Emergency Contraception Many women present for contraceptive care following consensual but unprotected sexual intercourse, or in some

cases, following sexual assault. In these situations, a number of methods substantially decrease the likelihood of an unwanted pregnancy when used correctly. Current methods of emergency contraception include COCs, progestin-only products, copper-containing IUDs, and mifepristone. Patients can obtain information regarding emergency contraception by calling 1-888-NOT-2LATE (888-668-2528) or accessing The Emergency Contraception Website: http://ec.princeton.edu/. History For many decades it was known that pharmacological doses of estrogens would prevent pregnancy when given for recent unprotected intercourse. A study by Demers (1971) published in the New England Journal of Medicine was entitled "The Morning-After Pill," which referred to diethylstilbestrol (DES) used successfully as a postcoital contraceptive. It was never approved for this purpose, and in fact, the FDA discouraged the practice. Nevertheless, DES was widely prescribed off-label to prevent pregnancy. For example, beginning in the 1960s, it was routinely offered to women who were "at risk" for pregnancy following sexual assault and who were cared for at the Parkland Hospital Ob-Gyn Emergency Room. DES production by Eli Lilly, the last U.S. manufacturer, ceased in 1997. In 1974, Yuzpe and colleagues published their pilot study of the use of combined hormone100 g ethinyl estradiol plus 1.0 mg dL-norgestrelfor postcoital contraception, and subsequently the Yuzpe method was found effective. In 1997, the FDA declared the Yuzpe method to be safe and effective for this off-label use and in 1998, approved the Yuzpe-method Preven Emergency Contraceptive Kit for prescriptive use. This kit was discontinued by the manufacturer in 2004. In 1999, the FDA approved Plan B, which was the first progestin-only emergency contraceptive for prescriptive use. Because of its efficacy and safety, and especially its intent in preventing unwanted adolescent pregnancy, a number of organizations, including the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, recommended over-the-counter (OTC) availability (Drazen and colleagues, 2004). In 2009, the FDA allowed the manufacturer to market Plan B without a prescription to women 17 years and older. Hormonal Emergency Contraception Estrogen-Progestin Combinations For reasons discussed above, this is also known as the Yuzpe method. A minimum of 100 g of ethinyl estradiol and 0.5 mg of levonorgestrel is given as shown in Table 32-9. The only FDA-approved dedicated estrogen- and progesteronecontaining product was the Preven Emergency Contraceptive Kit, which was for emergency contraception. These COC regimens are more effective the sooner they

are taken after unprotected intercourse. The first dose is taken ideally within 72 hours of intercourse but may be given up to 120 hours. The initial dose is followed 12 hours later by a second dose. Emergency hormonal contraceptive regimens are highly effective and decrease the risk of pregnancy by up to 94 percent (American College of Obstetricians and Gynecologists, 2005a).

Treatment consists of two doses taken 12 hours apart. Use of an antiemetic agent before each dose will lessen the risk of nausea, which is a common side effect. b For these multiphasic formulations, the color in parentheses indicates which pills to use for emergency contraception. EE = ethinyl estradiol. Nausea and vomiting are major problems due to high-dose estrogen in these regimens. For this reason, an oral antiemetic may be prescribed at least 1 hour before each dose. Oral pretreatment with 50-mg meclizine or with 10 mg of metoclopramide effectively decreases nausea (Ragan and associates, 2003; Raymond and colleagues, 2000). If a woman vomits within 2 hours of a dose, the dose must be repeated. Progestin-Only Preparations This progestin-only product provides two tablets, each containing 0.75 mg levonorgestrel. Optimally, the first dose is taken within 72 hours of unprotected coitus but may be given up to 120 hours. The second dose follows 12 hours later, although Ngai and colleagues (2005) showed that a 24-hour interval between the doses was also effective. Alternatively, a single, one-time 1.5-mg dose of

levonorgestrel may be used. The pregnancy rate with Plan B of 1.1 percent compares favorably with that of 3.2 percent in a similar group of women treated with the Yuzpe regimen. The major mechanism with all of these is inhibition or delay of ovulation. Other mechanisms include alteration of the endometrium, sperm penetration, and tubal motility. Established pregnancies are not harmed. Copper-Containing Intrauterine Devices Fasoli and co-workers (1989) summarized nine studies that included results from 879 women who accepted some type of copper-containing IUD as a sole method of postcoital contraception. The only reported pregnancy aborted spontaneously. Trussell and Stewart (1998) reported that when the IUD was inserted up to 5 days after unprotected intercourse, the failure rate was 1 percent. A secondary advantage is that this method also puts in place an effective 10-year method of contraception. Mifepristone (RU 486) This medication is discussed in Chapter 9, Medical Abortion, and relies on its antiprogesterone effects to delay or inhibit ovulation as its means of postcoital contraception. A single 10-mg dose provides pregnancy prevention comparable with that of Plan B (Task Force on Postovulatory Methods of Fertility Regulation, 1999; von Hertzen and associates, 2002). There are few side effects with mifepristone, and compared with the Yuzpe method it is better tolerated and more effective (Ashok and colleagues, 2002, 2004). In the United States, mifepristone is not used for emergency contraception because of its high cost and because it is not manufactured or marketed in an appropriate dose. Another progesterone-receptor modulatorCDB-2914was reported by Creinin and colleagues (2006) to be as effective as levonorgestrel in preliminary studies. Reference: Cunningham FG, KJ Leveno, SL Bloom, John C. Hauth, Dwight J. Rouse, Catherine Y. Spong, editor. 2010. Contraception. In: Williams Obstetrics, TwentyThird Edition. The McGraw-Hill Companies.