A commentary on ACOG Practice Bulletin Number 152: Emergency Contraception by Paula J Adams Hillard, MD
COMMITTEE ON PRACTICE BULLETINS-GYNECOLOGY
ACOG Practice Bulletin No. 152: Emergency contraception. September 2015. American College of Obstet Gynecol 2015;126:e1-11. Full text of ACOG Practice Bulletins is available to ACOG members at www.acog.org/Resource-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Emergency-Contraception.
Emergency Contraception Emergency contraception, also known as postcoital contraception, is therapy used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. Common indications for emergency contraception include contraceptive failure (eg, condom breakage or missed doses of oral contraceptives) and failure to use any form of contraception (1-3). Although oral emergency contraception was first described in the medical literature in the 1960s, the U.S. Food and Drug Administration (FDA) approved the first dedicated product for emergency contraception in 1998. Since then, several new products have been introduced. Methods of emergency contraception include oral administration of combined estrogen-progestin, progestin only, or selective progesterone receptor modulators and insertion of a copper intrauterine device (IUD). Many women are unaware of the existence of emergency contraception, misunderstand its use and safety, or do not use it when a need arises (4-6). The purpose of this Practice Bulletin is to review the evidence for the efficacy and safety of available methods of emergency contraception and to increase awareness of these methods among obstetrician-gynecologists and other gynecologic providers.
Used with permission. Copyright the American College of Obstetricians and Gynecologists
Evolution of emergency contraception
by Paula J Adams Hillard, MD
Paula J Adams Hillard, MD, is professor, Department of Obstetrics and Gynecology, and Chief, Division of Gynecologic Specialties, Stanford University School of Medicine, Stanford, CA.
Practice Bulletin #152 details the scientific evidence for the efficacy and safety of emergency contraception (EC), and makes a cogent case for promoting greater awareness of the current options for preventing unintended pregnancies.1 The Bulletin comes at the end of a long saga leading from studies of EC in the 1960s, to the first published combined estrogen-progestin oral contraceptive pill regimen (called the “Yuzpe regimen”) in 1974, to the US Food and Drug Administration (FDA) approval of a dedicated product for EC in 1998, to the lifting of age restrictions for an over-the counter (OTC) levonorgestrel product in 2013. In addition, the Bulletin presents evidence for the efficacy of the copper intrauterine device (IUD) and selective progesterone receptor modulators (SPRM) for EC.
Contemporary OB/GYN Editorial Board members have participated in the march toward the current status of EC. Dr Charles Lockwood was a member of the FDA advisory panel that, in 2003, voted unanimously that “Plan B” EC was safe for OTC use. It was then a number of years before the FDA approved OTC EC, initially with a controversial age restriction; the Secretary of the Department of Health and Human Services made the statement that more research was needed on the effects of EC on young girls. My own reaction was that any theoretical concerns about potential adverse effects on young adolescents had to be weighed against the very well-established adverse effects of pregnancy on young girls. Subsequently I was privileged to be on the US FDA advisory panel that recommended approval of the SPRM ulipristal for EC in 2010. It was not until 2014 that legal appeals ultimately resulted in FDA approval of generic one-pill EC for unrestricted sale on the shelf.
It is important to point out that EC does not interrupt an established pregnancy.2 The ACOG Bulletin cites the difference between EC and medical abortion, noting that EC is ineffective after implantation.
The Practice Bulletin provides clinically relevant details about the various options for EC, including efficacy, details of prescribing, method of action, short-term adverse effects, and the absence of serious complications or effects on pregnancy. This information is useful for clinicians.
The Bulletin also notes that the availability of EC has not been shown to encourage risky sexual behavior.3 Surveys have repeatedly documented barriers to the use of EC, including the fact that many women are unaware of the availability of EC, many clinicians do not recommend it (particularly to sexually active adolescents), and access to EC is limited at many pharmacies, student health centers, urgent care centers, and emergency departments. A detailed description of clinical recommendations notes that there are no medical conditions for which the risks of EC outweigh the benefits; that no clinical exams or pregnancy testing is necessary before provision of EC; that the optimal timing of EC is as soon as possible after unprotected or inadequately protected intercourse, and depends on the specific method, but that some studies support efficacy of copper IUD insertion up to 10 days; that efficacy is greatest for the copper IUD, with ulipristal providing greater efficacy than levonorgestrel oral regimens, which in turn provide greater effectiveness and less nausea/vomiting than combined estrogen-progestin regimens.
One finding that may be relatively new to practicing clinicians is that body weight influences the effectiveness of oral EC regimens; levonorgestrel EC may be less effective in overweight or obese women, and ulipristal may be less effective in obese women. While the effectiveness of the copper IUD is not affected by body weight and its high rates of effectiveness should encourage clinicians to promote its use in all women, oral regimens should not be withheld from obese women, and data are not available to indicate a threshold weight.
Other important messages about EC include the recommendation that clinicians educate women about the availability of EC in advance of need. Including information about EC with our counseling about contraception should be a routine component of our office practices. With that practice, we can potentially help more women avoid an unintended pregnancy.
ACOG Abstract References
1. Lete I, Cabero L, Alvarez D, Olle C. Observational study on the use of emergency contraception in Spain: results of a national survey. Eur J Contracept Reprod HealthCare 2003;8:203-9. (Level II-2)
2. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women’s sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004;17:87-96. (Level II)
3. Harvey SM, Beckman LJ, Sherman C, Petitti D. Women’s experience and satisfaction with emergency contraception. Fam Plann Perspect 1999;31:237,40,260 (Level III)
4. Baldwin SB, Solorio R, Washington DL, Yu H, Huang YC, Brown ER. Who is using emergency contraception? Awareness and use of emergency contraception among California women and teens. Womens Health Issues 2008;18:360-8. (Level II-3)
5. Chuang CH, Freund KM. Emergency contraception knowledge among women in a Boston community. Massachusetts Emergency Contraception Network. Contraception 2005;71:157-60. (Level II-3)
6. Aiken AM, Gold MA, Parker AM. Changes in young women’s awareness, attitudes, and perceived barriers to using emergency contraception. J Pediatr Adolesc Gynecol 2005;18:25-32. (Level II-3)
1. Practice Bulletin Summary No. 152: Emergency Contraception. Obstet Gynecol. 2015;126(3):685-686.
2. Gold RB. The implications of defining when a woman is pregnant. The Guttmacher Report on Public Policy. The Guttmacher Institute. 2005;8(2).
3. Rodriguez MI, et al. Advance supply of emergency contraception: a systematic review. Contraception. 2015;87(5):590-601.