Transcript Progestin-Only Emergency Contraception

Combination Oral
Contraceptives
Most popular method of reversible contraception in the U.S.
Used by over 10 million women in the U.S. and 60 million
women worldwide
Mechanism of Action (COCs)
Suppress ovulation
contraceptive
Reduce sperm transport
in fallopian tubes
contraceptive
Change endometrium
making implantation less
likely
interceptive
Thicken cervical mucus
(preventing sperm
penetration)
contraceptive
Pharmacologic Actions of Progestin and
Estrogen
Progestin
Estrogen
Ovarian and pituitary
inhibition
Ovarian and pituitary
inhibition
Thickening of
cervical mucus
Thinning of/increase
in cervical mucus
Endometrial
atrophy/transformation
Endometrial
proliferation
Cycle control
Cycle control
Characteristics of COCs
Individual product depend on three factors:
1. Estrogen dose
 Ethinyl Estradiol - found in almost all COCs
 Estradiol valerate -
 Mestranol - Only found in high-dose COCs
 Metabolized to ethinyl estradiol
 50 mcg of mestranol = 35 mcg ethinyl estradiol
 High vs Low Dose
 High-dose COCs contain >30mcg of estrogen
 Low-dose COCs contain <30 mcg of estrogen
2. Choice of progestin
3. Route of administration
Progestins in Oral Contraceptives
19-Nortestosterone
Estranes - 1st
generation
 Norethindrone
 Norethindrone
acetate
 Ethynodiol
diacetate
 Norethynodrel
Spironolactone
Gonanes
2nd generation –
most androgenic
 Levonorgestrel
 Norgestrel
3rd generation –
least androgenic
 Desogestrel
 Norgestimate
Adapted from Sulak PJ. OBG Management. 2004;Suppl:3-8.
Antimineralocorticoid
 Drospirenone
 Dienogest
Antimineralocorticoid progestins
(drosperinone and dienogest)
spironolactone analogs with antimineralcorticoid/
antiandrogenic activity
reduces fluid retention, bloating, weight gain,
irritability and anger
Need to monitor potassium during first month of
use
Caution with other medications that can cause
hyperkalemia (ACE inhibitors, NSAID)
Component of Yasmin,Yaz, Beyaz, Safyral, Natazia,
Angeliq (this product is for vasomotor symptoms)
Beyaz contains levomefolate calcium, a metabolite
of folic acid
Not all progestins are created
equal
Risk of thromboembolism?
Why?
•
Estrogen promotes clotting factors
•
Patch may increase overall exposure to estrogen –
constant dose rather than peak and trough
•
Ring may significantly increase sex hormone binding
globulin that can increase risk of thrombosis
Progestin
Risk of VT
non-user
2-3 per 10,000
LNG-IUS
may benefit
etonorgestrel implant
1.7 per 10,000
older progestin
6 per 10,000
etonorgestrel (ring)
8 per 10,000
Product Label
Lists related CIs
drosperinone
10-15 per 10,000
Yes
norelgestromin (patch)
10-15 per 10,000
Yes
pregnancy
10 per 10,000
post-partum
50 per 10,000
• Rate of TE higher during 1st year of use with some products
• Consider low-dose estrogen/older progestin products or LNG-IUS to ↓ risk of
thrombosis
• For women at ↑ risk of TE consider IUD or other estrogen-free product
• >35 yrs, hx of VTE, severe HT, hypercoagulopathy
Androgenic properties of COCs
 Adverse effects include:
 Hirsutism
 Acne
 Weight Gain
 Two ways to decrease unwanted androgenic
effects:
 Choose progestin with lower androgenic
properties
 Increase estrogen, increases SHBG and
decreases unbound testosterone
Phasic Formulations of COCs
 Purpose – ↓ dose-dependent ADRs of progestins
 Monophasic - Fixed amt of progestin + estrogen X 21 days
 Biphasic - Fixed estrogen X 21 days; ↑ed progestin:estrogen
ratio in 2nd half
 Triphasic - Estrogen the same, progestin changes; or dose of
both changes
 Four phasic - Estrogen ↑s, progestin ↓s
 A Cochrane review found:
 Choice of progestin is more important than phasic formulation
Serious Adverse Effects of COCs
Primarily due to estrogen content
Serious ADRs
Abdominal Pain – gallbladder disease, VTE
Chest Pain - MI
Headaches – stroke, hypertension, migraine
Eye Problems – stroke, hypertension, vascular problems
Severe Leg Pain –VTE in legs
 VTE most common cardiovascular event among COC users (e.g.
PE, DVT)
 Risk is estimated at one case/10,000 women
 Risk increases for smokers (especially >35 yo), hypertensive
patients or those who take estrogen products >35mcg
Cases per 100,000 Woman-Years
Cardiovascular Mortality Risk with Smoking and
Combination Oral Contraceptive Use
Oral contraceptive nonuser
Oral contraceptive user
30
25
20
15
10
5
0
Attributable
Risk/100,000
User-Years
Nonsmoker
Smoker
0.06
1.73
< 35 years of age
Nonsmoker
Smoker
3.03
19.4
≥ 35 years of age
Oral Contraceptives and Breast Cancer
Risk
 large epidemiologic study suggests that OCs do not cause
breast cancer
 Breast cancer risk in women who have not taken OCs for
≥10 years is the same as those who have never used them
 Tumors are more likely to be localized in oral
contraceptive users than in nonusers
 Recommendation:
 Family history of breast cancer or history of benign breast
disease: All forms of contraception are acceptable.
 Current or past history of breast cancer: Copper IUD
preferred. The theoretical and proven risks with all
hormonal forms of contraception are unacceptable.
Who should not take COCs?





High risk of VTEs
> 35 yrs with obesity or smoker
Newly breastfeeding
Estrogen-related cancers
hypertensive:
 Systolic >160mm Hg or diastolic > 100mm Hg, or
uncontrolled
 Migraine with aura
 Patient has ed risk of stroke
 Without aura or menstrual migraine is okay
 See handout “Contraception for Women with Chronic Medical
Conditions”
Factors that Increase Risk of
Breakthrough Bleeding
 beginning a new form of hormonal contraception
 For adolescents, breakthrough bleeding may discourage
continued use
 inconsistent use or missed doses
 chlamydial cervicitis and/or endometritis
 likely cause when breakthrough bleeding appears several
months after initiating an OC regimen
 Smoking
 possibly due to fluctuations in estrogen levels
Controlling breakthrough bleeding
 Usually occurs during first 3 months
 More common with low dose pills
 If problem continues after 3 months:
  estrogen if current product has <30mcg
 Change progestin to one with more estrogenic effect
 If patient is taking a progestin only pill or a multi-phasic pill,  progestin dose
 If patient has amenorrhea
 Always rule out pregnancy
 Often caused by insufficient estrogen to stimulate growth
of endometrium
Drug-Drug Interactions
Which ones are significant?
 Drugs that may decrease COC
enterohepatic circulation
 Ampicillin, tetracycline, sulfa
 Drugs that induce COC metabolism
 Carbamazepine
 Phenytoin
 Phenobarbital
 Primidone
 Ethosuximide
 Rifampin
Cause spotting or
breakthrough bleeding
Extended Cycle Products
 Shortens or eliminates hormone-free days
 consecutive days of hormone therapy extend to 84
or 365 days
 Can use monophasic pills to achieve this regimen
 Initially may cause intermenstrual bleeding and
spotting
 First three months
Reasons for switching to extended cycle
products
 decrease menstrual-related symptoms experienced by
women during the HFI
 Dysmenorrhea, endometriosis, menorrhagia, PMS,
PMDD
 improve efficacy in women who forget to restart the pill
 patient preference to decrease the frequency of menstruallike bleeding
 Also perimenopausal women, athletes, military women,
developmentally delayed women, adolescents
Examples - Extended Cycle Products
 84/7 regimens - Seasonale , Jolessa, Quasense
 30µg EE + LNG 0.15mg
 Seasonique
- 84 tab 30µg EE/0.15mg LNG, 7 tabs of 10µg EE
 24/4 regimens – Yaz, Beyaz
 20µg EE+ 3 mg drospirenone
 24/2/2 regimen - Lo Loestrin
 24 tab containing 10µg EE+ 1mg norethindrone acetate followed by 2 tab
containing 10µg EE followed by 2 placebo tab
 42/21/21/7 – Quartette
 LNG 0.15mg X 84 days with 20µg EE X 42 days, 25µg EE X 21 days, 30µg EE
X 21 days; then 10µg EE X 7 days
 Continuous regimen - Amethyst
 20µg EE+ 90µg LNG – no days off
EE = ethinyl estradiol; LNG = levonorgestrel
Why is efficacy decreased in lower dose
products?
 Less “forgiving” if doses are missed
 Drug interactions are more likely
 Body weight
 Reduced efficacy
 Recommendation
 Consider OC with 30-35mcg estradiol in obese women
 Due to risk of thrombosis, consider extended cycle
instead of higher dose
 Don’t use 50mcg due to risk of VTE
Starting COCs
Method
First Day Start
Sunday Start
Today Start
Description
First active pill is taken on
first day of menses
First active pill taken
Sunday after period
STARTS
First active pill taken day of
doctor visit regardless of
timing of menses if urine
pregnancy test is negative
BTB = Breakthrough bleeding
Advantages
•
Immediate Protection

Less BTB
•
Most packs set up for
Sunday start

Weekends free from period
•
Motivated pts can start
pills right away
Disadvantages
•
Pts with irregular cycles or
amenorrhea may have to
wait several weeks-months
to start
•
Forgetting to start when
Sunday comes several days
after periods ends

Back up protection
required for patch 7 days
•
More likely to have BTB

Must use back-up method
for 2 weeks if begun midcycle

Confusion using packs
Counseling Points for COCs
 Remind patient COC ≠ protection against STDs
 Discuss common side effects and warning signs for
ACHES
 Some side effects may decrease over time,
recommend at least 3 month trial of new COCs
 Missed pills:
 1 missed/late pill = Take ASAP, even double up
 2 missed pills = Take 2 pills on day remembered, then 2
pills the next day. Use back up method for 7 days
 3+ missed pills = Use back up method and call
physician
Noncontraceptive Benefits
of Oral Contraceptives
 Improvement of
cycle-related
conditions:
 Acne
 Irregular menstrual
cycles
 Dysmenorrhea
 Menorrhagia
 Anemia
 Functional ovarian cysts
 Protective against cancer
of certain organs:
 Ovary
 Endometrium
 Colon and rectum
Wallach M, et al., eds. Modern Oral Contraception: Updates from The
Contraception Report. Emron, 2000.
Indications for COC other than
contraception
 PCOS - regulate menstrual cycles in women who don't want
to get pregnant. COCs also help decrease androgen levels
 Endometriosis
 Acne
 Peri-menopause
Use of COCs in perimenopausal women
 Controls vasomotor symptoms and DUB while providing
contraception
 May increase BMD and decrease risk of ovarian and endometrial
cancer
 Extended cycle products may prevent hot flashes during HFI
 Can be used in healthy nonsmokers >35 yo
 Can continue use until age 55*
 Remember that patch, vaginal ring, drosperinone-containing or
desogestrel-containing products may have ↑ed risk of VTE than other
estrogen-containing products
 Consider implant or LNG-IUS rather than Depo Provera in women
who are not candidates for estrogen-containing products
*If no risk factors
Why is failure rate for COCs so much
higher than the ideal?
 Noncompliance (~15%)
 forgetfulness, didn’t refill, away from home
 Women discontinue the pill because:
 Side effects (46%) - Bleeding irregularities, nausea, weight gain,
mood changes, breast tenderness, headaches
 No further need (23%) - pregnant or relationship ended
 Method-related (14%) - hard to use, concern over hormones,
expense
 61% of COC users who discontinue without use of another
method or substitute a less effective method get pregnant
 Most women who d/c COCs do so in the first 2 months
 ~50% did not consult a healthcare provider
Am J Obstet Gynecol, Vol. 179, Rosenberg MJ, Waugh MS, Oral contraceptive discontinuation: A prospective evaluation of frequency
and reasons. 577-582, 1998.
Vaginal Contraceptive Ring
4 mm
54 mm
Why Vaginal Contraception?
 Similar efficacy and ADRS to COCs
 Higher compliance rates
 Continuous release; constant hormone levels
 Low ethinyl estradiol dose
 Avoids GI interference with absorption
 Avoids hepatic first-pass metabolism of the
progestin
 No GI interaction with antibiotics
Veres S, Miller L , Burington B. Obstet Gynecol. 2004;104:555– 63.
Slide Source:
ContraceptionOnline
www.contraceptiononline.org
Vaginal Contraceptive Ring: Administration
 Vinyl, polymer ring
 Continuous delivery of EE 15µg + etonorgestrel 120µg
 Flexible, easy to insert/remove
 Begin within 5days of onset of menses
 Wear for 3 weeks, followed by a drug-free week
What to Do if the Vaginal Ring…?
…slips out or is left out
 Expulsion occurs at least once in 1:4 users
 Within 3 hours, rinse and re-insert
 After 3 hours, rinse and re-insert AND use
a back-up contraceptive for one week
…is not replaced at day 8
 Consider emergency contraception
 Rule out pregnancy
 Insert new ring
 Use a back-up contraceptive for one week
Slide Source:
ContraceptionOnline
www.contraceptiononline.org
Transdermal
Contraceptive Patch
Slide Source:
Contraception Online
www.contraceptiononline.org
Ortho Evra Patch
 Matrix system with 3 layers
 6mg norelgestromin (active metabolite of norgestimate)
and 0.75mg EE
 Apply to buttocks, upper outer arm, lower abdomen, or the
upper torso (excluding the breast)
 Don’t cut or flush down toilet
Transdermal Contraceptive Patch
Advantages
Disadvantages
 Weekly application encourages
 Application site reactions
compliance
 Verification of presence
reassures user of protection
 No
1st
pass effect
 Contraceptive effects -rapidly
reversible
 Excellent cycle control after 3
months
 Less effective >198 lbs
 ADRs similar to COCs except:
- ↑ breast pain X first 2 months
- ↑ dysmenorrhea
 ↑ total estrogen exposure (peak
blood level 25% of COC)
 May be difficult to conceal
 No protection against STDs
Ortho Evra – change to label (2008)
Patch users at ↑risk for VTE than COC users
 Women with risk factors for VTE should consider
use of nonhormonal contraceptives
 >35 years of age
 smoking
 obesity
 < 4 weeks post-partum
 4 weeks prior to surgery and 2 weeks after surgery
 Bed rest
 Personal or family history of heart attack, stroke or DVT
http://www.fda.gov/medwatch/safety/2008/safety08.htm#orthoevrapatch
Progestin-Only Oral Contraceptives
Minipills, The Shot, Implant, IUS
Progestin-Only Contraceptives Available
in U.S.
 Oral
 Norethindrone (350 µg; Micronor, NorQD –




generics)
Emergency contraception
 Levonorgestrel (two doses of 750 µg or 1 dose of
1.5mg)
DepoProvera – injectable
Nexplanon - implant
Mirena, Skyla, Liletta - IUS
Pharmacologic Effects of Progestins as
Contraceptives
Inhibit ovulation by
GnRH
suppressing function of the
hypothalamic-pituitaryovarian axis
Modify midcycle surges of
luteinizing hormone (LH)
and follicle-stimulating
hormone (FSH)
LH, FSH
Diminish ovarian hormone
production
Produce endometrial
changes unfavorable for
ovum implantation
Thicken cervical mucus to
impede sperm transit
Inhibit sperm action
GnRH = gonadotropin-releasing hormone
Candidates for Progestin-Only Oral
Contraceptives
 Women with contraindications for combination
hormonal contraceptives, including a history of:
 Venous thrombosis
 Vascular disease
 Hypertension
 Smoking (>35 years)
 Lactating women
 Women preferring no estrogen or these dosage
forms
Progestin-Only Pills
 Advantages
 Decreased menstrual blood loss (amenorrhea 10%)
 Avoids estrogen-related side effects
 May be started immediately post-partum, after
miscarriage or abortion
 Disadvantages
 Irregular bleeding
 Must be taken same time every day; no missed days
 Patient may still ovulate with typical use
 Less effective than COCs with typical use (95-99%)
Contraceptive Implant
Nexplanon
 Single-rod implant contains 68 mg etonogestrel
 Also contains barium sulfate to make it radiopaque
 Duration of use: 3 years
 >99% effective
 MOA
 Suppresses ovulation within 1 day of insertion
 Ovulation in <5% of users after 30 months of use
 Increases viscosity of the cervical mucous
 Rapid return of fertility - menstruation within 3 months
 Appropriate for lactating women - 4th postpartum week
 Requires clinician visit for insertion and removal
 Does not protect against STDs
Adverse Effects of Nexplanon
 Most common – changes in menstrual bleeding
 Longer or shorter bleeding, spotting, change in length
of time between periods
 Adverse events
 Acne
 Mood swings
 Headache
 Weight gain
 Depression
 Implant site - mild pain of short duration
 $400-800
Injectable Contraceptive
Depot-Medroxyprogesterone Acetate
 Depo-Provera - 150 mg DMPA deep IM
injection; gluteal or deltoid muscle
 Depo-subQ Provera 104 - 104 mg DMPA
SC injection; anterior thigh or abdomen
 Duration of protection: 3 months (13 weeks)
 MOA
 Inhibits ovulation
 Thickens cervical mucus
 Endometrial atrophy
DMPA = depot-medroxyprogesterone acetate
Slide Source:
Contraception Online
www.contraceptiononline.org
Depo Provera
Advantages
 Continuous protection X 3
mo
 No estrogen
 No adverse effects seen
among lactating women
 ↓ risk VTE compared to
estrogen
 Minimal drug-drug
interactions
 Reduction of menstrual
bleeding and lower risk of
anemia
Disadvantages
 Bleeding irregularity and
amenorrhea
 Weight gain (>2 kg) common
 Depression
 ↓bone density
 ADRs continue approximately 6 -
8 mos after last injection
 Return to fertility up to 6-12 mos
 MD visit every 11-13 weeks
 Changes in lipid profile
 No protection against HIV,
other STDs
Injectable Depot-Medroxyprogesterone Acetate:
Food and Drug Administration Black Box Warning
November 17, 2004:
Women who use Depo-Provera Contraceptive Injection may
lose significant bone mineral density. Bone loss is greater with
increasing duration of use and may not be completely
reversible.
It is unknown if use of Depo-Provera Contraceptive Injection
during adolescence or early adulthood, a critical period of
bone accretion, will reduce bone mass and increase the risk of
osteoporotic fracture in later life.
Depo-Provera Contraceptive Injection should be used as a
long-term birth control method (e.g., longer than 2 years)
only if other birth control methods are inadequate.
Depo Provera: Management of Prolonged
Spotting or Moderate Bleeding
 Reassure patient - irregular and prolonged bleeding
episodes are common during first 3 - 6 months
 Consider short-term management:
 Combined oral contraceptive for one cycle
 Ibuprofen (up to 600 mg 3 times/day for 5 days)
 Other forms of exogenous estrogen for 5 days
 Explain that irregular bleeding may recur
 Assess for nonhormonal causes (cervicitis, sexually
transmitted infections, uterine pathology)
Depo Provera : Noncontraceptive Benefits
 Amenorrhea in 25 - 50% of women at one year
 ↓ menstrual cramps, pain, mood changes,
headaches, breast tenderness, and nausea
 ↓ risk of ovarian cancer
 ↓ risk of pelvic inflammatory disease
 ↓ pain associated with ovulation and
endometriosis
Timing of Depo Provera Injection
 Initial injection:
 On day 1 to 5 of menstrual cycle
 Within first 5 days of the postpartum period if not
breastfeeding
 After the 6th postpartum week if breastfeeding
 Immediately or within first 7 days after abortion
 Reinjection (week 11 to 13):
 If injection is missed or late (+14 weeks), back-up
contraception should be used and absence of pregnancy
should be confirmed
Emergency Contraception
widespread use of emergency
contraception could prevent 1
million abortions and 2 million
unintended pregnancies each year
in the United States
What is Emergency Contraception?
“Therapy used to prevent pregnancy after an
unprotected or inadequately protected act of sexual
intercourse.” ACOG
 Not just “morning-after pill” – hormonal EC can be
given up to 72 hours (or 120 hrs) after unprotected
intercourse
 Oral contraceptive formulations
®
 Plan B and Ella
 Mifepristone (off label, <120 hrs after unprotected sex)
 Copper IUD (up to 5 days after ovulation)
Emergency Contraception:
Indications
 Intercourse within past 72 hours (or 5 days) without
contraceptive protection (independent of time in the
menstrual cycle)
 Contraceptive mishap
 Barrier method dislodgment/breakage
 Expulsion of IUD
 Missed oral contraceptive pills
 Error in practicing coitus interruptus
 Sexual assault
 Exposure to teratogens (e.g., cytotoxic drugs)
Yuzpe Regimen:
Oral Contraceptive Formulations
Brand Name
Pills/Dose
EE
µg/Dose
Levonorgestrel
mg/Dose
Ovral
Alesse
2 white
5 pink
100
100
0.50
0.50
Levlite
5 pink
100
0.50
Nordette
Levlen
Levora
Lo/Ovral
Triphasil
Tri-Levlen
Trivora
4 light orange
4 light orange
4 white
4 white
4 yellow
4 yellow
4 pink
120
120
120
120
120
120
120
0.60
0.60
0.60
0.60
0.50
0.50
0.50
EE = ethinyl estradiol
Yuzpe regimen = ethinyl estradiol + levonorgestrel
Yuzpe Regimen
 In a meta-analysis of 8 studies,Yuzpe resulted in an
estimated 75% ↓ in number of pregnancies
 Side effects
 Nausea (50%)
 Vomiting (20%)
 Heavy menses/breast tenderness
 Antiemetic 1 hr before first dose ↓s nausea and vomiting
 Menses occurs within 3 weeks in up to 98% of women
 No evidence of teratogenicity (based on COC data)
Progestin-Only Emergency Contraception
 Single dose of 1.5 mg levonorgestrel appears as effective and
causes similar ADRs as traditional two-dose levonorgestrel.
 Unlabeled equivalent
 20 pills/dose of Ovrette taken 12 hours apart
 More effective/fewer side effects than Yuzpe
 MOA: primarily prevents ovulation and fertilization; does not
disrupt events that occur after implantation.
 Recent evidence suggests that there is no interceptive action*
 Only contraindication – known pregnancy
* Noe G, Croxatto HB, Salvaiterra AM, et al. Contraceptive efficacy of emergency contraception with levonorgestrel given before or after ovulation. Contraception 2010;81:414–20.
Durand M, del Carmen Cravioto M, Raymond EG, et al. On the mechanisms of action of short term levonorgestrel administration in emergency contraception. Contraception
2001;64:227–34.
Plan B One-Step and Next Choice
 Plan B One-Step, Next Choice One Dose
 Single dose version – one 1.5mg
levonorgestrel (LNG) tablet
 Next Choice
 Two 0.75mg LNG tablets
 Can take both tablets in one dose
 Available over the counter to female or males of any age
Patient Counseling for EC
 How to take medication (provide written instructions )
 Take ASAP
 Expected side effects (nausea/vomiting/cramping)
 Use antiemetic one hr before the 1st dose if Yuzpe regimen
 If patient vomits tablet in 3 hrs, repeat dose
 Enzyme inducers – rifampin, phenytoin may ↓ effectiveness
 Expected menses >98% bleed within 21 days of EC
 If period does not occur after 3 weeks, rule out pregnancy
 Remind patient that EC does not prevent STDs
 Do not use EC as a regular means of contraception; seek
another more efficacious method
Ella (ulipristal) - Rx only EC
 Can be used up to 5 days post-coitus - One 30mg tablet
 Progesterone receptor modulator
 May delay ovulation or inhibit follicular development
 Phase III study data
 If vomiting occurs within 3 hrs, repeat dose
 Comparative study with LNG
halved pregnancy risk of LNG products if taken <72hrs
risk reduced by almost 2/3 if taken within 24 hrs
H/A (19%), dysmenorrhea (13 /14%), nausea (13 / 11%),
abdominal pain (5 /7%), dizziness (5%), fatigue (6/ 4%)
 Disruption of menstrual bleeding common – ~2 days
Ella (ulipristal)
 Safety appears similar to LNG
 Estimated cost = $50
 Recommended for EC between 72 -120 hrs after
unprotected sex
 Investigational for treatment of symptomatic uterine
fibroids, endometriosis , breast cancer
 Somewhat controversial
 MOA similar to mifepristone (Mifiprex)
 Could interfere with hormonal contraceptives in same
cycle
 Effectiveness may be  by drugs that induce CYP 3A4
(anticonvulsants, rifampin, St John’s wort, etc)
Emergency Contraception in Obese
women
 For women who weigh >154 pounds, levonorgestrel may not
work as well
 Ulipristal seems to be less effective in women who weigh
over 187 pounds
 However, this doesn't mean that overweight women
shouldn't use these products, especially if they are the only
options available
Copper IUD for EC
 Estimated failure rate  0.1% (n=8,400) – most effective
 Mechanism(s) of action
 Impairs fertilization
 Alters sperm motility and integrity
 Impairs implantation
 Indications:
 Unprotected intercourse
 Need/desire for long-term contraception
 May insert <5 days after earliest estimated ovulation
 Contraindications - Pregnancy or sexual assault with high
risk of STD
 May be difficult to have it placed within 5 days
Approval of OTC use of oral
contraceptives
 Oregon law went into effect 1/1/16
 California law soon to be in effect
 http://www.oregon.gov/pharmacy/Pages/ContraceptivePr
escribing.aspx#Tool-Kit_Resources
Resources: Emergency Contraception
 Hotlines
 1-888-NOT-2-Late or 1-800-584-9911
 Web Sites
 The Emergency Contraception Website—http://www.NOT-2-
Late.com
 Consortium for Emergency Contraception—
http://www.cecinfo.org/
 American College of Obstetricians and Gynecologists—
http://www.acog.org
 National Women's Health Information Center Emergency
Contraception Information—
http://www.4woman.gov/faq/econtracep.htm