Gynecology Book

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Emergency ContraceptionAka: Morning After Pill, Postcoital Contraception

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  1. Background
    1. Requires a prescription in most states
    2. No emergency Contraception prescription needed in
      1. California
      2. Alaska
      3. Washington
      4. New Mexico
      5. Hawaii
      6. Maine
  2. Indications
    1. Sexual Assault
    2. Failure of ongoing contraceptive method
    3. Unprotected Intercourse
  3. Mechanism
    1. Semen remain viable for up to 7 days after ejaculation
    2. Emergency Contraception effects
      1. Suppresses Ovulation (Follicular Phase <12 days)
      2. Interception by preventing nidation (post Ovulation)
    3. No impact on implanted fetus!
      1. No increase in Spontaneous Abortion rate
      2. No increase in birth defects
      3. No increase in Ectopic Pregnancy
      4. No Teratogenic or other toxic effects
  4. Contraindications
    1. Ongoing Pregnancy (No benefit to use)
    2. Past history of thrombosis
      1. Consider Progesterone only option
    3. Concurrent Focal Migraine
    4. Concurrent Lactation (relative contraindication)
  5. Method requirements
    1. Oral Contraceptive taken within 5 days of intercourse
      1. Previously limited to within 72 hours
      2. Best efficacy within 72 hours
    2. Traditional Yuzpe method hormonal requirements
      1. Oral Contraceptive: 2 doses, 12 hours apart
      2. Progesterone: Norgestrel, Levonorgestrel 0.5-0.6 mg
      3. Estrogen is not necessary in Emergency Contraception
  6. Doses: General
    1. Do not use Placebo pills!
    2. Start dosing so that both doses are during awake time
  7. Doses: New single dose methods
    1. Options
      1. Mifepristone 10 mg PO for 1 dose or
      2. Levonorgestrel 1.5 mg for 1 dose
    2. Efficacy
      1. As effective as Levonorgestrel 0.75 mg x2 doses
    3. Adverse Effects
      1. Fewer side effects than traditional method (below)
      2. Bleeding (up to 31%)
      3. Nausea (15%)
      4. Fatigue (15%)
      5. Abdominal Pain (15%)
      6. Headache (10%)
    4. References
      1. von Hertzen (2002) Lancet 360:1803
  8. Doses: Traditional Yuzpe Method
    1. Background
      1. Levonorgestrel is key component for Contraception
      2. Most options below contain Levonorgestrel
      3. Each Norgestrel pill contains 50% Levonorgestrel
    2. Option 1: 100 mcg Estrogen/dose (2 tabs q12h x2 doses)
      1. Ovral 2 white pills (0.5 mg Levonorgestrel/dose)
      2. Ogestrel 2 pills (0.5 mg Levonorgestrel/dose)
      3. Preven 2 blue pills (0.5 mg Levonorgestrel/dose)
        1. Contains a total of 4 Ovral tablets
        2. Least expensive option and includes home UPT
    3. Option 2: 120 mcg Estrogen/dose (4 tabs q12h x2 doses)
      1. Lo/Ovral 4 white pills (0.6 mg Levonorgestrel/dose)
      2. Low-Ogestrel 4 tablets (0.5 mg Levonorgestrel/dose)
      3. Nordette 4 light-orange (0.3 mg Levonorgestrel/dose)
      4. Levlen 4 light-orange (0.3 mg Levonorgestrel/dose)
      5. Triphasil 4 Yellow (0.25 mg Levonorgestrel/dose)
      6. Tri-Levlen 4 Yellow (0.25 mg Levonorgestrel/dose)
      7. Levora 4 white pills (0.3 mg Levonorgestrel/dose)
    4. Option 3: 100 mcg Estrogen/dose (5 tabs q12h x2 doses)
      1. Alesse 5 pink pills (0.25 mg Levonorgestrel/dose)
      2. Levlite 5 pink pills (0.25 mg Levonorgestrel/dose)
    5. Pre-packaged kit
      1. Preven (see Option 1 above)
      2. Plan B (No Estrogen)
        1. Contains 2 white 0.75 Levonorgestrel tablets
        2. One tablet taken q12 hours or two tablets once
        3. See single dose option above
    6. Antiemetic 1 hour before dose
      1. Used for Estrogen induced Nausea
      2. Over the counter
        1. Meclizine (Dramamine)
        2. Diphenhydramine (Benadryl)
      3. Presciption Antiemetics
        1. Promethazine (Phenergan)
        2. Trimethobenzamide (Tigan)
  9. Efficacy
    1. Unprotected intercourse randomly in cycle: 8% pregnancy
    2. Emergency Contraception efficacy depends on dose timing
      1. Dose taken <12 hours from intercourse: 0.5% pregnancy
      2. Dose taken <24 hours from intercourse: 1.5% pregnancy
      3. Dose taken <36 hours from intercourse: 1.8% pregnancy
      4. Dose taken <48 hours from intercourse: 2.5% pregnancy
      5. Dose taken <60 hours from intercourse: 3.1% pregnancy
      6. Dose taken <60 hours from intercourse: 4.0% pregnancy
      7. Piaggio (1999) Lancet 353:721
    3. Progestin only method is more effective than OCP method
      1. Example: Plan B (Levonorgestrel only)
      2. (1999) Lancet 352:428
    4. Advance EC does not increase unprotected intercourse
      1. Gold (2004) J Pediatr Adolesc Gynecol 17:87
  10. Adverse Effects
    1. No evidence for Teratogenicity in case of pregnancy
    2. Most adverse effects associated with Estrogen dose
    3. Nausea (30-54%)
    4. Vomiting (15-20%)
    5. Breast tenderness (12-30%)
    6. Other effects
      1. Headache
      2. Fluid retention
      3. Dizziness
      4. Fatigue
    7. Menstrual effects
  11. Follow-up
    1. Pregnancy Test in 3 weeks if no Menses
  12. Patient Information
    1. Princeton Hotline in English, Spanish
      1. http://not-2-late.com
      2. 1-800-Not-2-Late
    2. Program for appropriate technology in health (PATH)
      1. http://www.path.org/index.htm
    3. PATH Materials
      1. http://www.path.org/resources/ec_client-mtrls.htm
    4. Preven
      1. http://www.preven.com
      2. 1-888-Preven2
    5. Emergency Contraception Newsletters
      1. http://cecinfo/html/updates.htm
  13. References
    1. Hatcher (1994) Contraceptive Technology P. 415
    2. Nelson (1999) CMEA Gynecology Lecture, San Diego
    3. Thomas (2001) Clin Obstet Gynecol 44(1):101
    4. Weismiller (2004) Am Fam Physician 70:707

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