When to resume or begin contraception post ECPs?
When to resume or begin contraception post ECPs?
You have just prescribed the selective progesterone receptor modulator emergency contraceptive pill (ECP), ulipristal acetate (ella, Watson Pharma, Morristown, NJ), to the patient sitting in front of you. What is your counsel on when to initiate hormonal birth control following use of the ECP?
A new review of existing research looks at current guidance on resuming or initiating hormonal contraception after use of ECPs, particularly ulipristal acetate.1 The drug was approved by the Food and Drug Administration in 2010 for use as an emergency contraceptive. It is unknown how administration of hormonal contraception following use of ulipristal acetate might alter the effectiveness of the emergency or hormonal contraceptive, the review notes.1
The review was conducted in preparation for the U.S. adaptation of the World Health Organization's (WHO's) Selected Practice Recommendations for Contraceptive Use. The publication is WHO's companion guidance document to its Medical Eligibility Criteria for Contraceptive Use.2 The practice recommendations provide evidence-based guidance on contraceptive management questions, such as when can women start specific contraceptive methods, what exams and tests are needed prior to starting a method, what follow-up is needed, and how various side effects can be managed, says Kathryn Curtis, PhD, an epidemiologist in the Women's Health and Fertility Branch in the Division of Reproductive Health Centers at the Centers for Disease Control and Prevention (CDC). (Review the practice recommendations at the WHO web page, http://bit.ly/z3jHlN.)
In October 2011, the CDC held a meeting to adapt the practice recommendations for use by U.S. healthcare providers, following a process similar to its adaption of the international agency's contraceptive use criteria, says Curtis, a co-author of the current review. Meeting participants examined the scientific evidence and the U.S. context to see whether and how the recommendations might be adapted for best implementation in the United States, she notes.
The U.S. group added a few new recommendations, one which will address how a woman can start regular contraception after emergency contraceptive pills, says Curtis. The current review was conducted in preparation for discussions on the recommendation at the October 2011 meeting.
"The guidance document itself, 'US Selected Practice Recommendations for Contraceptive Use, 2013,' which will contain this recommendation, is expected to be released sometime in early 2013," states Curtis.
Reviewers performed a systematic review of the literature to identify articles concerning the resumption or initiation of regular contraception within the same cycle as ECP use. Searches were conducted for articles in any language, published between 1980 and April 2012, and included all methods of ECPs available in the United States. The search strategy identified 184 articles; none met inclusion criteria.1
The package insert for ulipristal acetate advises that due to the medication's high affinity binding to the progesterone receptor, its use might reduce the contraceptive action of regular hormonal methods. Therefore, the package insert advises that a reliable barrier method of contraception be used with subsequent acts of intercourse that occur in the same menstrual cycle.1 However, the precise duration over which the drug might decrease the effectiveness of regular hormonal methods is uncertain, the review notes.1
Advice on levonorgestrel-only ECPs
How about levonorgestrel-only ECPs? Package inserts recommend that routine contraception should be continued or initiated as soon as possible following use. "Given levonorgestrel's function as a progesterone agonist, there is no similar theoretical concern for decreased effectiveness of either the levonorgestrel ECP or hormonal contraceptive methods if administered concurrently or in close succession," the reviewers note.
Guidance from the American College of Obstetricians and Gynecologists states that short-term hormonal contraceptives, such as pills, patches, and rings, may be initiated or resumed immediately with a backup barrier method or after the next menstrual period.3 Its recommendations advise that long-term hormonal methods, such as the levonorgestrel intrauterine system, progestin contraceptive implant, or depot medroxyprogesterone acetate (DMPA), be initiated or resumed after the next menstrual period, when it is clear that the woman is not pregnant.3
The current review validates clinicians' current practice of combining levonorgestrel emergency contraception with immediate Quick Start protocols, especially for DMPA and next-day start for combined hormonal methods, says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles. It leaves unanswered the new concern that coadministration of ulipristal acetate and any progestin-containing contraceptive might compromise the efficacy of each method, due to the action of the antiprogestin versus the progestin, she notes.
Providers can cope with the decrease in efficacy of the ongoing progestin-containing method by requiring 14 days of back-up method, but you should keep in mind not to do anything that could reduce the efficacy of the emergency contraceptive, says Nelson. This concept is particularly important for overweight and obese patients who might not be able to rely on levonorgestrel emergency contraception, she notes. Results of a 2011 meta-analysis of two randomized controlled trials comparing the efficacy of ulipristal acetate with levonorgestrel suggest obese women who used levonorgestrel EC were at greater risk of pregnancy.4
References
- Salcedo J, Rodriguez MI, Curtis KM, et al. When can a woman resume or initiate contraception after taking emergency contraceptive pills? A systematic review. Contraception 2012. Doi:10.1016/j.contraception.2012.08.013.
- World Health Organization. Medical Eligibility Criteria for Contraceptive Use. Fourth ed. Geneva: WHO; 2009.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol 2010; 115(5):1,100-1,109.
- 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(4):363-367.
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