Emergency Contraception: What’s your Best Option?

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

Expert Opinion: Over-the-Counter Contraceptives for Adolescents

PURPOSE

This article by Upadhya et al. (JAH, 2017) aimed to review the regulatory and scientific issues with changing oral contraceptives (OCs) to over-the-counter status for adolescents under 18 years of age.

METHODS

Expert Opinion

RESULTS

This review delves into information about: 1) how the process of switching a drug to over-the-counter status works, 2) risk of pregnancy and the safety of OC use in adolescents, 3) adolescents’ ability to properly use OCs, 4) access to over-the-counter OCs, 5) effects on sexual risk behaviors, 6) potential in reduction of occasions for doctors to inform adolescents about reproductive health care. There is strong rationale for allowing adolescents access to over-the-counter OCs if there occurs any regulatory change. OCs are effective and safe for adolescents, and easy access to OCs, condoms, and emergency contraception increases their use while not increasing sexual risk behaviors.

Learn More – Primary Sources

Over-the-Counter Access to Oral Contraceptives for Adolescents

Optimizing Contraception for the HIV-positive Woman

The ideal contraceptive for an HIV-positive woman prevents pregnancy as well as transmission of HIV and STDs.  Dual contraception using condoms plus an additional contraceptive is the best strategy. Preexposure (PrEP) and postexposure (PEP) prophylaxis should be available to partners regardless of contraceptive method used.

There does not appear to be an association between the use of non-injectable hormonal contraception and risk of HIV acquisition. Studies regarding the risk of HIV acquisition with the use of progestin only DMPA injectable are conflicting, and the CDC continues to recommend it.

SUMMARY:

  • Combined hormonal contraception (pill, patch and ring) and progestin-only pills
    • Considered MEC cat. 1 for patient who are not on antiretrovirals or are not clinically well
    • For patients who are taking antiretrovirals, can decrease hormone levels but are still considered safe (either cat. 1 or 2 depending on which antiretroviral is being used)
    • Protease inhibitors, pharmacologic boosters, and efavirenz can cause decreased effectiveness of hormonal contraception
    • Fostemsavir: can cause increased levels of ethinyl estradiol and raise risk of thromboembolic events. Dosing of ethinyl estradiol should not be higher than 30 mcg daily.
  • Contraceptive implants are highly effective and benefits outweigh risks in HIV positive women (MEC cat. 1)
  • Injectable depot medroxyprogesterone acetate (DMPA) is safe and effective (MEC cat. 1) and does not appear to have interactions with antiretrovirals
    • Studies regarding increased risk of HIV transmission and acquisition are conflicting.
  • Intrauterine devices, both copper containing and levonorgestrel-releasing
    • MEC cat. 1 for women with HIV who are clinically well and on antiretrovirals, with no known drug interactions with antiretrovirals
    • For women with HIV who are not clinically well or not on antiretrovirals, initiation of IUD is considered MEC cat. 2, but continuation for an already placed IUD is cat.1
    • Limited data suggest a low risk of pelvic inflammatory disease and no changes in genital shedding of HIV RNA
  • Condoms reduce transmission of HIV between discordant partners but are not represent optimal contraception, with an annual pregnancy rate of over 15% per year. Should be used concurrently with another contraceptive method
  • Spermicides: not recommended due to potential of causing genital lesions
    • Nonoxynol-9, the active ingredient in most formulations, can cause genital lesions and may increase the likelihood of HIV transmission to a partner

KEY POINTS:

  • HIV infection does not pose a barrier to sterilization, which remains an appropriate contraceptive option
  • Emergency contraception including hormone based (progestin-only pills, ulipristal acetate, combined oral contraceptives) and the copper IUD should be offered to HIV positive women whenever appropriate
  • Spermicides and are not recommended

Learn More – Primary Sources:

CDC United States medical eligibility criteria for contraceptive use, 2016

Contraception: Contraceptive failure in the United States

Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV

HIV in Women: National HIV Curriculum

Emergency Contraception: What, When and How?

Emergency contraception interventions are intended to prevent an unplanned pregnancy after unprotected or inadequately protected intercourse. Contraceptive failure or failure to use contraception are common indications for use.

CLINICAL ACTIONS:

  • Offer emergency contraception (EC) to all women who have had unprotected or inadequately protected intercourse and who do not desire pregnancy
    • There are no exclusionary health conditions –women who have contraindications to oral contraceptives can be given EC
  • Offer EC to all reproductive-aged women who have sustained sexual assault
  • No clinical examination or pregnancy testing is necessary
  • Treatment should be initiated as soon as possible, and should be made available up to 5 days after unprotected or inadequately protected intercourse
  • If menses are delayed by a week or more, a woman who has received EC should have a pregnancy test and clinical evaluation
  • EC may be used more than once even in the same menstrual cycle
  • Regular contraception should be started immediately after EC and women should abstain or use barrier contraception for 14 days or until onset of next menses
    • Those receiving uripristal acetate should delay starting hormonal contraception until 5 days after use

SYNOPSIS:

All of the methods below are effective only before a pregnancy is established. Hormonal EC does not pose a risk to an established pregnancy and is not associated with embryonal developmental abnormalities. Adverse effects for all of the oral methods include nausea and headache as well as irregular bleeding. Adverse effects for the copper IUD include perforation, changes in menses or dysmenorrhea. Pregnancy rates after EC range from 0-2.2%, and may be impacted by body weight.

KEY POINTS:

  • Uripristal acetate, a selective progesterone receptor modulator, is given as a single 30 mg dose
    • Requires a prescription
    • Efficacy may be reduced in women with BMI ≥30
    • Effective up to 5 days after unprotected intercourse
    • FDA approved for EC
  • Progestin only EC, either 1 tablet Levonorgestrel in a single dose (1.5 mg) or as a split dose (1 dose of 0.75 mg of levonorgestrel followed by a second dose of 0.75 mg of levonorgestrel 12 hours later)
    • May be less effective in women with BMI ≥25
    • 1 tablet formulation available over the counter without age restriction
    • 2 tablet formulation available over the counter to women ≥17 years with photo ID
    • Effective for up to 3 days after unprotected intercourse
    • FDA approved for EC
  • Copper IUD insertion
    • Requires office visit and insertion by a clinician
    • Efficacy not impacted by body weight
    • Effective up to 5 days after unprotected intercourse
    • Safe and effective but not FDA labeled for use as EC
    • LNG-IUDs “are currently being investigated” (ACOG PB) | Recent RCT suggests LNG-IUD is not inferior to copper IUD (see ‘Learn More – Primary Sources’)
  • Combined progestin-estrogen pills
    • Can use a variety of formulations (see ‘Learn More – Primary Sources’ below for a list of appropriate formulations)
    • Two doses every 12 hours
    • All aim for 100-120 micrograms of ethinyl estradiol and 0.5-0.6 milligrams of levonorgestrel per dose
    • Requires a prescription
    • Effective up to 5 days after unprotected intercourse
    • Safe and effective but not FDA labeled for use as EC

Learn More – Primary Sources:

Practice Bulletin No. 152: Emergency Contraception

CDC Contraceptive Guidance for Health Care Providers

CDC: U.S. Selected Practice Recommendations for Contraceptive Use, 2016 – Recommendations and Reports