Emergency Contraception - Counselling (1)

Emergency Contraception - Counselling Notes

Introduction to Emergency Contraception (EC)

Emergency contraception (EC) is a critical intervention designed to prevent unintended pregnancies following unprotected sexual intercourse (UPSI) or contraceptive failure. It should not be seen as a replacement for regular contraception and is intended for occasional use only. Notably, EC is not an abortion method, as established by a judicial review in 2002, which clarified that pregnancy commences at implantation rather than fertilization. Thus, any EC intervention must either inhibit fertilization or prevent implantation but must not disrupt an already established pregnancy.

Session Objectives

Participants in this training session will:

• Understand key features of emergency contraception.

• Be informed on which form of EC to prescribe based on circumstances.

• Recognize side effects and interactions of EC.

• Deal sensitively with vulnerable patients.

• Know how to conduct consultations for emergency hormonal contraception (EHC).

Resources for Reference

Important guidelines and resources include:

• NICE Clinical Knowledge Summaries (CKS) on emergency contraception.

• The Faculty of Sexual and Reproductive Healthcare (FSRH) guidance.

• Safety and prescribing references such as the Summary of Product Characteristics (SPC) or British National Formulary (BNF).

• Public health resources from NHS UK and guidance from the General Pharmaceutical Council (GPhC).

• Interaction references from Stockley and training resources from CPPE.

Historical Timeline of Emergency Contraception in Pharmacy

• 1999: Emergency contraception first supplied in Manchester via Patient Group Directive (PGD).

• 2001: Levonorgestrel classified as a P medicine.

• 2005: Enhanced service introduced in the new community pharmacy contract framework (CPCF).

• 2012: First PGDs implemented for Ulipristal.

• 2015: Ulipristal (Ella-One) classified as a P medicine.

Types of Emergency Contraception

1. Copper Intrauterine Device (Cu-IUD)

2. Oral Emergency Contraception

   • Levonorgestrel (LNG-EC)

   • Ulipristal (UPA-EC)

Mechanism of Action

Sperm can survive in the female genital tract for about five days after unprotected intercourse. If ovulation occurs within this period, fertilization can lead to pregnancy. EC methods aim to prevent this outcome.

• Cu-IUD prevents fertilization by hindering sperm movement and causing local inflammatory responses that inhibit embryo implantation.

• Levonorgestrel works primarily by delaying or preventing ovulation if administered before the LH surge.

• Ulipristal acetate inhibits or delays ovulation successfully even after the LH surge has started.

Efficacy and Recommendations

• Copper IUD: Most effective method (<0.1% pregnancy rate) and can be used within 5 days after UPSI.

• Ulipristal Acetate: Licensed for use within 120 hours after UPSI, with a pregnancy rate of around 1-2%.

• Levonorgestrel: Licensed for use within 72 hours, with a pregnancy rate around 0.6 - 2.6%.

Consultation Guidelines

Consultation Process

1. Initiate session: Establish rapport.

2. Gather information: Ask relevant questions (age, last period, current medications, past usage of EC, etc.).

3. Provide explanation: Inform about the available EC options and their mechanisms.

4. Planning: Discuss ongoing contraceptive methods.

5. Close session: Ensure understanding and provide reassurance.

Key Consultation Questions

• Is the emergency contraception for you?

• How old are you?

• When did you have unprotected sex?

• Was the sex consensual?

• Did you use any contraception?

• When was the first day of your last period?

• Could you already be pregnant?

• Have you already used emergency contraception this cycle?

• Are you taking any other medicines?

• Do you have any other medical conditions?

• Have you had a previous reaction to emergency contraception?

• Are you breastfeeding?

• Do you know your weight or BMI?

Special Considerations for Young Patients

For under 16s, awareness of Fraser competency is necessary, as consent cannot be provided by those under 13. Proper safeguarding protocols should be strictly observed to ensure the welfare of the patient.

Medical Conditions Impacting the Effectiveness of EC

Certain conditions can affect the absorption of oral EC:

• Vomiting or severe diarrhea can reduce the effectiveness of oral EHC. If vomiting occurs within three hours of administration, a repeat dose should be provided.

• Conditions that cause malabsorption, such as Crohn's disease, may necessitate consideration of the Cu-IUD as a first-line option.

• Severe liver disease may restrict the use of UPA-EC due to potential interactions; however, guidelines from FSRH highlight that oral EC is generally safe.

Side Effects and Interactions

Common side effects include:

• Headache, nausea, abdominal pain, dysmenorrhea, dizziness, breast tenderness, and fatigue. Special instructions for re-dosing in case of vomiting are critical.

• Notably, ectopic pregnancies can occur with very low absolute risk.

• Potential interactions with other medications, particularly enzyme inducers, should be noted as these can affect the efficacy of EC methods.

Conclusion

Emergency contraception plays a significant role in reproductive health, requiring appropriate knowledge for effective patient counseling. As new guidelines evolve, it is crucial that practitioners stay informed about the different options for EC and the specific needs of diverse patient populations.