Are you up to speed on emergency contraception (EC)? The Association of Reproductive Health Professionals (ARHP) has just released a two-part webinar to help providers review evidence-based information on all things EC, from its efficacy to the state of access in the United States. (Go to the “On Demand Webinars” of the ARHP website at http://bit.ly/1QregZM. Select the two titles on emergency contraception.)
What proportion of sexually active U.S. women have used EC? According to the most recent National Survey of Family Growth, the answer is 18%, says James Trussell, PhD, professor of economics and public affairs emeritus and senior research demographer of the Office of Population Research at Princeton (NJ) University.1 Trussell co-presented at the first webinar, along with David Turok, MD, MPH, associate professor in the Department of Obstetrics and Gynecology at the University of Utah in Salt Lake City.
“That is up from 4% in 2002, but is still quite low when we consider that half of all pregnancies in the U.S. are unintended,” Trussell notes.
The copper intrauterine device (IUD) is the most effective EC method available in the United States today, states Trussell. While use of the copper IUD as EC has been documented for at least 40 years, it remains underutilized, observes Trussell. In addition to its capabilities as an emergency contraceptive, the device provides at least 12 years of highly effective protection, he states.
According to World Health Organization guidelines, when the time of ovulation can be estimated, the copper IUD can be inserted beyond five days after intercourse, if necessary, as long as the insertion does not occur more than five days after ovulation, says Trussell.2
“This recommendation is not based on a safety concern for the patient, but rather is intended to minimize the possibility that the IUD could interfere with the implantation of a fertilized egg or be inserted into a uterus with an existing pregnancy,” states Trussell.
The most commonly available form of EC is levonorgestrel (LNG) pills. One-dose LNG EC products have almost entirely replaced the two-dose products, notes Trussell. Although the package label directions state to take the pill within 72 hours after intercourse, studies have shown that progestin-only EC pills may be effective up to 120 hours after intercourse; however, an analysis of four World Health Organization trials showed that it is effective only up to four days, states Trussell.2,3 Since LNG EC works by delaying ovulation, women should be advised to take them as soon as possible, because it is difficult for a woman to know when ovulation is about to happen.
All one-dose LNG EC products are available over the counter with no age restrictions or ID requirements. However, labeling for the generic EC products can be confusing, advises Trussell. “Regulations around the sale of EC have changed so frequently over the past few years, and it can be confusing for pharmacy staff and for consumers,” explains Trussell. “Part of the confusion is that the generic packages actually say different things, depending on whether it’s a generic made by the company that makes the brand or whether it’s from another company.”
An example is the packaging for My Way (Gavis Pharmaceuticals, Somerset, NJ), says Trussell. The packaging states, “For women 17 years of age and older.” While this wording may look like a restriction, it is not, Trussell says. It’s a “use recommendation” that is in place for complicated reasons related to the patent by Frazer, PA-based Teva Women’s Health for Plan B One-Step, he states.
“Women and men of any age can buy this product without ID, but even well-meaning pharmacy staff might interpret this as a restriction,” says Trussell. “This use recommendation should be removed in 2016, when the market exclusivity for Plan B One-Step expires.”
Ulipristal acetate (UPA), sold as ella by Afaxys in Charleston, SC, by prescription only in the United States, has been approved for sale over the counter in Europe. In a growing number of U.S. states, pharmacists can directly write the prescription.
Ulipristal acetate is the only EC product labeled for use up to 120 hours after unprotected intercourse, notes Trussell. However, like levonorgestrel EC, it works by inhibiting ovulation, so it should be taken as soon as possible.4
There is some evidence that ECPs may be less effective for women at higher body mass index (BMI) or weight.5 In one study, the odds of ECP failure was calculated for obese women compared with women of normal BMI. Levonorgestrel showed a rapid decrease of efficacy with increasing BMI, and it reached the point at which it appeared no different from pregnancy rates expected among women not using ECPs at a BMI of 26, compared with 35 for ulipristal acetate.1
Discussion of emergency contraceptive pills at Contraceptive Technology conferences often raises the question of the use of two levonorgestrel tablets or two ulipristal acetate tablets in overweight or obese women, notes Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine, Atlanta. To Hatcher’s knowledge, there are no data of the efficacy of this approach.
PILLS EASY TO ACCESS
Most women have found over-the-counter LNG pills to be the most convenient way to access EC, states Don Downing, RPh, clinical professor in the University of Washington’s School of Pharmacy in Seattle.
While pharmacists can prescribe prescription-only EC in many states, there are 50 states with 50 different pharmacist-prescribing laws, which makes this mode of access extremely variable and uncertain, states Downing. Downing was a co-presenter of the second webinar, along with Beth Kruse, MS, CNM, ARNP, family planning nurse practitioner at Seattle–King County Public Health Department in Seattle.
In states where pharmacists do prescribe EC (Alaska, California, Hawaii, Massachusetts, New Hampshire, Vermont, and Washington), Downing says it improves access in three ways:
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It provides women with ulipristal acetate, the most effective oral emergency contraceptive.
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If the woman has insurance coverage, then a pharmacist prescription creates a zero copay and zero deductible insurance situation that lowers the threshold for access.
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It provides for a patient-provider interaction to determine if the woman’s current form of contraception is the most appropriate/effective method for her.
REFERENCES
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Martinez GM, Abma JC. Sexual activity, contraceptive use, and childbearing of teenagers aged 15-19 in the United States. NCHS Data Brief 2015; 209:1-8.
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World Health Organization. Medical Eligibility Criteria for Contraceptive Use. Fifth edition. Geneva; 2015.
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Arowojolu AO, Okewole IA, Adekunle AO. Comparative evaluation of the effectiveness and safety of two regimens of levonorgestrel for emergency contraception in Nigerians. Contraception 2002; 66:269-273.
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Trussell J, Raymond EG, Cleland K. Emergency Contraception: A Last Chance to Prevent Unintended Pregnancy. Accessed at http://bit.ly/20Vr8i7.
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Glasier A, Cameron ST, Blithe D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception 2011; 84:363-367.
