contraception administered

after ovulation is ineffective.

Levonorgestrel is effective if taken within 72 hours (3 days)

of unprotected intercourse and may also be used between 72

and 96 hours after unprotected intercourse [unlicensed use],

but efficacy decreases with time. Ulipristal acetate is

effective if taken within 120 hours (5 days) of unprotected

intercourse. Ulipristal acetate has been demonstrated to be

more effective than levonorgestrel for emergency

contraception.

It is possible that a higher body-weight or BMI could

reduce the effectiveness of oral emergency contraception,

particularly levonorgestrel; if BMI is greater than 26 kg/m2 or

body-weight is greater than 70 kg, it is recommended that

either ulipristal acetate or a double dose of levonorgestrel

[unlicensed indication] (see Emergency contraception under

levonorgestrel) is given. It is unknown which is more

effective .

Ulipristal acetate should be considered as the first-line

hormonal emergency contraceptive for a woman who has

had unprotected intercourse 96–120 hours ago (even if she

has also had unprotected intercourse within the last

96 hours). It should also be considered first line for a woman

who has had unprotected sexual intercourse within the last

5 days if it is likely to have taken place during the 5 days

before the estimated day of ovulation. h

Hormonal emergency contraception interactions

See Contraceptives, interactions below.

Starting hormonal contraception after emergency hormonal

contraception

Emergency hormonal contraception methods do not provide

ongoing contraception.g After taking levonorgestrel,

women should start suitable hormonal contraception

immediately. They must use condoms reliably or abstain

from intercourse until contraception becomes effective.

Women should wait 5 days after taking ulipristal acetate

before starting suitable hormonal contraception. Women

must use condoms reliably or abstain from intercourse

during the 5 day waiting period and also until their

contraceptive method is effective. h

The copper intra-uterine device immediately provides

effective ongoing contraception.

Useful Resources

Emergency Contraception. The Faculty of Sexual and

Reproductive Healthcare. Clinical guidance. March 2017.

www.fsrh.org/standards-and-guidance/documents/ceu-clinicalguidance-emergency-contraception-march-2017

Contraceptives, interactions 06-Jun-2017

Overview

The effectiveness of combined oral contraceptives,

progestogen-only oral contraceptives, contraceptive patches,

vaginal rings, and emergency hormonal contraception can be

considerably reduced by interaction with drugs that induce

hepatic enzyme activity (e.g. carbamazepine p. 311,

eslicarbazepine acetate, nevirapine p. 645, oxcarbazepine

p. 321, phenytoin p. 323, phenobarbital p. 335, primidone

p. 336, ritonavir p. 659, St John’s Wort, topiramate p. 331

and, above all, rifabutin p. 575 and rifampicin p. 582). and

possibly also griseofulvin p. 601. A condom together with a

long-acting method (such as an injectable contraceptive)

may be more suitable for patients with HIV infection or at

risk of HIV infection; advice on the possibility of interaction

with antiretroviral drugs should be sought from HIV

specialists.

Combined hormonal contraceptives interactions

Women using combined hormonal contraceptive patches,

vaginal rings or oral tablets who require enzyme-inducing

drugs or griseofulvin should be advised to change to a

reliable contraceptive method that is unaffected by enzymeinducers, such as some parenteral progestogen-only

contraceptives (medroxyprogesterone acetate p. 810 and

norethisterone p. 764) or intra-uterine devices

(levonorgestrel p. 806; see also Contraceptives, nonhormonal p. 793). This should be continued for the duration

of treatment and for four weeks after stopping. If a change in

contraceptive method is undesirable or inappropriate the

following options should be discussed:

Short course (2 months or less) of an enzyme-inducing drug

Continuing the combined hormonal contraceptive method

may be appropriate if used in combination with consistent

and careful use of condoms for the duration of treatment and

for four weeks after stopping the enzyme-inducing drug.

Long-term course (over 2 months) of an enzyme-inducing drug

(except rifampicin or rifabutin) or a course of griseofulvin

Use a monophasic combined oral contraceptive at a dose of

ethinylestradiol p. 759 50 micrograms or more daily

[unlicensed use] and use either an extended or a ‘tricycling’

regimen (i.e. taking three packets of monophasic tablets

without a break followed by a shortened tablet-free interval

of four days [unlicensed use]); continue for the duration of

794 Contraception BNF 78

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7

treatment with the interacting drug and for four weeks after

stopping.

If breakthrough bleeding occurs (and all other causes are

ruled out) it is recommended that the dose of

ethinylestradiol is increased by increments of 10 micrograms

up to a maximum of 70 micrograms daily [unlicensed use] on

specialist advice, or to use additional precautions, or to

change to a method unaffected by the interacting drugs.

Use of contraceptive patches and vaginal rings (including

concurrent use of two patches or two vaginal rings) is not

recommended for women taking enzyme-inducing drugs

over a long period.

Long-term course (over 2 months) of rifampicin or rifabutin

An alternative method of contraception (such as an IUD) is

always recommended because they are such potent enzymeinducing drugs; the alternative method of contraception

should be continued for four weeks after stopping the

enzyme-inducing drug.

Antibacterials that do not induce liver enzymes

It is recommended that no additional contraceptive

precautions are required when combined oral contraceptives,

contraceptive patches or vaginal rings are used with

antibacterials that do not induce liver enzymes, unless

diarrhoea or vomiting occur. These recommendations should

be discussed with the woman.

There had been concerns that some antibacterials that do

not induce liver enzymes (e.g. ampicillin p. 550, doxycycline

p. 564) reduce the efficacy of combined oral contraceptives by

impairing the bacterial flora responsible for recycling

ethinylestradiol from the large bowel. However, there is a

lack of evidence to support this interaction.

Oral progestogen-only contraceptives interactions

Effectiveness of oral progestogen-only preparations is not

affected by antibacterials that do not induce liver enzymes.

The efficacy of oral progestogen-only preparations is,

however, reduced by enzyme-inducing drugs or griseofulvin

and an alternative contraceptive method, unaffected by the

interacting drug, is recommended during treatment with an

interacting drug and for at least 4 weeks afterwards.

For a short course of an enzyme-inducing drug (less than

two months), continuing the progestogen-only oral method

may be appropriate if used in combination with consistent

and careful use of condoms for the duration of treatment and

for four weeks after stopping the enzyme-inducing drug.

Parenteral progestogen-only contraceptives interactions

Effectiveness of parenteral progestogen-only contraceptives

is not affected by antibacterials that do not induce liver

enzymes. The effectiveness of intramuscular norethisterone

injection and intramuscular and subcutaneous

medroxyprogesterone acetate injections is not affected by

enzyme-inducing drugs and they may be continued as

normal during courses of these drugs.

Effectiveness of the etonogestrel-releasing implant p. 809

may be reduced by enzyme-inducing drugs or griseofulvin

and an alternative contraceptive method, unaffected by the

interacting drug, is recommended during treatment with the

interacting drug and for at least 4 weeks after stopping.

For a short course of an enzyme-inducing drug, if a change

in contraceptive method is undesirable or inappropriate,

continued contraception with the implant may be

appropriate if used in combination with consistent and

careful use of condoms for the duration of treatment and for

4 weeks after stopping the enzyme-inducing drug.

Hormonal emergency contraception interactions

The effectiveness of levonorgestrel and ulipristal acetate

p. 804 is reduced in women taking enzyme-inducing drugs or

griseofulvin (and for at least 4 weeks after stopping).g A

copper intra-uterine device can be offered instead. If the

copper intra-uterine device is declined or unsuitable, the

dose of levonorgestrel should be increased (See Dose

adjustments due to interactions under levonorgestrel). There

is no need to increase the dose for emergency contraception

if the patient is taking antibacterials that are not enzyme

inducers. h

The effectiveness of ulipristal acetate for emergency

contraception in women using drugs that increase gastric pH

has not been studied. Levonorgestrel or a copper intrauterine device should be considered as alternatives.

g Hormonal contraception should not be newly

initiated in a patient until five days after administration of

ulipristal acetate as emergency hormonal contraception—

the contraceptive effect of ulipristal acetate will be reduced.

Consistent and careful use of condoms is recommended.

Ulipristal acetate can be used as emergency hormonal

contraception more than once in the same cycle. h

Conversely, manufacturer advises that use of levonorgestrel

as emergency contraception more than once in the same

cycle is not advisable due to increased risk of side-effects

(such as menstrual irregularities).

g Levonorgestrel should not be used (as emergency

hormonal contraception) within 5 days of administration of

ulipristal acetate (as emergency hormonal contraception), as

the contraceptive effect of ulipristal acetate may be reduced

by progestogens.

Ulipristal acetate is not recommend for use in women who

have severe asthma treated by oral corticosteroids, due to

the antiglucocorticoid effect of ulipristal acetate. h

Useful Resources

Drug interactions with hormonal contraception. The Faculty

of Sexual and Reproductive Healthcare. Clinical guidance.

January 2018.

www.fsrh.org/standards-and-guidance/current-clinical-guidance/

drug-interactions

Emergency Contraception. The Faculty of Sexual and

Reproductive Healthcare. FSRH guideline. December 2017.

www.fsrh.org/documents/ceu-clinical-guidance-emergencycontraception-march-2017/

3.1 Contraception, combined

OESTROGENS COMBINED WITH

PROGESTOGENS

Combined hormonal f

contraceptives

l CONTRA-INDICATIONS Acute porphyrias p. 1058 . gallstones . heart disease associated with pulmonary

hypertension or risk of embolus . history during pregnancy

of cholestatic jaundice . history during pregnancy of

chorea . history during pregnancy of pemphigoid

gestationis . history during pregnancy of pruritus . history

of breast cancer (but can be used after 5 years if no

evidence of disease and non-hormonal methods

unacceptable). history of haemolytic uraemic syndrome . migraine with aura . personal history of venous or arterial

thrombosis . sclerosing treatment for varicose veins . severe or multiple risk factors for arterial disease . severe

or multiple risk factors for venous thromboembolism . systemic lupus erythematosus with (or unknown)

antiphospholipid antibodies .transient cerebral ischaemic

attacks without headaches . undiagnosed vaginal bleeding

l CAUTIONS Active trophoblastic disease (until return to

normal of urine- and plasma-gonadotrophin

concentration)—seek specialist advice . Crohn’s disease . gene mutations associated with breast cancer (e.g. BRCA

1) . history of severe depression especially if induced by

hormonal contraceptive . hyperprolactinaemia (seek

specialist advice) . inflammatory bowel disease . migraine . personal or family history of hypertriglyceridaemia

BNF 78 Contraception, combined 795

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(increased risk of pancreatitis).risk factors for arterial

disease .risk factors for venous thromboembolism . sicklecell disease . undiagnosed breast mass

CAUTIONS, FURTHER INFORMATION

▶ Risk of venous thromboembolism There is an increased risk of

venous thromboembolic disease in users of combined

hormonal contraceptives particularly during the first year

and possibly after restarting combined hormonal

contraceptives following a break of four weeks or more.

This risk is considerably smaller than that associated with

pregnancy (about 60 cases of venous thromboembolic

disease per 100 000 pregnancies). In all cases the risk of

venous thromboembolism increases with age and in the

presence of other risk factors, such as obesity. The risk also

varies depending on the type of progestogen.

Provided that women are informed of the relative risks

of venous thromboembolism and accept them, the choice

of oral contraceptive is for the woman together with the

prescriber jointly to make in light of her individual medical

history and any contra-indications.

Combined hormonal contraceptives also slightly

increase the risk of arterial thromboembolism; however,

there is no evidence to suggest that this risk varies

between different preparations.

▶ Risk factors for venous thromboembolism Use with caution if

any of following factors present but avoid if two or more

factors present:

. family history of venous thromboembolism in first-degree

relative aged under 45 years (avoid contraceptive

containing desogestrel or gestodene, or avoid if known

prothrombotic coagulation abnormality e.g. factor V

Leiden or antiphospholipid antibodies (including lupus

anticoagulant));

. obesity; body mass index
30 kg/m2 (avoid if body mass

index
35 kg/m2 unless no suitable alternative); (in

adolescents, caution if obese according to BMI (adjusted

for age and gender); in those who are markedly obese,

avoid unless no suitable alternative);

. long-term immobilisation e.g. in a wheelchair (avoid if

confined to bed or leg in plaster cast);

. history of superficial thrombophlebitis;

. age over 35 years (avoid if over 50 years);

. smoking.

Combined Hormonal Contraception and Risk of

Venous Thromboembolism

Progestogen in Combined

Hormonal Contraceptive

Estimated incidence per 10 000

women per year of use

Non-pregnant, not using

combined hormonal

contraception

2

Levonorgesterol1 5–7

Norgestimate1 5–7

Norethisterone1 5–7

Etonogestrel1 6–12

Norelgestromin1 6–12

Gestodene1 9–12

Desogestrel1 9–12

Drospirenone1 9–12

Dienogest2 Not known—insufficient data

Nomegestrol2 Not known—insufficient data

1 Combined with ethinylestradiol 2 Combined with estradiol

▶ Risk factors for arterial disease Use with caution if any one of

following factors present but avoid if two or more factors

present:

. family history of arterial disease in first degree relative

aged under 45 years (avoid if atherogenic lipid profile);

. diabetes mellitus (avoid if diabetes complications

present);

. hypertension; blood pressure above systolic 140 mmHg or

diastolic 90 mmHg (avoid if blood pressure above systolic

160 mmHg or diastolic 95 mmHg); (in adolescents, avoid

if blood pressure very high);

. smoking (avoid if smoking 40 or more cigarettes daily);

. age over 35 years (avoid if over 50 years);

. obesity (avoid if body mass index
35 kg/m2 unless no

suitable alternative); (in adolescents, caution if obese

according to BMI (adjusted for age and gender); in those

who are markedly obese, avoid unless no suitable

alternative);

. migraine without aura (avoid if migraine with aura (focal

symptoms), or severe migraine frequently lasting over

72 hours despite treatment, or migraine treated with

ergot derivatives).

▶ Migraine Women should report any increase in headache

frequency or onset of focal symptoms (discontinue

immediately and refer urgently to neurology expert if focal

neurological symptoms not typical of aura persist for more

than 1 hour).

Combined hormonal contraceptives should be stopped

(pending investigation and treatment), if serious

neurological effects occur, including unusual severe,

prolonged headache especially if first time or getting

progressively worse or sudden partial or complete loss of

vision or sudden disturbance of hearing or other

perceptual disorders or dysphasia or bad fainting attack or

collapse or first unexplained epileptic seizure or weakness,

motor disturbances, very marked numbness suddenly

affecting one side or one part of body.

l SIDE-EFFECTS

▶ Common or very common Acne . fluid retention . headaches . metrorrhagia . nausea . weight increased

▶ Uncommon Alopecia . hypertension

▶ Rare or very rare Venous thromboembolism

SIDE-EFFECTS, FURTHER INFORMATION

Breast cancer There is a small increase in the risk of

having breast cancer diagnosed in women taking the

combined oral contraceptive pill; this relative risk may be

due to an earlier diagnosis. In users of combined oral

contraceptive pills the cancers are more likely to be

localised to the breast. The most important factor for

diagnosing breast cancer appears to be the age at which

the contraceptive is stopped rather than the duration of

use; any increase in the rate of diagnosis diminishes

gradually during the 10 years after stopping and

disappears by 10 years.

Cervical cancer Use of combined oral contraceptives

for 5 years or longer is associated with a small increased

risk of cervical cancer; the risk diminishes after stopping

and disappears by about 10 years. The possible small

increase in the risk of breast cancer and cervical cancer

should be weighed against the protective effect against

cancers of the ovary and endometrium.

l PREGNANCY Not known to be harmful.

l BREAST FEEDING Avoid until weaning or for 6 months

after birth (adverse effects on lactation).

l HEPATIC IMPAIRMENT Avoid in active liver disease

including disorders of hepatic excretion (e.g. DubinJohnson or Rotor syndromes), infective hepatitis (until

liver function returns to normal), liver tumours.

l DIRECTIONS FOR ADMINISTRATION

▶ With oral use Each tablet should be taken at approximately

same time each day; if delayed, contraceptive protection

may be lost. 21-day combined preparations, 1 tablet daily

for 21 days; subsequent courses repeated after a 7-day

interval (during which withdrawal bleeding occurs); if

796 Contraception BNF 78

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