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Family Planning Module: 10. Emergency Contraception (EC)

Study Session 10  Emergency Contraception (EC)

Introduction

Sometimes sexual intercourse takes place without the intention of the woman and she is then at risk of becoming pregnant. In many developing countries, including Ethiopia, many pregnancies are unintended and unwanted, despite there being highly effective and safe methods of contraception. These unintended or unwanted pregnancies may carry a higher risk of morbidity and mortality for women, often due to the risk of unsafe abortions. Many of these unplanned pregnancies could have been avoided by using emergency contraception. It is a fact that emergency contraception can help women by providing the last opportunity to prevent pregnancy after unprotected sex.

In this study session, you will learn about the definitions, types and mechanism of action, effectiveness, advantages and disadvantages, precautions, side effects, and management of side effects, in relation to emergency contraception (EC).

Learning Outcomes for Study Session 10

When you have studied this session, you should be able to:

10.1  Define and use correctly all of the key words printed in bold. (SAQ 10.1 and 10.2)

10.2  Describe the types, effectiveness and precautions of emergency contraception (EC). (SAQs 10.2, 10.3, 10.6 and 10.7)

10.3  Describe the advantages and disadvantages of EC. (SAQs 10.3 and 10.6)

10.4  Explain the management of common side-effects of EC. (SAQs 10.5 and 10.7)

10.1  Definition of emergency contraception (EC)

A girl sits on the floor sobbing.
Fig 10.1  I had sex, but the condom broke. What shall I do?

Emergency contraception (EC) is a method used to prevent unwanted pregnancy, and is usually effective up to five days following unprotected sexual intercourse. Unprotected sexual intercourse means that either the woman did not use any contraceptive method to prevent pregnancy, or the birth control method failed (for example, a condom broke, Figure 10.1). The use of emergency contraception should be the last option for a woman who has experienced accidental and unprotected sexual intercourse, or whose birth control method has failed, or for whom abortion is not acceptable or accessible.

Emergency contraception can involve the use of either hormonal pills, or a copper-bearing intrauterine contraceptive device (IUCD). However, neither method is a substitute for the correct use of other regular contraceptives. See Box 10.1 for a summary of situations where emergency contraception can be appropriate.

Emergency contraception can prevent 95% of expected pregnancies, providing it takes place within the first 24 hours after intercourse.

Box 10.1  Situations when emergency contraception is appropriate

Emergency contraception can be appropriate:

  • in cases where the woman has not used contraception
  • in cases where sex has been forced or coerced, or the woman has been raped
  • when a woman must deal with a contraceptive mistake, such as a condom breaking or used incorrectly, an IUCD dislodging, a diaphragm removed too early, or the man failing to withdraw before ejaculation.

10.2  Types of emergency contraception

In an emergency situation there are two major types of emergency contraceptive methods available:

  • Hormonal methods, known as emergency contraceptive pills (ECPs)
  • Copper-bearing intrauterine contraceptive devices (IUCDs).

10.2.1  Emergency contraceptive pills

Be aware that this contraceptive method is not for regular use, but intended only for emergency situations.

Emergency contraceptive pills (ECPs) are hormonal methods of contraception that can be used to prevent pregnancy following unprotected sexual intercourse. Some women call this method ‘morning-after pills’or ‘post-coital pills’.

ECPs contain the same concentrated dose of hormones found in daily contraceptive pills. You will remember from your study session on oral contraceptives that these comprise combined pills containing oestrogen and progesterone, and pills containing progesterone only.

The exact mechanism by which emergency contraceptive pills prevent pregnancy is not completely understood. But the principles behind the mechanism of action are summarised in Box 10.2.

Box 10.2  Mechanism of action of emergency contraceptive pills

Emergency contraceptive pills work in a number of different ways:

  • If the ovaries have not yet released an egg (ovulation), they can stop or slow down this process (called the suppression of ovulation).
  • If an egg has already been released, they can stop sperm from fertilising it by thickening the cervical mucus to make it difficult for sperm penetration.
  • If an egg has already been released and been fertilised, they can prevent it from implanting in the uterus wall by thinning the endometrial lining of the uterus.

If a woman is already pregnant when she uses ECPs, they will not cause an abortion, or any disruption to the fertilised egg, once implantation has taken place. So they do not affect an existing pregnancy.

Women who take ECPs should understand that they could still become pregnant the next time they have sex, unless they immediately start using another method of contraception. This is because ECPs delay ovulation in some women, so they may be at their most fertile soon after taking ECPs. You should therefore advise women that they use condoms until the beginning of their next menstrual period. For ongoing protection from pregnancy, they must start using another contraceptive method at once.

Combined emergency contraceptive pills

Combined emergency contraceptive pills are formulations of oestrogen (commonly ethinyl estradiol) and progesterone (commonly levonorgestrel or norgestrel). There are two common types of combined emergency contraceptives available in Ethiopia, and it is recommended that they be taken within five days following unprotected sexual intercourse.

µg means ‘microgram’.

  1. The Neogynone pill contains 50 µg ethinyl estradiol and 0.5 mg norgestrel. You give two pills as the first dose as soon as convenient within five days (120 hours) after unprotected sexual intercourse. The second dose of the two pills should be after 12 hours. This is a total of four pills within a 12-hour period.
  2. The Eugynon pill contains 30 µg ethinyl estradiol and 0.3 mg norgestrel. You give four pills as the first dose within five days (120 hours) after unprotected sexual intercourse, and another four pills after 12 hours as a second dose. This is a total of eight pills within a 12 hour interval.
Progestin-only pills

The progestin-only or levonorgestrel pill has less effect than the combined one, but has fewer side-effects. The timing of the pill is the same as above.

  1. The Postinor pill contains 0.75 mg levonorgestrel. You give one pill as a first dose within five days (120 hours) of unprotected sexual intercourse, and the second dose of one pill should be repeated 12 hours after the first dose.
  2. If the only pill available is Microlut or Norgeston, which only contain 0.03 mg Levonorgestrel, then give 20 pills for the first and the second dose, each dose 12 hours apart, so a total of 40 pills are needed.
Effectiveness and precautions

The effectiveness of emergency contraceptive pills is dependent on the time taken after incidental unprotected sexual intercourse. If the client takes emergency contraception within five days (120 hours) of unprotected sexual intercourse, it can be as effective as 75% to 89% (WHO, 2007).

This range indicates to you that the sooner you give the pills to your client the better chance they have of preventing pregnancy. The pills work most effectively if started immediately after unprotected sexual intercourse, and work even more effectively if unprotected sex happened during the infertile days of the woman’s menstrual cycle.

  • Can a woman still get pregnant after taking emergency contraceptive pills?

  • Yes, this method may fail to prevent pregnancy in the following situations:

    • If the fertilised egg has already implanted in the uterus, because hormonal ECPs do not cause abortion.
    • If too much time has passed since unprotected sexual intercourse.
    • Because of the failure of the pill itself, as no method is 100% effective under all circumstances.

If the client has used emergency contraceptive pills and has not menstruated for a week or more after the expected date of menstrual bleeding, she may be pregnant. You should refer her for a pregnancy test to confirm the pregnancy. If the client is pregnant, you can explain to her the available options, and ask her to decide on the most appropriate option for her situation. If the client chooses to continue with the pregnancy, you can reassure her that emergency contraceptive pills will not have harmed the fetus.

10.2.2  Intrauterine contraceptive devices (IUCDs)

A copper-bearing IUCD can be used within five days of unprotected sexual intercourse as an emergency contraceptive. If you remember from Study Session 4 on Natural Family Planning (NFP) methods, in a woman’s normal menstrual cycle ovulation occurs on the 14th day before the next menstrual bleeding. So an IUCD can be inserted within five days of unprotected sexual intercourse, provided it is after the earliest calculated day of ovulation (e.g. up to day 19 in the case of a 28-day cycle). Implantation may occur 6–12 days after ovulation. Therefore, inserting an IUCD would be effective in making implantation difficult, but would not cause the abortion of an existing implanted fetus.

Box 10.3  Mechanism of action of copper-bearing IUCD for emergency contraception

Based on evidence from a number of studies, copper-bearing IUCDs prevent pregnancy by:

  • interfering with fertilisation, by stopping the sperm from fertilising the egg.
  • decreasing the number of sperm reaching the uterine tube and interfering with their motility.
  • preventing the fertilised egg from implanting in the uterus.
When to use an IUCD
  • When would you advise using an IUCD as an emergency contraception?

  • You can use an IUCD as an emergency contraception:

    • five days after unprotected sexual intercourse but not more than five days after ovulation
    • if the client also wants to use an IUCD for continuous long-term contraception.

For this reason, emergency contraceptive pills may be a better choice for nulliparous women. However, if the client does not wish to become pregnant in the next few years, the copper-bearing IUCD might be an option for her.

Bear in mind that insertion of an IUCD in women who have never given birth can be very painful and difficult.

The insertion of a copper-bearing IUCD as an emergency contraceptive requires a trained professional, and follows the same eligibility criteria as covered in Study Session 7 on IUCDs. Generally, while advising on both emergency contraceptive pills and copper-bearing IUCDs, you should also encourage clients to use barrier methods (male or female condoms) in order to prevent STIs. Remember, emergency contraceptives cannot protect against STIs, including HIV.

10.3  Advantages and disadvantages of emergency contraception

Advantages of emergency contraception

Emergency contraception is very effective when used early, with only 3% of women becoming pregnant if used within 24 hours of unprotected sexual intercourse. Its use can also provide an appropriate opportunity for a client to start an ongoing family planning method, such as an IUCD.

Disadvantages of emergency contraception

Box 10.4 summarises the disadvantages of using emergency contraception that you should be aware of when advising women.

Box 10.4  Disadvantages of emergency contraception

  • It does not work if women are already pregnant.
  • It has a limited time frame of 5 days following unprotected intercourse.
  • Women still have a small chance of getting pregnant.
  • IUCD insertion requires a trained professional.
  • Neither method provides protection from sexually transmitted infections.

10.4  Management of common side-effects

After you give emergency contraceptive pills to your client, they may complain about nausea, which is usually limited to the first three days following treatment. Nausea can be reduced if the client takes her pills with food or milk, or at bedtime, so advise her accordingly. In some cases, clients may develop vomiting, which is a common problem within two hours of taking emergency contraceptive pills. In this case, the same dose should be repeated, because the pill may have been vomited out without being absorbed in her stomach. However, if the client suffers from severe or continuous vomiting, advise her to put the same dose in her vagina, and this will then be absorbed into the bloodstream.

Some women may experience withdrawal bleeding (spotting) after taking emergency contraceptive pills. In this case, you should counsel them not to confuse this bleeding with menstrual bleeding. Inform women that emergency contraceptive pills do not bring on menstruation immediately. In cases where there is a delay in menstruation of more than one week, you may refer the client for pregnancy testing.

Other side-effects after using emergency contraception include breast tenderness, headaches, abdominal pain, dizziness and fatigue. These side-effects usually resolve themselves, or last less than two days. If your client complains of breast tenderness and severe headaches, you can give her a painkiller such as Asprin (300 mg), Ibuprofen (400 mg) or Paracetamol (500 mg), to take as needed.

Summary of Study Session 10

In Study Session 10, you have learned that:

  1. Emergency contraception (EC) is a method used to prevent the possibility of unwanted pregnancy, and is effective up to five days following unprotected sexual intercourse.
  2. Unprotected sexual intercourse means that either a couple did not use any contraceptive method to prevent pregnancy, or their birth control method failed (for example, a condom breaking or slipping).
  3. Combined emergency contraceptive pills (ECPs) are formulations of oestrogen (ethinyl estradiol) and progesterone (levonorgestrel or norgestrel).
  4. The progestin-only pill consists of levonorgestrel. It is less effective than the combined pill, but has a lower incidence of side effects.
  5. A copper-bearing IUCD can be used within five days of unprotected sexual intercourse as an emergency contraceptive. It works primarily by interfering with the sperm so it doesn’t reach the egg, and subsequently by preventing the fertilised egg from implanting in the uterus.
  6. Common side-effects from using ECPs are nausea and vomiting. Other side-effects include breast tenderness, headaches, abdominal pain, dizziness and fatigue. These side-effects usually resolve themselves, or last less than two days.

Self-Assessment Questions (SAQs) for Study Session 10

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 10.1 (tests Learning Outcome 10.1)

Identify the main reasons for using emergency contraceptives.

Answer

The main reasons for using emergency contraception are:

  • When a women has not used contraceptives prior to sexual intercourse.
  • If sexual intercourse has been forced or coerced.
  • If the client has incorrectly used a contraceptive method.

SAQ 10.2 (tests Learning Outcome 10.2)

Describe the mechanism of action of emergency contraceptives.

Answer

Emergency contraceptives work by:

  • Suppression of ovulation.
  • Thickening of cervical mucus to make it difficult for sperm penetration.
  • Thinning the endometrial lining of the uterus to prevent the fertilised egg from attaching and developing.

SAQ 10.3 (tests Learning Outcomes 10.2 and 10.3)

  • a.What are the key time limits when taking emergency contraception?
  • b.What should you do if the client fails to menstruate following emergency contraception?
Answer
  • a.It should be as soon as possible after unprotected sex and must be within five days following unprotected sexual intercourse.
  • b.If your client has failed to menstruate a week or more following emergency contraception, she may be pregnant. You can refer her for a pregnancy test to confirm the pregnancy. If the client is pregnant, you can tell her the available options, and ask her to choose the most appropriate option for her situation. If the client would like to continue with the pregnancy, you can reassure her that emergency contraceptive pills will not have harmed the fetus.

SAQ 10.4 (tests Learning Outcome 10.2)

At what time intervals should the two recommended doses of emergency contraceptive pills be taken after a woman has had unprotected sexual intercourse?

Answer

The first dose must be within five days of unprotected sexual intercourse, if possible within 24 hours (depending on the types of emergency contraceptive used). The second dose should be taken 12 hours after the first dose.

SAQ 10.5 (tests Learning Outcome 10.4)

W/ro Almaz comes to you with side-effects, complaining of nausea and vomiting after taking emergency contraceptive pills. What do you advise her to do?

Answer

In the case of nausea, advise her to take the pills with food or milk. In the case of vomiting, give her an additional dose of ECPs, because the pill may have been vomited out without being absorbed in the stomach. If she vomits continuously, advise her to put the same dose of the pill in her vagina, from which it will be absorbed into the bloodstream.

SAQ 10.6 (tests Learning Outcomes 10.2 and 10.3)

How long do emergency contraceptive pills protect a woman from pregnancy?

Answer

Women who take ECPs should understand that they could become pregnant the next time they have sex unless they begin to use another method of contraception at once. This is because ECPs delay ovulation in some women. So they may be most fertile soon after taking ECPs. If a woman wants ongoing protection from pregnancy, she must start using another contraceptive method at once.

SAQ 10.7 (tests Learning Outcomes 10.2 and 10.4)

W/ro Lule, a 32-year old woman in your community who has just taken her second dose of emergency contraceptive pills four days after unprotected sexual intercourse, comes to you complaining of a very strong headache. How would you handle her concern?

Answer

Tell W/ro Lule that headaches are a possible side-effect of using emergency contraceptive pills, and that it will not last long. For pain relief, offer her either Aspirin (300 mg), Ibuprofen (400 mg), or Paracetamol (500 mg).