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10.1576/toag.13.1.29.27638 http://onlinetog.org

2011;13:2934

Review

Review Postcoital contraception


Authors Ruzva K Bhathena / John Guillebaud

Key content:
The progestogen-only postcoital pill (containing levonorgestrel) impairs
ovulation and inhibits fertilisation, but there is little evidence to support a direct
anti-implantation effect.
Ulipristal acetate acts primarily by inhibiting ovulation but it may also impair
implantation.
The copper-bearing intrauterine device prevents fertilisation and inhibits
implantation; it is the most effective method of emergency contraception.
The levonorgestrel-releasing intrauterine system is not suitable and is not licensed
for emergency contraception.

Learning objectives:
To learn about the options available to women when there is risk of pregnancy
following unprotected sexual intercourse.
To be aware of the use of the copper intrauterine device for emergency contraception.
To be aware of provisions for advance emergency contraception.
To understand the opportunity that emergency contraception offers for sexual
health risk assessment and testing, particularly regarding insertion of the
intrauterine device.

Ethical issues:
A womans beliefs may preclude intervention postcoitally or, more importantly,
post fertilisation.
If a practitioners own beliefs preclude similar interventions, the practitioner
should ensure timely referral to another practitioner.
Keywords copper intrauterine device / levonorgestrel-containing emergency
contraceptive pill / morning after pill / pregnancy rates/ ulipristal acetate
Please cite this article as: Bhathena RK, Guillebaud J. Postcoital contraception The Obstetrician & Gynaecologist 2011;13:2934.

Author details
Ruzva K Bhathena FRCOG MD FFSRH
Consultant Obstetrician and Gynaecologist,
BD Petit Parsee General and Masina
Hospitals, B Petit Road, Cumballa Hill,
Mumbai 400036, India
Email: rkbhathena@gmail.com
(corresponding author)

John Guillebaud MA FRCSEd FRCOG Hon FFSRH


Hon FCOG(SA)
Emeritus Professor of Family Planning and
Reproductive Health,
University College London; and
Ex-Medical Director,
Margaret Pyke Centre for Study and Training
in Family Planning, Elliot-Smith Clinic,
Churchill Hospital, Oxford OX3 7LJ, UK

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Introduction
Postcoital or emergency contraception is used to
prevent unwanted pregnancy after unprotected
sexual intercourse or to avert potential contraceptive
failure. In the UK, oral progestogen-only emergency
contraception is available as the levonorgestrel
emergency contraceptive pill; the copper
intrauterine device (IUD) can also be inserted as a
postcoital contraceptive.1 The levonorgestrelreleasing intrauterine system is not suitable and is
not licensed for emergency contraception.2
Ulipristal acetate, a synthetic, orally active selective
progesterone receptor modulator, has recently been
licensed for emergency contraception in Europe and
has been marketed in the UK since October 2009.3

Mechanisms of action and


effectiveness
The levonorgestrel pill
The levonorgestrel emergency contraceptive pill
(Levonelle 1500 [Bayer Schering, Newbury, Berks,
UK]) is licensed for use for up to 72 hours after
unprotected sexual intercourse, in a single dose of
1.5 mg. It interferes with follicular development
and impairs ovulation.46 There is little evidence,
however, to suggest that it inhibits implantation.6
When only those women who would be expected to
conceive without treatment were included, the
levonorgestrel hormonal method, based on a trial
by the World Health Organization,7 was calculated
to prevent 95% of expected pregnancies when
used within 24 hours of the first episode of
unprotected sexual intercourse, 85% if used
between 2548 hours, but only 58% if used between
4972 hours.810 The woman should, therefore, be
advised to take it as soon as possible. Levonorgestrel
emergency contraception can also be considered
(although ulipristal acetate may now be preferable)
for use more than 72 hours and up to 120 hours
after unprotected intercourse if the copper IUD is
not an acceptable option. The woman should be
informed of the decreased efficacy of the method
beyond 72 hours and that such use is outside the
product licence.1,911

Box 1

Circumstances in which caution


should be exercised when
prescribing the levonorgestrel
emergency contraceptive pill

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There is evidence that there is reduced effectiveness


when the levonorgestrel emergency contraceptive
pill is taken relatively late in the cycle (after
ovulation but before expected implantation)12 and
ulipristal acetate is now preferred at that stage if a
copper IUD cannot be used or is not acceptable.
The reduced effectiveness that comes with a delay
in the use of the levonorgestrel postcoital pill, even
when use is adjusted for the day of the cycle on
which unprotected intercourse took place, is
consistent with a contraceptive mechanism that is
independent of effects on implantation.13 If the
levonorgestrel postcoital pill did interfere with
implantation, a delay in use would not reduce
effectiveness as long as it was used just before or
during implantation.13
If clinically indicated, the levonorgestrel pill can be
used more than once in a cycle (named patient
prescribing), after discussion and
documentation.1,11 Repeated administration can
lead to disturbances in the menstrual cycle.1 The
use of the levonorgestrel pill will not induce an
abortion if the woman is already pregnant.1,11
Aside from the extremely rare history of a serious
allergic reaction to a constituent, there are no
medical contraindications to the use of the
levonorgestrel emergency contraceptive pill.14
However, caution needs to advised in some
circumstances (Box 1).
If, as in many countries, a product specifically
for emergency use is not available, an effective
substitute is to take four tablets of the very
widely available combination preparation
containing levonorgestrel 150 mcg and ethinyl
estradiol 30 mcg (Microgynon 30 [Bayer
Schering]) and to repeat the dose of four tablets
after 12 hours.16 With this preparation, there is a
rather high risk of nausea and up to 20% of
women may vomit.7,16
The copper IUD
(See Table 1.) This can be inserted up to 5 days after
the first episode of unprotected sexual intercourse. If

Use of liver enzyme-inducing drugs, such as


rifampicin, griseofulvin, barbiturates,
phenytoin, carbamazine or the herbal
medicine St Johns wort

Women on these drugs should be counselled


about a reduction in the efficacy of the
levonorgestrel pill.1 The preferred method
would be the copper IUD. If the latter option
is not acceptable, the woman should be
advised to take two tablets (3 mg) of
Levonelle 1500 as soon as possible within
72 hours of unprotected intercourse.1,11 Such
use is outside the product licence.1,11

Use of anticoagulant drugs such as warfarin

Women should be counselled that the


anticoagulant effects can be altered and there
will be a need for testing of the international
normalised ratio within the following
34 days.1,15

A woman's beliefs forbid her to use a method


with a possible post-fertilisation intervention

A frank and clear explanation of the mode of


action may help some women to find the
method acceptable.

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Review

Method

Timing

Dosage

Efficacy

Table 1

Levonorgestrel pill

Up to 72 hours after unprotected


sexual intercourse

Single dose of 1.5 mg; can be used


more than once in a cycle after
discussion and documentation

98% within 72 hours8

Summary of methods of
postcoital contraception

Copper IUD

Up to 5 days after the first episode of


unprotected sexual intercourse
As soon as possible within 5 days of
the earliest episode of unprotected
sexual intercourse,3 regardless of the
number of coital acts within those
120 hours

Ulipristal acetate

the timing of ovulation can be estimated, insertion


can be carried out later, even when multiple episodes
of intercourse have taken place, as long as the
insertion is not done later than 5 days after
ovulation.1 Its effectiveness is due to the direct toxicity
of copper ions on sperms inhibiting fertilisation and
because the copper in the endometrium inhibits
implantation.1719 When used within 5 days of
unprotected intercourse the failure rate of the copper
IUD as a contraceptive is less than 1%.20
When a woman requests emergency contraception,
even if she presents within 72 hours of unprotected
sexual intercourse, the option of the relatively more
effective copper IUD and its potential for use as an
ongoing method of long-term contraception
should be discussed.
Intrauterine devices with banded copper on the arms
covering an area of 380 mm2 (such as the TT 380
Slimline [Durbin PLC, South Harrow, Middlesex,
UK] or T-Safe 380A QuickLoad [Williams Medical
Supplies Ltd, Rhymney, Gwent, UK]) have the lowest
failure rates and the longest licensed duration of use.
They should be the first-line choices, especially if the
woman wishes to continue to use the device for longterm contraception.1,8,21 For a nulliparous woman
there is also the Mini TT 380 Slimline, which has the
same area of copper on a smaller plastic frame. If the
internal cervical os proves difficult to negotiate there
are also devices with narrower insertion tubes
(Flexi-T 300 [Durbin PLC] and Nova T 380
[Bayer Schering]).8 However, their relatively lower
long-term efficacy makes them suitable primarily
when the womans sexual history makes it more
appropriate for her to use another method in the long
term, such as an injectable or implant, with removal
of the IUD when the other method is operative.

99% within 72 hours20


Single oral dose of 30 mg

99% within 5 days26,27

contraception by the European Medicines Agency


and has been marketed in the UK since October
2009.3 Ulipristal acetate is a synthetic orally active
(second-generation) selective progesterone
receptor modulator which acts by high-affinity
binding to the human progesterone receptor. The
primary mechanism of action is inhibition of
ovulation but alterations in the endometrium may
also have effects that impair implantation.3 It is
used in a single dose of 30 mg, to be taken as soon as
possible within 5 days of the earliest episode of
unprotected sexual intercourse,3 regardless of the
number of coital acts within those 120 hours.25
In a meta-analysis of two randomised controlled
trials,26 the conception rates in women who were
given emergency contraception 0120 hours after
unprotected intercourse were 1.3% for ulipristal
acetate and 2.2% for levonorgestrel (odds ratio
0.55, P  0.0253). In two trials26,27 in which
ulipristal acetate was administered beyond
72 hours, the failure rates did not show the increase
with time that is observed with levonorgestrel.
Indeed, in one study26 there were no failures from
72120 hours, although the numbers were small.
Ulipristal acetate appears to be a more potent
inhibitor of ovulation than levonorgestrel.28,29
When levonorgestrel is administered as emergency
contraception in the immediate pre-ovulatory
phase of the cycle, ovulation is delayed by 5 days in
12% of women.4 When ulipristal acetate is given in
the pre-ovulatory phase, ovulation is delayed by
5 days in 59% of women.29 These data support the
greater efficacy shown in clinical studies.28
Ulipristal can be taken with or without food. If
vomiting occurs within 3 hours of taking the
medication, the dose should be repeated as soon as
possible.3,30

Ulipristal acetate
In the past few years progesterone receptor modulators
have been studied for their effectiveness as postcoital
contraception.7,9 Mifepristone,a progestogen (the first
selective progesterone receptor modulator),has
proved effective when used in a single dose of 10 mg
within 120 hours of unprotected sexual
intercourse.7,9,2224 Adverse effects are minimal and
patient acceptability is high.6,24 However,mifepristone
is not licensed for emergency contraception in the UK.

Women should be informed that the onset of the


next menstrual bleeding may be delayed.30 In about
20% of women where the method is successful, the
delay is more than 7 days; they should be
forewarned of this potential cause of anxiety.30 From
the limited data available,30 there is no evidence of
any adverse outcomes in the few method failure
pregnancies that have occurred to date.

Ulipristal acetate (ellaOne [HRA Pharma UK Ltd,


London, UK]) has been licensed for emergency

Ulipristal is not recommended in women with severe


hepatic impairment or with asthma poorly controlled

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by oral glucocorticoids.3,30 Liver enzyme-inducing


drugs may reduce plasma concentrations of ulipristal
and so reduce efficacy.3 To date there has been no
official guidance on concomitant use, but the authors
of this article consider it logical to double the dosage if
this product is indicated in a woman taking an
enzyme inducer, as described for the levonorgestrel
method (and, similarly, following accepted guidance
for use outside the product licence).1,11
Ulipristal acetate binds to progesterone receptors
with high affinity and may consequently reduce the
efficacy of drugs containing progestogen.30,31
Pending more data, the form of emergency
contraception containing levonorgestrel would
normally be preferred if emergency contraception
is required by a woman using the combined oral
contraceptive pill who has had sexual intercourse
during a significantly long pill-free interval,8 or
who is commencing or recommencing
progestogen-only contraception.8 If ulipristal is
deemed necessary, the manufacturer and the
Faculty of Sexual and Reproductive Healthcare
Clinical Effectiveness Unit25 advise taking
additional contraceptive precautions until the
onset of the next menstrual cycle.30
It is recommended that ulipristal should not be
used more than once in a cycle, as the efficacy and
safety of repeated exposure within the same cycle
have not been adequately assessed.3,30
There are no data as yet on cost effectiveness.
Although ulipristal acetate is three times the price
of levonorgestrel (Levonelle 1500), if a woman
presents after 72 hours and up to 120 hours for
postcoital contraception and is unwilling to opt
for the copper IUD, ulipristal should be used in
preference to levonorgestrel, taking into account
the cost of an unplanned pregnancy.31

repeats the vomited dose as soon as possible.32 An


anti-emetic tablet (such as domperidone 10 mg) can
be given with the supplementary dose.Alternatively,
insertion of a copper IUD can be considered.
A womans sexual history allows some estimation of
the risk of sexually transmitted infection. If a woman
opts for the copper IUD and she is not thought to be
at low risk, she should be advised to have screening
for Chlamydia trachomatis (the principal relevant
sexually transmitted pathogen in women); because
the result will not be available, a suitable prophylactic
antibiotic should be prescribed.1,8
Women should be advised that if they have pelvic
pain with any of the emergency contraceptive
methods, they should attend promptly for review, in
view of the rare possibility of ectopic pregnancy,
especially if there is a past history of pelvic infection.8
If a woman has received the copper IUD method,
she should return after her next menstruation,
either for removal of the device before continuing
with an alternative contraceptive of her choice, or
for a check-up if, after counselling, she opts to use
the copper IUD in the long term.
When any woman attends requesting emergency
contraception, the attending health professional
should discuss the options available as a regular
method of contraception, while informing her about
a small possibility of failure of the emergency method.
In case of failure of the method, there is no evidence of
teratogenic effects with the levonorgestrel pill.33

Provision of emergency
contraception

A detailed menstrual and sexual history should be


taken from any woman requesting emergency
contraception.She should be informed that the
menstrual cycle can be disturbed by the use of the
levonorgestrel pill or ulipristal.The woman should be
forewarned that the method does not provide
contraceptive protection for the remaining part of the
cycle,so she should immediately use an alternative
method.She should be advised that if there is a delay of
more than 7 days in the onset of menstrual bleeding,it
would be appropriate to take a pregnancy test.

The levonorgestrel emergency contraceptive pill is


available in the UK both on prescription (as
Levonelle 1500) and over the counter in pharmacies
(as Levonelle One Step [Bayer Schering]). It can be
obtained from general practitioners; nurse-led family
planning centres (under a patient group direction);
gynaecology and sexual health clinics; and
genitourinary medicine and accident and emergency
departments.A recent study34 provides clear evidence
that community pharmacy emergency hormonal
contraception services in the UK provide timely
access to treatment and are highly appreciated by
women.Another study, from Australia,35 suggests that
wider availability of the emergency contraceptive pill
over the counter increases womens awareness about
the method but not about its use.

Women should also understand that nausea occurs in


a small number of women after administration of the
levonorgestrel pill. The World Health Organization
recommends that if a woman vomits within 2 hours
of taking it or, more commonly, the previously
described constructedemergency contraception
method using two doses of combined pills, that she

Provision in advance of levonorgestrel emergency


contraception may be considered for women at
risk of unintended pregnancy.1,11 Although as yet,
surprisingly, there is no evidence that advance
provision decreases unintended pregnancy rates
when compared with conventional provision, it at
least enables women to have easy and early access to

Clinical management

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emergency contraception.3638 With advance


provision there is no negative impact on sexual and
reproductive health behaviours and outcomes,
including the likelihood of sustained use of other
contraceptives.36,37
An adverse consequence of the availability of the
levonorgestrel-containing emergency contraception
pill without a prescription is the loss of personal
communication with a clinician. Although
improved access is commendable, discussion about
the choice of method of emergency contraception
and promotion of future use of one of the long-term
reversible methods is compromised. If a woman
obtains emergency contraception from a pharmacy,
she also loses the opportunity for insertion of a
copper IUD, which may be preferable, unless the
pharmacist can make an appropriate referral.
Another postulated disadvantage is that the
perceived ready availability of emergency
contraception may demotivate partners to use
condoms, although it appears that there is no
documented evidence to support that probability.

Conclusions
The levonorgestrel emergency contraceptive pill,
licensed for use for up to 72 hours after unprotected
sexual intercourse, may be used as often as needed.
There is reduced effectiveness with a delay in
treatment. The observed failure to reduce
pregnancy rates in population studies is likely to be
due to insufficient use by those at greatest risk.
Ulipristal acetate, which was recently licensed as a
single-dose oral preparation for emergency
contraception for up to 120 hours after unprotected
sexual intercourse, appears to be more effective
than the levonorgestrel emergency contraceptive
pill within that time frame and for women
presenting in the first 24 hours.3,26
The copper IUD remains the postcoital method
with greatest efficacy when used within 5 days of
unprotected intercourse or up to 5 days after
ovulation when this can be satisfactorily estimated,
even in women who have had multiple episodes of
unprotected intercourse (Table 1).
Disclosure of interests
Ruzva K Bhathena has occasionally received travel
grants from pharmaceutical companies to
participate in academic meetings on reproductive
healthcare in the UK.
Professor John Guillebaud has received payments
from pharmaceutical companies distributing
contraceptives (including emergency
contraceptives) for lecture fees, travel and
accommodation expenses, short-term consultancy
work and occasional legal advice.
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