Sexual Health
Question 5 of 180
A 21 year old woman presents to the Emergency Department seeking emergency contraception. Which of the following statements regarding emergency contraception is INCORRECT?
Answer:
Levonorgestrel is licensed to be used within 72 hours after UPSI or contraceptive failure. It may also be used between 72–96 hours after UPSI or contraceptive failure (unlicensed use), but efficacy decreases with time.Emergency Contraception
Sexual Health
Last Updated: 7th March 2021
Emergency contraception is an intervention aimed at preventing unintended pregnancy after unprotected sexual intercourse or contraceptive failure.
When a woman requests emergency contraception (EC):
- Reassure her that the consultation will remain confidential, but explain the circumstances in which confidentiality may need to be breached (for example, suspected child protection issues).
- If a girl younger than 16 years of age requests EC without parental consent, assess her competency to independently consent to treatment, and document in her case notes that she meets (or does not meet) the Fraser criteria.
- Carry out a risk assessment for sexual abuse and non-consensual sex, particularly if the woman is considered to be vulnerable (that is, younger than 16 years of age; is from a disadvantaged background; is in, or is leaving, care; has low educational attainment). Note that the legal age of consent to sexual activity is 16 years in the UK. Sexual activity under the age of consent is an offence, even if consensual. Offences are considered more serious (statutory rape) when the person is younger than 13 years of age.
- Consider the risk of sexually transmitted infections (STIs). Offer the woman the opportunity to test for STIs, including HIV.
- Assess whether EC is indicated. Consider EC if a woman does not wish to conceive and has had unprotected sexual intercourse (UPSI):
- On any day of a natural menstrual cycle.
- After regular hormonal contraception has been compromised or used incorrectly.
- From day 21 after childbirth, unless all the lactational amenorrhea method (LAM) criteria are met (complete amenorrhea, fully or nearly fully breastfeeding [that is, baby getting more than 85% of its feeds as breast milk], and 6 months or less postpartum).
- From day 5 after miscarriage, abortion, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease (GTD).
- Take a full history to help decide on the most appropriate method of EC:
- Ask when the most recent UPSI occurred and whether additional UPSI has occurred in the same cycle. Consider arranging a pregnancy test if the woman has had UPSI earlier in the cycle. Be aware that pregnancy testing cannot reliably exclude pregnancy if there has been an episode of UPSI less than 21 days previously.
- Ask about the date of the start of her last menstrual period (LMP) and the usual cycle length. Calculate the earliest likely date of ovulation (estimated as the date of the start of her LMP plus the number of days in the shortest cycle minus 14).
- Ask about previous use of hormonal EC (confirm which was taken and when it was taken).
- Ask about other factors that could affect the choice of EC, including:
- Whether she is postpartum or breastfeeding.
- Current medications (with particular attention to liver enzyme-inducing drugs and progestogens).
- Contraindications/restrictions.
Methods of emergency contraception:
Three methods of emergency contraception (EC) are currently available in the UK:
- Levonorgestrel — a progestogen, taken orally as a single dose 1.5 mg tablet
- Ulipristal acetate — a selective progesterone receptor modulator, taken orally as a single dose 30 mg tablet
- Copper intrauterine device (IUD) - a non-hormonal intrauterine device that comes in various shapes and sizes
| Method | Levonorgestrel (single dose 1.5 mg tablet) | Ulipristal acetate (single dose 30 mg tablet) | Copper intrauterine device (Cu-IUD) |
|---|---|---|---|
| Mode of action | Thought to act by inhibiting ovulation, thereby delaying or preventing follicular rupture and causing luteal dysfunction. If taken prior to the start of the LH surge, it inhibits ovulation for the next 5 days, until sperm from the UPSI for which it was taken are no longer viable. In the late follicular phase, however, levonorgestrel becomes ineffective. Levonorgestrel is not effective once the process of implantation has begun. | Acts by inhibition or delay of ovulation via suppression of the luteinising hormone (LH) surge. Even when it is taken immediately before ovulation is scheduled to occur (when LH has already started to rise), ulipristal acetate is able to postpone follicular rupture for at least 5 days. However, it has not been demonstrated to be effective as EC when administered after ovulation. | Inhibits fertilisation by its toxic effect on sperm and ova; copper has been shown to adversely affect the motility and viability of sperm as well as the viability and transport of ova. If fertilisation does occur, the local endometrial inflammatory reaction resulting from the presence of the Cu-IUD prevents implantation. |
| Timeframe | Licensed to be used within 72 hours after UPSI or contraceptive failure. It may also be used between 72–96 hours after UPSI or contraceptive failure (unlicensed use), but efficacy decreases with time. | Licensed to be used within 5 days (120 hours) after UPSI or contraceptive failure. | Can be inserted for EC within 5 days (120 hours) after the first UPSI in a cycle or within 5 days of the earliest estimated date of ovulation, whichever is later. |
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When prescribing oral emergency contraception:
- Discuss (and provide information on) the mode of action, efficacy, advantages and disadvantages, and possible risks and adverse effects of the EC.
- Advise the woman that:
- She should take the tablet as soon as possible after unprotected sexual intercourse (UPSI).
- If she vomits up to 3 hours after taking the tablet, she should take a second dose as soon as possible.
- Her next menstrual period might be different:
- If she has early mild bleeding or spotting, this is probably caused by the EC and may not be the start of the next menstrual cycle. She should not regard this time as safe for UPSI.
- Most women will have a normal period at the expected time; some women will have their period later or earlier than normal.
- EC is not 100% effective. She should have a pregnancy test if her next period is more than 7 days late or bleeding is lighter than usual.
- The risk of ectopic pregnancy is very small. However, she should seek prompt medical attention if she experiences severe lower abdominal pain after taking EC.
- EC does not protect against sexually transmitted infections (STIs). Only a barrier method of contraception (such as a condom) can reduce the risk of STIs.
- If the woman is not currently using ongoing contraception, advise that she would need to use ongoing contraception or abstain from sex to avoid further risk of pregnancy. Advise that:
- EC is intended for occasional use and should in no instance replace a regular contraceptive method.
- EC does not provide contraceptive cover for the remainder of the cycle or for subsequent UPSI. There is a significantly increased risk of pregnancy with further UPSI later in the cycle in which oral emergency contraception has been taken.
- EC can be used more than once in the same cycle, but repeated administration is not advisable because of the possibility of disturbance of the cycle.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
