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Grand Rounds

Emergency Contraception: What’s your Best Option?

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BACKGROUND AND PURPOSE:

  • Shen et al. (Cochrane Review, 2017) sought to determine which emergency contraceptive method is the most effective, safe and convenient to prevent pregnancy

METHODS:

  • Systematic review and meta-analysis
  • Pooled data from different databases and literature
  • Primary outcome was observed number of pregnancies
  • Secondary review outcomes were side effects and changes in menses

RESULTS:

  • 115 trials with 60,479 women were included
  • Pharmacologic emergency contraceptives were ranked as follows (from most to least effective)
    • Mifepristone
      • Mid-dose mifepristone (25 mg to 50 mg) associated with fewer pregnancies than low-dose (less than 25 mg)
    • Ulipristal acetate (a selective progesterone receptor modulator)
    • Levonorgestrel
      • Inconclusive whether single-dose levonorgestrel (1.5 mg) or two-dose regimen (0.75 mg 12 hours apart) is superior
    • Yuzpe method (estradiol-levonorgestrel combination)
  • No statistical difference identified between Cu-IUD and mifepristone
  • Nausea and vomiting
    • Yuzpe > Mifepristone
    • Yuzpe > Levonorgestrel
  • Menstrual irregularities
    • Ulipristal acetate users are more likely than levonorgestrel to have delayed menstruation
    • Menstrual delay was more common with mifepristone than with any other intervention and appeared to be dose-related
  • Obesity: The authors cite results from Jatlaoui and Curtis (Contraception, 2016) systematic review
    • Levonorgestrel
      • 4-fold increase risk of pregnancy in obese women (BMI ≥ 30 kg/m2) compared to BMI ≤ 25 kg/m2
      • At weight of 80 kg, pregnancy rate > 6% which is the same as probability without contraception
      • At weight < 75 kg, rate of pregnancy < 2%
    • Ulipristal acetate
      • 2-fold increase risk of pregnancy in obese women (BMI ≥ 30 kg/m2) compared to BMI <30 kg/m2 but CIs wide and did not reach statistical significance
    • However, other analyses did not demonstrate consistent association when adjusting for other covariates

CONCLUSION:

  • Levonorgestrel and mid-dose mifepristone were more effective than Yuzpe with fewer side effects
  • Cu-IUD is the most effective emergency contraceptive along with mifepristone and the only method that will provide ongoing contraception and not weight sensitive
  • With respect to obesity, data is considered limited and poor to fair quality but suggests reduced effectiveness, especially with levonorgestrel

Learn More – Primary Sources:

Cochrane 2017: Interventions for emergency contraception

Safety and effectiveness data for emergency contraceptive pills among women with obesity: a systematic review

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Related ObG Topics:

Emergency Contraception: What, When and How?
IUDs and Implants: How to Manage Potential LARC Complications
Expert Opinion: Over-the-Counter Contraceptives for Adolescents

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