Emergency contraception
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1492 (Published 19 March 2012) Cite this as: BMJ 2012;344:e1492
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I commend the authors on their succinct summary of the latest guidelines on emergency contraception . However, I believe they should have been more explicit in mentioning recommendations for follow up in those patients who have IUD's inserted.
The guidelines state that patients should "see a doctor or nurse three to four weeks after the IUD is fitted."
This is if the copper IUD is to be used as an ongoing contraceptive method , and the aim is for a follow up appointment after the first menses (or 3–6 weeks) after insertion. (1)
This specific advice for IUDs is given alongside general follow up for..."pregnancy test, STI screening, Cu-IUD
removal"(1) or any concerns or difficulties with their contraception.(1)
This information is relevant as patients may be reluctant to return for IUD follow up, if only wishing to be seen for purposes of emergency contraception.
Ref:
(1) Faculty of Sexual and Reproductive Health Care. Intrauterine Contraception. 2007. http://www.fsrh.org/admin/
uploads/CEUGuidanceIntrauterineContraceptionNov07.pdf [Accessed 14 June 2011]
Competing interests: No competing interests
Although Prabakar and Webb present a cogent review of current guidance on emergency contraception we feel that insufficient consideration was given to the possibility of sexually transmitted infections(STIs). The request for emergency contraception implies at least one episode of unprotected sexual intercourse. The risk of pregnancy which prompts the request is accompanied by the risk of STI.
Taking a robust sexual history will help to stratify risk but it is worth noting that current guidance exhorts us to avoid making assumptions about risk and to offer STI testing, including HIV testing, to "all women irrespective of age, relationship or ethnicity." In other words, irrespective of our perception of their risk.
The window periods for STI testing should not deter opportunistic screening at first presentation, when we have the patient in the room. In the same spirit, many services would have a very low threshold for presumptive treatment of chlamydia at the time of insertion of an emergency IUD. Of course, diagnostic samples should always be obtained at the time if antibiotics are administered.
Competing interests: No competing interests
The popular expression "morning after pill" is a misleading marketing concept for many young couples who believe they should wait for the next day before taking the emergency contraceptive pill.
Although most aging couples may have intercourse late in the evening and wait the next morning for buying the emergency contraceptive pill, teenagers usually prefer the moment in the daytime when their parents are not at home. In our center, we frequently provide emergency contraception on Sunday mornings whereas the intercourse occurred on a Saturday morning.
Since the efficacy of emergency contraception decreases with time, we suggest the term "morning after pill" should be replaced by rescue or emergency contraception.
Competing interests: No competing interests
It is essential in any scientific paper to use words with accuracy. Misnamed post coital contraception is in essence, on most occasions, not contraception at all, rather do the chemicals prevent implantation of the fertilised ovum and therefore the drugs act as abortifacients and should be described as such.
Competing interests: No competing interests
This article provides a practical and informative overview of the options available for women who need emergency contraception. From my experience, many women are unaware that there is any emergency contraception available more than 72hrs after unprotected sexual intercourse. Whilst working in a GU clinic I was always surprised when people presented several days after unprotected sexual intercourse requesting an STI screen, but had not even considered the option of emergency contraception until I discussed it with them. I feel more information needs to be available to ensure women are aware that, although it is preferable to seek advice as early as possible, there are still options available even if they present late. Perhaps this is an area which needs to be addressed in sex education lessons as well as via patient information resources.
When a patient asks for ‘the morning after pill’ it is often easy, particularly when under the pressure of time constraints, to prescribe Levonelle without exploring the patient’s understanding of the alternatives, and discussing their relative efficacy. However, to ensure you obtain fully informed consent, patients must be aware of all the facts. I believe it is crucial to ensure you phrase the information objectively, thus allowing women to choose for themselves. This could avoid deterring them from opting for an IUD, which is often initially seen as a less favourable option, when it has the obvious benefits of increased efficacy and ongoing contraceptive cover. Furthermore, as stated in the article, it is imperative to have a simple and prompt referral pathway for women who choose to have a coil fitted. After all, what use is it to offer an option if you cannot practically implement it in the appropriate time frame?
Competing interests: No competing interests
Re: Emergency contraception
I am re-writing our standard operating procedures around Emergency Contraception. So I have been relooking at the evidence, and I thank you for your piece in the BMJ. Currently we promote IUDs as first line and only offer Ulipristal, UPA, if by pre-defined standards related to a known LMP have had “high risk” UPSI (unprotected sexual intercourse) or the UPSI occurred over 120 hours ago; otherwise we offer Levonogestrel.
Another approach would be to offer choice of IUD, UPA or Levonogestrel to the patient if they have only had one episode of UPSI in the cycle and that it was within the last 120 hours. This would avoid the guesswork around estimating risk of pregnancy from one episode of sex. And this perhaps should hinge on ongoing contraception needs and their relative effectiveness. Then offer only IUD or Levonogestrel to patients that have had more than one episode of UPSI in this cycle.
How to talk about effectiveness is then very well covered with your fig 2; showing comparative predicted estimates of the number of pregnancies if 1000 women at risk used various forms of emergency contraception. When I have showed it to patients they always choose the red one over the purple one (UPA over Levonogestrel).
Interestingly this approach depends on the fact that Ella One is infact better than levonogestrel. As you put in the review as a meta-analysis concluded that the pregnancy rate was significantly lower with ulipristal than with levonogestrel with an odds ration of 0.58 (CI 0.33-0.99) 0-72 hours and 0.55 (CI 0.32-0.93) at 0-120 hours. However the Faculty state in their guidance1 the authors concluded that the pregnancy rate was significantly lower in the UPA group rather than stating that it was. They note that a metaanalysis combing 2 non-inferiority trials that were not designed to show superiority and contained a small number of subjects…
I suspect that ulipristal is infact more effective than levonogestrel however I don’t see the evidence to support this. I also suspect that there will never be an RCT to compare UPA to levonogestrel. I also think that there will be a myth that there was a systematic meta analysis that proves that UPA is better than levonogestrel.
With this in mind what criterion does your clinic use to decide when to use UPA or levonogestrel?
Ref
1 FSRH Emergency Contraception Aug 2011 update Jan 2012 viewed on 19th July at
http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf
Competing interests: No competing interests