Repeating ECPs: What are the recommendations?
A missed pill, a broken condom, and you have a potential candidate for emergency contraceptive pills (ECPs). But what if your patient needs to repeat ECPs?
The following questions come from Lorna Townell, BScN, sexuality educator with Northern Lights Regional Health Services in Fort McMurray, Alberta, Canada:
• If a client has a broken condom four days after using ECPs, will they need to repeat ECPs?
• What are recommendations in regard to repeat ECPs in the same month for a patient using antibiotics and oral contraceptives (OCs)?
Tackling these questions are Contraceptive Technology Update Editorial Advisory Board members Anita Nelson, MD, medical director of the Women’s Health Care Clinic, Harbor-UCLA Medical Center in Torrance, CA; Sharon Schnare, FNP, CNM, a Seattle-based family planning clinician and consultant; and Susan Wysocki, RNC, BSN, NP, president of the National Association of Nurse Practitioners in Reproductive Health in Washington, DC.
Nelson: In response to question two, in the United States, general experience with simultaneous use of virtually all antibiotics and oral contraceptives has allayed former concerns that antibiotics would reduce OC efficacy. The only antimicrobial agents that pose such a threat are rifampin and griseofulvin. Therefore, we do not see a need to offer EC in this situation, unless women have failed to take their OCs due to illness or unless the effectiveness of their OCs may have been reduced by vomiting or severe diarrhea.
Schnare: Do you need to repeat ECPs if the patient had unprotected intercourse four days after using EC? Yes, I would repeat the ECPs, and I would discuss the availability of more effective contraceptive methods. I would inform her that the ECPs may be less effective because she would be taking them beyond the 72-hour window. She also may be a candidate for a postcoital T380A IUD as an emergency contraceptive.
I would ask her if she has had difficulties using other effective methods. I would inquire about the circumstances related to the condom breakage. Are she and her partner using the condoms correctly? I would assess whether she has been coerced to have intercourse. I would discuss issues related to ambivalence to pregnancy. Because she had a method failure, I would advise her to abstain from intercourse until her menses begins and, at that time, initiate a more effective method. I also would give her a pack of pills to start on the first day that her next menses begins if she is interested in using pills and if she is a candidate for OCs.
As for question two: Would I use ECPs with a patient on OCs who concomitantly used antibiotics? Only if the antibiotic was rifampin or griseofulvin. I would also consider an emergency postcoital T380A IUD for this patient if she is a candidate.
Wysocki: For your first question, I would recommend repeating the ECP regimen again and checking whether the need for the first dose was also a condom break. If yes, what is causing this condom breakage? Is it use of oil-based lubricants? Incorrect use of condom? Lack of lubrication? I don’t think anyone has studied using ECP many times in one month. Multiple use of ECP would seem to indicate the need for a more effective method of contraception. Also, it would be a drag for someone to be nauseated more than once.
Now to the second question: Unless that antibiotic is rifampin or griseofulvin, my understanding is that antibiotics do not interfere with pill efficacy. However, I hear a lot of clinicians who are nervous about this, based on what we thought in the past about antibiotics and OCs. Since I don’t want clinicians to be nervous, if they want to recommend something, I would recommend skipping the pill-free interval instead and going directly from the active pills to the start of the next pack. Skipping the pill-free interval can’t hurt anything in any case.
[Editor’s note: Progress continues on the EC front. Somerville, NJ-based Gynetics Inc. recently announced its plans to market ECPs, making it the first American company to take action since the U.S. Food and Drug Administration approved using oral contraceptives for emergency birth control. Marketing and packaging of pills as emergency contraceptives may remarkably increase their use, suggests Robert A. Hatcher, MD, MPH, professor of gynecology and obstetrics, Emory University, Atlanta, and chairman of the CTU editorial advisory board.
Clinicians may want to check out an article by Anna Glasier, MD, of the Department of OB/GYN at the University of Edinburgh in the Oct. 9 issue of the New England Journal of Medicine (1997; 337:1058-1064). Glasier reviews a number of research articles. She concludes that emergency contraceptive is very effective and is limited "largely by ignorance." A supporting editorial is penned by David Grimes, MD, professor and vice chairman of the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco.
In her article, Glasier notes that unwanted pregnancy is common worldwide, causing about 50 million abortions. It has been calculated that each year, the widespread use of emergency contraception in the United States could prevent more than one million abortions and two million unintended pregnancies that end in childbirth.
Do you have a question about a specific contraceptive method or procedure? Mail your question to Contraceptive Technology Update, P.O. Box 740056, Atlanta, GA 30374. Be sure to tell us how to contact you.]
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