New EC guidance explained

Guidance on emergency contraception has been updated – so what are the changes and how will they affect pharmacy services?


  • Copper IUDs remain first line for emergency contraception but, in pharmacy, oral ECs should be given to women who have had unprotected sex and don’t want to conceive, assuming they fall within the usual criteria
  • Ulipristal is first choice for women who have had unprotected sex in the five days prior to ovulation, more than three days previously, or who are overweight. It can thus be considered as first-line oral treatment in most cases
  • Levonorgestrel is preferred if the woman wants to start hormonal contraception promptly, is at risk of pregnancy because of missed pills, or is on enzyme inducing medication
  • In all cases, the usual counselling should be provided with regards to ongoing contraception and STIs

 

The Faculty of Sexual and Reproductive Healthcare (FSRH), part of the Royal College of Obstetricians and Gynaecologists (RCOG), has updated its 2012 guidance on emergency contraception (EC). This document is intended for use by healthcare professionals providing EC.

Why EC and not EHC?

Not just hormonal methods of emergency contraception are included – the copper-containing intrauterine device (Cu-IUD) remains first-line. This is because it is the most effective method of EC, the only method that is effective after ovulation has taken place, is unaffected by a woman’s body mass index or any medication she is taking, and provides immediately effective ongoing contraception.

But IUDs aren’t very popular, are they?

Long-acting reversible contraceptives, such as the Cu-IUD, have in fact been increasing in popularity over recent years, but oral contra-ceptives remain the commonest form in use. According to figures published by NHS Digital, in the year to March 31, 2016, 45 per cent of women stated that the pill was their main method of birth control.

IUDs aren’t really within the remit of community pharmacy, so why is this document relevant? For women who have had unprotected sexual intercourse and do not wish to become pregnant, and for whom Cu-IUD is inappropriate or unacceptable, oral EC should be offered. In fact, the FSRH says that if a woman is referred for an IUD, oral EC should be provided in case of delay to fitting or the woman changing her mind. Two oral EC products are available over-the-counter and on prescription, and in many places as part of a pharmacy service: ulipristal acetate (UPA-EC) and levonorgestrel (LNG-EC).

So there’s nothing new here?

Actually, there is. The FSRH favours UPA-EC over LNG-EC in many situations because it has been demonstrated to be more effective, is effective for longer after unprotected sexual intercourse (up to 120 hours) and in cases where this is likely to have taken place in the five days prior to ovulation.

In addition, UPA-EC does not appear to have reduced effectiveness in women with a body mass index in excess of 26kg/m2 or body weight over 70kg – something very pertinent given that the most recently published Health Survey for England (HSE 2015) says that 58 per cent of women have a BMI greater than “healthy” – whereas a double dose of LNG-EC would otherwise need to be taken.

Is there any point in levonorgestrel any more?

Yes. If starting hormonal contraception quickly is a priority, LNG-EC is a better choice. This is because the ability of UPA-EC to delay ovulation is reduced if a progestogen is taken in the following 120 hours. The same theoretically applies if a woman has recently taken a progestogen; for example, she needs EC because of missed pills.

Furthermore, because both UPA-EC and LNG-EC may have reduced effectiveness if the woman is also taking an enzyme inducer drug (e.g. griseofulvin, many antiepilepsy and TB medicines, and St John’s wort), a double dose of LNG-EC can be taken to compensate whereas this is outside the current licensing restrictions for UPA-EC.

Does this apply to all women?

Pretty much. The guidance applies on any day of a natural menstrual cycle (as although the risk of pregnancy is highest during the six days leading up to and including ovulation, pregnancy is theoretically possible after unprotected sexual intercourse on most days of the cycle).

Also, from day 21 after childbirth unless all criteria for lactational amenorrhoea are met (the woman gave birth less than six months previously, has had no signs of her periods returning and is providing her baby with at least 85 per cent of its feeds as breast milk); from day five after miscarriage, abortion, ectopic pregnancy or uterine evacuation; and after regular hormonal contraception has been compromised or used incorrectly.

Anything else you need to know?

The 55-page FSRH document stresses that all healthcare professionals should ensure that their EC consultations include advice about the importance of ongoing contraception; information about available contraceptive methods; checking that the woman has prompt access to her contraceptive method of choice; assessment of the patient’s risk of sexually transmitted infections plus testing or appropriate signposting; and follow-up pregnancy testing if necessary.

When will it be next updated?

According to the document, March 2022, although any major changes will presumably warrant earlier edits.

Find out more...

The guidance can be downloaded here.

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