FHI - Emergency Contraceptive Pills

Emergency contraceptive pills (ECPs) are a safe and effective contraceptive method that can be used after unprotected sexual intercourse or a contraceptive method failure.
- Emergency contraceptive pills are effective at reducing the risk of pregnancy for up to 120 hours after unprotected intercourse or a contraceptive accident, although they are more effective if used within 72 hours. Women should be advised to take ECPs as soon as possible, but treatment should not be withheld from those who request ECPs after the 72-hour guideline (as long as clients are within 120 hours of unprotected intercourse).
  - Ellertson C, Evans M, Ferden S, et al. Extending the time limit for starting the Yuzpe regimen of emergency contraception to 120 hours. Obstet Gynecol 2003;101(6):1168-71. (full text)
  - Ellertson C, Trussell J, Stewart F, et al. Emergency contraception. Semin Reprod Med 2001;19(4):323-30. (abstract)
  - Grimes D, Raymond E. Emergency contraception. Ann Intern Med 2002;137(3):180-89. (full text)
  - Rodrígues I, Grou F, Joly J. Effectiveness of emergency contraceptive pills between 72 and 120 hours after unprotected sexual intercourse. Am J Obstet Gynecol 2001;184(4):531-37. (abstract)
  - Task Force on Post-Ovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352(9126):428-33. (abstract)
  - Trussell J, Rodríguez G, Ellertson C. Updated estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception 1999;59(3):147-51. (full text)
  - Von Hertzen H, Piaggio G, Ding J, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial. Lancet 2002;60(9348):1803-10. (abstract)
- Emergency contraceptive pills are more effective the sooner they are used. A study showed that when levonorgestrel (progestin-only) or Yuzpe (combined pills) ECPs are used within 12 hours after unprotected intercourse, the pregnancy rate was 0.5 percent. However, in women who used ECPs between 60 and 72 hours after unprotected intercourse, the pregnancy rate was as high as 4.1 percent.
  - Piaggio G, von Hertzen H, Grimes D, et al. Timing of emergency contraception with levonorgestrel or the Yuzpe regimen. Lancet 1999;353(9154):721. (abstract)
- In a recent review, authors found that the mid-dose of mifepristone (25 mg to 50 mg) was more efficacious than low-dose mifepristone (<25 mg) or a levonorgestrel regimen. The levonorgestrel regime of ECPs is more effective and has fewer side effects than the Yuzpe regimen. Nausea and vomiting were significantly less frequent with the levonorgestrel regimen than with the Yuzpe regimen. However, Yuzpe should be offered if it is the only available option.
  - Cheng L, Gulmezoglu AM, Piaggio G, et al. Interventions for emergency contraception (Review). Cochrane Database of Systematic Reviews 2008;(2):1-148. (abstract)
  - Task Force on Post-Ovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352(9126):428-433. (abstract)
- A single dose of levonorgestrel (1.5 mg) given within five days after unprotected intercourse is at least as effective and has the same frequency of side effects as the commonly used regimen of two 0.75-mg doses of levonorgestrel given 12 hours apart. Using a single-dose regimen may increase compliance and, thus, the effectiveness of treatment.
  - Cheng L, Gulmezoglu AM, Piaggio G, et al. Interventions for emergency contraception (Review). Cochrane Database of Systematic Reviews 2008;(2):1-148. (abstract)
  - Von Hertzen H, Piaggio G, Ding J, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial. Lancet 2002;60(9348):1803-10. (abstract)
- Mifepristone can cause menstrual delay. The effect of the single-dose levonorgestrel ECP regimen on the timing and duration of the next menstrual period depends on when during the cycle the pill is taken. The pill may cause early menses. Intermenstrual bleeding after treatment is uncommon.
  - Cheng L, Gulmezoglu AM, Piaggio G, et al. Interventions for emergency contraception (Review). Cochrane Database of Systematic Reviews 2008;(2):1-148. (abstract)
  - Raymond EG, Goldberg A, Trussell J, et al. Bleeding after use of levonogestrel emergency contraceptive pills. Contraception 2006;73(4):376-381. (abstract)
- While effective for occasional use, ECPs are not recommended as a regular contraceptive. When taken repeatedly, ECPs seem to be less effective than most regular methods of contraception and have more side effects, including menstrual disturbances.
  - Task Force on Post-Ovulatory Methods of Fertility Regulation. Efficacy and side effects of immediate postcoital levonorgestrel used repeatedly for contraception. Contraception 2000;61(5):303-8. (abstract)
Analysis has shown that ECPs are a cost-efficient approach to preventing unintended pregnancy after unprotected intercourse, assuming clients take the pills. However, recent work has found that earlier cost-effectiveness estimates may have been overstated.
Emergency contraceptive pills do not interfere with an established pregnancy. They are not effective after implantation takes place. Depending on the stage of the menstrual cycle during which they are taken, ECPs act primarily by inhibiting or delaying ovulation. Other mechanisms are not well established but may include interference with sperm and egg movement through fallopian tubes or thickening of the cervical mucus, which prevents the sperm from reaching the egg.
When women already have ECPs on hand, they use the ECPs sooner after unprotected intercourse or method failure than if they have to go to a provider to get them afterwards.
- However, research indicates that advanced provision of ECPs does not reduce pregnancy rates in the populations studied.
  - Polis CB, Schaffer K, Blanchard K, et al. Advance provision of emergency contraception for pregnancy prevention: A meta-analysis. Cochrane Database of Systematic Reviews 2008;4. (abstract)
  - Raymond EG, Trussell, J, and Polis CB. Population effect of increased access to emergency contraceptive pills: a systematic review. Obstet Gynecol 2007;109(1):181-8. (abstract)
The availability of ECPs does not reduce use of regular contraceptive methods.

Belzer M, Yoshida E, Tejirian T, et al. Advanced supply of emergency contraception for adolescent mothers increased utilization without reducing condom or primary contraception use. J Adolesc Health 2003;32(2):122-23. (abstract)
Blanchard K, Bungay H, Furedi A. Evaluation of an emergency contraception advance provision service. Contraception 2003;67(5):343-48. (abstract)
Ellertson C, Ambardekar S, Hedley A, et al. Emergency contraception: randomized comparison of advance provision and information only. Obstet Gynecol 2001;98(4):570-75. (abstract)
Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med 1998;339(1):1-4. (abstract)
Kirby D. The impact of programs to increase contraceptive use among adult women: A review of experimental and quasi-experimental studies. Perspectives on Sexual and Reproductive Health 2008;40(1):34-41. (abstract)
Polis CB, Schaffer K, Blanchard K, et al. Advance provision of emergency contraception for pregnancy prevention: A meta-analysis. Cochrane Database of Systematic Reviews 2008; 4. (abstract)
Trussel J, Raymond E. Advances in fertility studies and reproductive medicine – IFFS 2007. "Chapter Ten: Emergency contraception: a cost-effective approach to preventing unintended pregnancy." Cape Town: Juta & Co., 2007, pp.250-266. (abstract)

A recent study concluded that access to ECPs may contribute to increased sexual activity. However, other evidence suggests that ECP access does not increase sexual risk-taking among adults or adolescents.

Harper CC, Weiss DC, Speidel JJ, et al. Over-the-counter access to emergency contraception for teens. Contraception 2008;77(4):230-233. (abstract)
Raine T. Effect of an emergency contraceptive pill intervention on pregnancy risk behavior -- an erroneous conclusion [letter]. Contraception 2008;78(4):347. (abstract)
Raymond EG, Weaver MA. Effect of an emergency contraceptive pill intervention on pregnancy risk behavior. Contraception 2008;77(5):333-6. (abstract)

It is safe to provide ECPs over the counter.
- Emergency contraceptive pills meet all the customary criteria for over-the-counter use, including low toxicity, lack of potential for overdose or addiction, no teratogenicity, no need for medical screening, self-identification of the need, uniform dosage, and lack of drug interactions. There are no pre-existing conditions that preclude the use of ECPs, including history of severe cardiovascular complications or liver disease. Over-the-counter provision to adolescents, a population in particular need of ECPs, is also safe.

Emergency contraceptive pills are largely underused worldwide.
- Several studies have shown that community health workers, pharmacists, and midwifery students lack important knowledge about ECPs, and there is a need for initial and ongoing education among these groups.
  - Byamugisha JK, Mirembe FM, Faxelid E, et al. Knowledge, attitudes and prescribing pattern of emergency contraceptives by health care workers in Kampala, Uganda. Acta Obstetricia Et Gynecologica Scandinavica 2007;86(9):1111-1116. (abstract)
  - Celik M, Ekerbicer HC, Ergun UG, et al. Emergency contraception: knowledge and attitudes of Turkish nursing and midwifery students. Eur J Contracept Reprod Health Care 2007;12(1):63-9. (abstract)
  - Fuentes EC, Azize-Vargas Y. Knowledge, attitudes and practices in a group of pharmacists in Puerto Rico regarding emergency contraception. P R Health Sci J 2007;26(3):191-7. (abstract)
- Some providers do not dispense ECPs because of their own discomfort with the method, supply stock-outs, and safety concerns.
  - Card RF. Conscientious objection and emergency contraception. American Journal of Bioethics 2007;7(6):8-14. (full text)
  - Yam EA, Gordon-Strachan G, McIntyre G, et al. Jamaican and Barbadian health care providers' knowledge, attitudes and practices regarding emergency contraceptive pills. Int Fam Plan Perspect 2007;33(4):160 (abstract)
- Research indicates that in many settings, knowledge of ECPs is low among potential users.
  - Kang HS, Moneyham L. Use of emergency contraceptive pills and condoms by college students: a survey. Int J Nurs Stud 2008;45(5):775-83. (abstract)
  - Kongnyuy EJ, Ngassa P, Fomulu N, et al. A survey of knowledge, attitudes and practice of emergency contraception among university students in Cameroon. BMC Emerg Med 2007;7:7. (abstract)
  - Myer L, Mlobeli R, Cooper D, et al. Knowledge and use of emergency contraception among women in the Western Cape province of South Africa: A cross-sectional study. BMC Women's Health 2007;7(1):14. (abstract)
  - Puri S, Bhatia V, Swami HM, et al. Awareness of emergency contraception among female college students in Chandigarh, India. Indian Journal of Medical Sciences 2007;61(6):338-346. (abstract)
  - Sahin NH. Male university students' views, attitudes and behaviors towards family planning and emergency contraception in Turkey. Journal of Obstetrics and Gynaecology Research 2008;34(3):392-398. (abstract)
- Interventions to increase knowledge of ECPs among potential users have been effective in a variety of settings. In Mexico, a ten-year multifaceted strategy to increase ECP access has been largely successful.
  - Garcia SG, Becker D, Martínez de Castro M, et al. Knowledge and opinions of emergency contraceptive pills among female factory workers in Tijuana, Mexico. Studies in Family Planning 2008;39(3):199-210. (abstract)
  - Gee RE, Delli-Bovi LC, Chuang CH. Emergency contraception knowledge after a community education campaign. Contraception 2007;76(5):366-371. (abstract)
  - Halpern CT, Mitchell EM, Farhat T, et al. Effectiveness of web-based education on Kenyan and Brazilian adolescents' knowledge about HIV / AIDS, abortion law, and emergency contraception: Findings from TeenWeb. Social Science and Medicine 2008;67(4):628-637. (abstract)
  - Schiavon R, Westley E. From pilot to mainstream: A decade of working in partnerships to expand access to emergency contraception in Mexico. Global Public Health 2008;3(2):149-164. (abstract)

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