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Gynaecological Management Update: Women’s Health
Emergency contraception
We’ve come a long way…or have we?
Emergency contraception (EC) has come a long way since the days when Family
Planning clinics and other services provided cut-up sections of pink oral
contraceptive pill strips and a dose or two of an antiemetic in tiny sealed plastic
bags to women who were lucky enough to know about this option.
The other available method of EC is insertion of a copper bearing intrauterine device (IuD) within five days of unprotected intercourse (uPSI). While an IuD is highly effective4,5 and has the advantage of providing immediate ongoing contraception, insertion needs to be done by a skilled medical practitioner. Historically, services nausea and vomiting for these women able to provide IuD insertion within this timeframe are very limited ‘in the know’. However, despite in Australia, so this in practice is a rarely used option. It should be noted that insertion of a LNG IuD (Mirena ®) cannot be used as Dr Caroline Harvey
EC as it is not effective for this indication.
Family Planning
Other regimens available elsewhere
Queensland
The antiprogestin, mifepristone, has been studied as an EC and is used in some countries for this indication. A Cochrane review5 found mid-dose (25 to 50mg) mifepristone to be superior in efficacy to other hormonal regimes and low-dose (less than 25mg) to be at EC is defined as a medication or device used to prevent pregnancy least as effective as the commonly used LNG 1.5mg regime.
after unprotected intercourse (including sexual assault) or after a ulipristal, a selective progesterone-receptor modulator, has recently recognised contraceptive failure. It has alternatively been called been marketed as EC in Europe. A randomised study comparing postcoital contraception or ‘the morning after pill’. These terms are ulipristal with LNG as EC, found it to be more effective overall and confusing and imply that EC pills can only be taken immediately, to have higher effectiveness between 73 and 120 hours after uPSI.6 which is incorrect. They can be used, while with decreasing efficacy, for up to five days post intercourse. Efficacy
Currently used hormonal methods of EC prevent about 50 to
There are no evidence-based absolute contraindications to 80 per cent of pregnancies.7 Efficacy rates for EC are estimated hormonal EC except established pregnancy (due to a lack of by comparing the number of pregnancies observed among a efficacy rather than specific adverse outcomes) and allergy. Side large number of women using the EC method to the number of effects are uncommon with the progestogen-only regimen and pregnancies that would be expected in an equivalent number of hormonal EC can be used more than once in a cycle if required. women with the same coital history, but using no contraception, It will not provide protection for the rest of the cycle, so ongoing and is expressed as a percentage. The number of ‘expected’ contraception should be addressed from the time of administration.2 pregnancies is based on a series of calculations based on numerous assumptions and suffers from the imprecision with which the day What is used in Australia?
of ovulation can be known in any woman.8 The generally quoted The oldest method of hormonal EC, the ‘Yuzpe’ method (named efficacy rates (see Table 1) have been criticised as an overestimate after the Canadian who described it), was introduced in 1974 and and several recent investigators have attempted to recalculate consisted of two doses of 100mcg of ethinyl estradiol and 500mcg the efficacy, suggesting that EC prevents, as a minimum, 50 of levonorgestrel, given 12 hours apart. Only a few countries ever per cent of pregnancies.8 It is known that efficacy for hormonal licensed this method, but it was widely used off-label, including in methods decreases with lengthening interval of administration after Australia. It is associated with side effects, particularly nausea and intercourse (see Table 2). This is not the case for a copper IuD, vomiting, due to the high estrogen dose and was therefore usually which is equally effective any time up to five days post intercourse.
administered with prophylactic antiemetics.
The progestogen method, using levonorgestrel (LNG), was found to be both more effective and associated with less side effects in a Efficacy rates for emergency contraception methods.
WHO study.1 LNG is administered in two doses of 0.75g 12 hours apart, or a single dose of 1.5mg is equally effective for EC.3 until Time between
2002, there was no prescribable EC brand in Australia, so LNG dose and UPSI
Pregnancy Prevented
EC was given off-licence as two doses of 25 minipills (this was pregnancies %
understandably sometimes viewed by women with great trepidation).
Postinor-2® became available on prescription in mid 2002 and then was rescheduled in January 2004 as a pharmacy supplied product. Since then, three other brands have been marketed – Mifepristone
Levonelle-2®, Norlevo® (both containing two 0.75mg tablets) and more recently Postinor-1® which delivers the 1.5mg as a single Copper IUD4
Women’s Health: Gynaecological Management Update
A Cochrane review found advance provision of EC did not reduce Pregnancy rates relative to timing.9
pregnancy rates when compared to conventional provision and this ready access did not change the use of regular contraception Time interval between UPSI and
or sexual behaviours.13 Random controlled trials (RCTs) have been EC administration (hours)
Pregnancy rate %
consistent with this encouraging finding (that ready access to EC does not negatively impact on sexual and reproductive health behaviours and outcomes), including studies specifically with teenagers.14,15 Follow-up at three years from a large trial, where 17,800 women had access to home supplies of EC in Scotland, found that routine use of more effective contraception actually It seems that even when women have ready access to EC, including advance supply, they often don’t use it after uPSI, most commonly due to a lack of recognition of the risk of pregnancy or a neglect of Mechanism of action
the perceived risk.13 Of 518 women seeking abortions in a Swedish Possible reproductive targets for EC include follicular development, study, 83 per cent knew of the ready availability of EC, but only ovulation, sperm transport, fertilisation, implantation and corpus 15 had used it to attempt to prevent the current pregnancy.16 The luteum function. As sperm are viable in the female reproductive available data suggest abortion rates have remained unchanged for tract for up to five (or sometimes seven) days, while ovum can complex reasons, where women at risk for unintended pregnancy only be fertilised within 24 hours of ovulation, the mechanism of action most likely differs depending on when hormonal EC is given in relation to the time of intercourse and the time of ovulation.10 Barriers to emergency contraception use
Research has shown that the primary mechanism of action is by the prevention or postponement of ovulation through its effect Knowledge
on the LH surge10, but that this will work only if given at least two Numerous studies have explored the levels of community days before ovulation.7 The overall biological data overall strongly knowledge about EC, but less is known about the situation in suggest that the most likely mode of action is thus prefertilisation. Australia. Two Australian studies found significant EC knowledge This is supported by (and explains) the reducing efficacy rates with gaps amongst tertiary students in Adelaide17 and Cairns18, including greater time interval between coitus and administration described poor understanding of the recommended timeframe, low levels above. That is, the later hormonal EC is given, the more likely it is of knowledge of the current ‘over the counter’ (OTC) status and that the LH surge has already occurred and ovulation will not be misunderstandings about the mechanism of action. Many women prevented. There is no data to support the view that LNG can impair also had poor knowledge of fertile times seeking in their cycles the development of the fertilised embryo or prevent implantation, meaning they are not well able to assess their pregnancy risk after but any post-fertilisation action cannot be completely excluded. uPSI.17 There has been little research in Australia on clinician However, it is clear that LNG does not disrupt an established knowledge, but studies from other countries suggest that clinicians pregnancy, defined as beginning with implantation, and is not have poorer than expected knowledge about EC. Poorly informed clinicians are unlikely to provide opportunistic education and advance provision to the women who could benefit from this Who uses emergency contraception?
information and opportunity for future access.19 Information about the users of EC is conflicting, with some studies showing more users to be young and unmarried, while other studies Provider and cost issues
have found more users to be older and in stable relationships. While OTC supply has the potential to increase access generally at Similarly, findings as to whether users are at high risk of sexually a population level, for individuals, pharmacy EC supply may add transmitted infections (STIs) and unwanted pregnancy more some specific barriers. Little has been published in the Australian generally, have differing findings.11 An Australian study of sexual situation, although it is of concern that more than 20 per cent of health clinic clients requesting EC found users were more likely to tertiary students in the Cairns study felt unable to purchase EC in a be a student, to have a regular sexual partner and less likely to pharmacy where they may be recognised.18 While pharmacies are have had an STI or previous unplanned pregnancy than controls.11 required to provide a designated private counselling area, in reality, It is clear that it is not accurate to stereotype the EC user as young, this space may feel less than private to many women seeking EC. irresponsible and at risk of STIs, which seems to be a common While most pharmacists have embraced the Schedule III listing and see EC supply as an extension of their role in the healthcare team, some women report seeking pharmacy supply as being confronting Wide access to emergency contraception –
and difficult experience. These perceived barriers are likely to be what happens?
even greater in secondary age students and marginalised groups. There has been considerable debate internationally over widening While a prescription is not required for EC, an advance prescription access to EC, including the concept of advance provision. From a by a medical practitioner (which will then be dispensed by the public health perspective, wider availability has been supported by pharmacist without need for a pharmacy ‘supply consultation’) is numerous reproductive and other professional health organisations, one strategy which could help overcome some perceived barriers as it seems logical that ready access to EC should reduce the number of unplanned pregnancies, along with the rate of abortions. Detractors have voiced concerns that wide access might result in EC is not Pharmaceutical Benefits Scheme (PBS) listed and may reduced use of regular contraception, encourage irresponsible sell for upwards of A$40 in some pharmacies, which may be a behaviours and increase STIs. Evidence, however, does not support disincentive to its use for some women. Doctors can prescribe a PBS either of these suggested outcomes. While increased access to EC listed 30mg progestogen ‘minipill’ (for example, Microlut®) and pills improves use, disappointingly, it has not shown in a systematic advise on the ‘25 pills and repeat in 12 hours’ regimen as used off review to have a population effect12, although there are no label pre 2002. For a healthcare or pension card holder, a single published population studies in the Australian context. script will give two EC treatments for approximately A$5. 56 O&G Magazine
Gynaecological Management Update: Women’s Health
Conclusions
Greene M. Emergency Contraception: A Reasonable Personal While we have come a long way with EC in Australia in terms of an Choice or a Destructive Societal Influence? Clinical Pharmacology & available OTC dedicated product, there are still significant barriers Piaggio G, von Herzen H, Grimes DA, et al. Timing of emergency to its use. While at a population level, international studies have contraception with LNG or Yuzpe regimen. Task force on post not found that wide availability decreases unplanned pregnancy, it ovulatory methods of fertility control. Lancet 1999; 353:721.
does not result in decreased use of regular methods or behaviour 10. Allen R and Goldberg A. Emergency Contraception: A Clinical Review. changes which would adversely affect other reproductive or sexual Clinical Obstetrics and Gynaecology 2007; Vol 50, No.4, 927-936.
health outcomes. While complex factors unfortunately seem to 11. Fox J, Weerasinghe D, et al. Emergency contraception: who are the prevent women taking EC, even when there is ready access, they users? International Journal of STD & AIDS 2004; 15,5:309-313.
won’t have the chance to even consider its use if they misunderstand 12. Raymond E, Trussel J, Polis CB. Population effext of increased access it or don’t know about it at all. EC is a woman’s last opportunity to emergency contraception pills: a systematic review. Obstet Gynecol. to prevent an unwanted pregnancy. Clinicians in Australia have a 13. Polis C, Grimes D, et al. Advance provision of emergency responsibility to inform women about emergency contraception and contraception for pregnancy prevention. Cochrane Database of consider the benefits of offering an advance prescription to sexually active women not using a long-acting contraceptive method.
14. Ekstrand M, Larsson M, et al. Advance provision of emergency contraceptive pills reduces treatment delay: a randomised controlled trial among Swedish teenage girls. Acta Obstetricia and Gynecologica References
15. Gold M, Wolford J, et al. The effects of advance provision or Task Force on Post-ovulatory Methods of Fertility Control. Randomised emergency contraception on adolescent womens sexual and controlled trial of levonorgestrel versus the Yuzpe regime of combined contraceptive behaviours. J Pediatric Adolesc Gynecol. oral contraceptives for emergency contraception. Lancet 1998; 352: 16. Aneblom G, Larsson M, et al. Knowledge, use and attitudes towards Sexual Health and Family Planning Australia. Contraception: An emergency contraceptive pills among Swedish women presenting for Australian Clinical Practice Handbook. 2008. SHFPA, Canberra.
induced abortion. Br J Obstet Gynecol. 2009; 109,155-160.
von Hertzen H, Piaggio G, et al. Low dose mifepristone and two 17. Calabretto H. Emergency Contraception – knowledge and attitudes in regimes of levonorgestrel for emergency contraception: a WHO a group of Australian university students. ANZJPH 2009; multicentre randomised trial. Lancet 2002; 360:1803-1810.
Trussell J, Ellertson C. Efficacy of emergency contraception. Topical 18. Mohoric-Stare D, de Costa C. Knowledge of emergency contraception reviews. Fertility Control Reviews 1995; 4:8-11.
amongst tertiary students in far North Queensland. Aust and New Cheng L, Gulmezoglu A, Piaggio G, Ercurra E, Van Look P. Zealand Journal Obstetrics Gynaecology 2009; 49:307-311.
Interventions for emergency contraception. Cochrane Database of 19. Broekhuizen F. Emergency contraception, efficacy and public health impact. Current Opinion in Obstetrics and Gynecology 2009; Glasier A, Cameron S, et al. ulipristal acetate versus levonorgestrel for emergency contraception:a randomised non inferiority trial and meta 20. Trussell J, Rodriguez G, Ellertson C. updated estimates of the analysis. Lancet 2010. Online 29 January. effectiveness of the Yuzpe regimen of emergency contraception.
Baird D. Emergency contraception:how does it work? Ethics, Biosciences and Life 2009; Vol 4,No.1.
The Royal Australian and New Zealand
College of Obstetricians and Gynaecologists
WANTED: VOLUNTEER FACILITATORS FOR
RANZCOG BASIC SURGICAL SKILLS WORKSHOPS
Fellows and Year 5 and 6 Trainees are needed to act as facilitators at the RANZCOG Basic Surgical Skills (BSS) workshops conducted annually in each State in Australia and in New Zealand. Attendance at a BSS workshop is compulsory for all Year 1 RANZCOG Trainees.
These practical, interactive two-day workshops are run on weekends and cover theatre etiquette, handling instruments, knot tying, incision/closure, episiotomy repair, haemostasis, electrocautery and stacks, hysteroscopy and laparoscopy.
Facilitators provide hands-on teaching and advice during the workshop and help with setting up on the day. Time commitment: ONE weekend per year.
Applications and enquiries: Shaun McCarthy, Training Services Manager tel +61 3 9412 2917, fax +61 3 9419 7817, email: [email protected]

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