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Sunday April 7, 2013 MYT 12:00:00 AM
Thursday May 23, 2013 MYT 1:53:56 PM
by dr milton lum
Emergency contraception is not a substitute for other contraceptive methods. It is to be used only when there is an episode of unprotected sex, or there is potential contraceptive failure.
EMERGENCY contraception (EC) provides women with a safe method of preventing pregnancy if there has been sexual intercourse without any contraceptive use or if there is potential contraceptive failure, eg burst, split, or dislodged condom, missed contraceptive pills, or expulsion of an intra-uterine contraceptive device (IUCD).
As other commonly used terms such as “morning-after pill” or “post-coital contraception” are often confusing, the term “emergency contraception” is preferred.
There are two types of EC available – hormones and IUCD. EC acts by stopping ovulation or fertilisation of an egg, or preventing a fertilised egg from implanting in the uterus.
Medical and legal opinions are clear that emergency contraception prevents pregnancy and is not a method of abortion. Abortion only takes place after a fertilised egg has implanted in the uterus.
However, those who believe that life begins when the egg and sperm are released or when the egg is fertilised may not wish to use EC.
The IUCD cannot be used in women who have a current pelvic infection. Care is needed in its use in women who are at risk of sexually transmitted infection (STI), ie those who have more than one sexual partner or the partner has more than one partner.
Women who are already pregnant cannot use EC. Hormones are not advisable for those who have a history of jaundice during pregnancy or oral contraceptive use, genital tract cancers, venous thromboembolism, and those who are on medicines like rifampicin, anti-epileptics, and possibly St John’s wort.
The hormone regimes available are levonorgestrel, ulipristal acetate and oestrogen-progestogen EC. The overall effectiveness of emergency hormonal contraception varies depending on the regime used and when it is initiated.
This effectiveness rate cannot be compared with the effectiveness rates for other contraceptives because it is for a single use.
Levonorgestrel (LNG), a progestogen, is thought to act by inhibiting ovulation. It should be taken within 72 hours (three days) of unprotected sexual intercourse (UPSI). It is more effective the sooner it is taken.
LNG taken on day five after UPSI has six times the pregnancy rate when compared to when it is taken on day one. It is not as effective as other contraceptive methods like the Pill or condoms, and it does not provide protection against STIs.
LNG is more likely to fail if the first dose is taken more than 72 hours after UPSI, the second dose is not taken or taken late, there is vomiting within three hours of taking the pills, or there is UPSI at another occasion, either since taking LNG or since the last menstrual period.
The first dose, which contains 0.75mg LNG, should be taken as soon as possible, and the second dose should ideally be taken 12 hours later, but not more than 16 hours later.
Sometimes, there may be concerns about poor compliance by the user. In such situations, a single dose of 1.5mg may be prescribed.
Most women can take LNG. However, if there is a medical condition or illness or concurrent consumption of prescribed or traditional medicine, it would be prudent to inform the doctor.
There are no serious side effects. About 20% of women will experience nausea and 5% vomiting. If there is vomiting within three hours of taking LNG, the doctor should be informed. They may prescribe extra pills, medicine to stop the vomiting, or suggest fitting an IUCD.
Other side effects include headache, breast tenderness, or abdominal pain.
Menstrual disturbances may occur after taking LNG. The next menstrual period will come earlier than expected or it may be up to a week late. On most occasions, it comes within a few days of the expected date. There may be some irregular bleeding between taking LNG and the next period.
There is still a small risk of pregnancy even if LNG is taken correctly. The possibility that the hormones in the pills may harm a developing baby cannot be completely ruled out, but this is thought to be very unlikely.
Ulipristal acetate (UA), a selective progestogen receptor modulator, acts by preventing or delaying ovulation. It should be taken as soon as possible and certainly no later than 120 hours (five days) after UPSI. It can be taken at any time of the menstrual cycle, but you must not be already pregnant before taking it.
Medical advice has to be sought if there is vomiting within three hours of taking UA as another tablet will have to be taken because of possible non-absorption.
As UA does not provide protection against pregnancy for the rest of the menstrual cycle, condoms have to be used until the next menstrual period because UA may reduce the effectiveness of the contraceptive Pill. The next period should be on time or a few days early or late.
Medical advice should be sought if the periods are more than seven days late, there is abnormal bleeding, or if you think you may be pregnant.
UA is unsuitable for regular use and cannot be used more than once during a menstrual cycle. It does not protect against STIs.
Oestrogen-progestogen emergency contraception
This is called the Yuzpe regime, named after the Canadian gynaecologist who first described it. It was the only method of EC until LNG and UA came along.
It involves taking pills containing 100mcg ethinyl oestradiol, and 0.5mg levonorgestrel or 0.5mg norgestrel, within 72 hours of UPSI, and then repeating the same dose 12 hours later. Its effectiveness is greatest when taken within the first 24 hours of UPSI, after which effectiveness decreases during each subsequent 24-hour period.
About 50% of women will experience nausea and 20% will vomit after taking the first or second dose. Another side effect is breast tenderness. It does not protect against STIs.
Intra-uterine contraceptive device (IUCD)
An IUCD containing copper can be inserted up to 120 hours (five days) after the first episode of UPSI at any time in the menstrual cycle, or up to 120 hours after the expected date of ovulation in a regular cycle.
Ideally, an IUCD should be inserted at the time a woman is first seen, but some women may need time to think about it. In this case, and if within 72 or 120 hours of UPSI, LNG or UA respectively will be prescribed.
The IUCD works by stopping an egg from being fertilised or implanting in the uterus. It prevents 99 % of expected pregnancies and can also provide continuing contraception if wanted.
Most women can use an IUCD. However, if a person is at risk of STI, there is risk of a pelvic infection. In such circumstances, screening tests will be done at the time the IUCD is fitted and antibiotics may be prescribed to those in high-risk groups to prevent a pelvic infection.
There is a six-fold increase in the risk of pelvic infection in the 21 days following insertion of an IUCD. The doctor will provide information about recognising symptoms and when to seek medical attention.
An IUCD is suitable if the user is too late to take LNG, does not want to take hormones, or wants to use the most effective method of EC.
Evaluation and follow-up
A medical history is taken from all those who request EC so that the risks of STI and the need for discussion on other sexual issues can be assessed. Screening for STI will be offered, especially to those who are at risk.
Information and counseling regarding the different methods of EC, as well as its side effects and effectiveness, will be provided to enable an informed choice to be made. Information and reassurance about confidentiality should readily be available as this is a concern for many young people.
The user of EC is advised to consult her doctor as instructed. After hormonal EC, about 87-90% of women will menstruate within seven days of their expected date. If the periods are delayed by more than seven days or are lighter than usual, a pregnancy test will be carried out.
If hormonal EC is used because of missed contraceptive pills, advice will be provided about the missed pills. Condoms should be used until these consecutive pills are taken.
Some fertility monitoring devices like the personal hormone monitoring system will not be reliable for up to three months after hormonal EC use.
It is important to see a doctor three to four weeks after an emergency IUCD has been fitted, whether or not there has been menses. The objective is to check if there is any pregnancy, the IUCD is in the correct place, and to discuss any problems.
If there is no desire to keep the IUCD as a regular contraceptive method, it can be removed any time after the next period if no UPSI has occurred after the menses or if hormonal contraception has been started within five days of the next cycle.
Another contraceptive method, eg condoms, has to be used for at least seven days prior to removal of the IUCD because sperm can live in the body for up to seven days and can fertilise an egg once the IUCD is removed.
It there is any concern about EC, it is advisable to consult the doctor as soon as possible. Medical attention should be sought immediately if there is any sudden or unusual lower abdominal pain as this may be due to ectopic pregnancy, a condition in which the pregnancy develops outside the uterus, which is potentially life threatening, although it is rare.
Hormonal EC does not protect against pregnancy for the remainder of the menstrual cycle. The doctor will counsel the user about other reliable and more regular contraceptive methods like the combined oral contraceptive pill, progestogen only pill, condoms, diaphragms, caps, fertility awareness methods, implants, injections and intra-uterine contraceptive device.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail email@example.com. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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