A clinical practice guideline for the safe, effective and appropriate prescription of oral emergency contraception for eligible women.
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The women's health nurse practitioner is responsible for the assessment and management of women requesting emergency contraception, for the supply or prescription of emergency contraceptives to eligible women and for referral of ineligible women requesting emergency contraception to the medical practitioner.
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Terms
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Unprotected sexual intercourse - sexual intercourse that occurs with the possible result of pregnancy due to lack of contraception or contraception failure.
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Eligible women are those who are at risk of an unplanned pregnancy and:
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- are not currently taking warfarin or antiepileptics or St John's Wort
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- have no unexplained vaginal bleeding or breast cancer
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- have elected to use oral emergency contraception after explanation has been provided regarding available methods, and
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- are within 72 hours of unprotected intercourse
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There is some contraceptive effect up to 120 hours using Postinor- 2™, although referral for an IUCD should be considered.
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At risk
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Women at risk for an unplanned pregnancy are those who have experienced:
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Potential pill failure when alternative methods not used / failed
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- when using progesterone only oral contraception and one tablet is missed
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- when using combined oral contraceptives and the hormonal pill free interval is extended to eight days or more
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- when using combined oral contraceptives and two or more active tablets are missed in the first seven or the last seven days of the cycle or
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- when using combined oral contraception and more than three tablets are missed after seven active tablets have been taken
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Unprotected vaginal sexual intercourse
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- such as consensual sex with no contraceptive method used
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- rape or sexual assault with risk of pregnancy
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- coitus interruptus / failed coitus interruptus or
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- ejaculation on external genitalia
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Potential barrier method failures
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- for example, condom rupture, dislodgement or misuse or
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- diaphragm / cap inserted incorrectly, torn, dislodged during intercourse, removed too early
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Potential Intrauterine Contraceptive Device (IUD) failure
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- complete or partial expulsion of an IUD
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Extreme anxiety
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- such as unprotected sexual intercourse at any time in the cycle, irrespective of contraceptive method used / not used, and experienced extreme anxiety regarding possibility of unplanned pregnancy following explanation of personal risk assessment, even if there is no risk of pregnancy
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Management
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History
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The Women's Health Nurse Practitioner should document:
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- date of last menstrual period, whether normal or not, cycle interval and volume, duration of bleeding, bleeding pattern
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- exclusion of pre-existing pregnancy
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- the day of cycle and hours elapsed since unprotected intercourse
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- any other episodes of unprotected sex during last cycle
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- contraception used this cycle
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- the woman's risk assessment for sexually transmissible infections (STIs)
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- the woman's social history, e.g. whether sex was consensual
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- and/or the use of any medications including over the counter such as St John's Wort
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Examination
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The women's health nurse practitioner should perform:
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- cervical screening if required
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- testing for STIs, blood borne viruses and genital tract infections as required
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- and/or pregnancy testing as required
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However, prescription / supply of emergency contraception can occur without examination.
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Information given to Client
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The women's health nurse practitioner should inform the woman:
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- of her individual risk assessment of pregnancy
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- of the mode of action of post-coital contraception, i.e. ovulation may be inhibited, tubal transport of the egg or sperm may be inhibited, implantation may be prevented by alteration of the uterine lining
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- of failure rate of the chosen post coital contraception method (see below)
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- of any possible side effects, e.g. nausea, vomiting, breast tenderness, expected menstruation patterns - that the period should come within three days of expected time - and follow up
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- how to take the post coital contraception
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- that steroids given within 16 days of fertilisation are not considered to cause fetal abnormalities
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- of long term contraception options
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Specific advice to women prescribed emergency contraception
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- women should be advised to return for review if vomiting occurs within two hours of taking the tablets
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- women should be provided with written information pertaining to emergency contraception, and telephone advice lines, e.g. Family Planning Victoria, women's hospitals
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Percentage of pregnancies prevented with Levonorgestrel Emergency Contraception
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|  | | | | | | | | | | Efficacy continues to decrease after 72 hours
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| | | Effectiveness of a post coital IUCD within 5 days of unprotected intercourse is
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| | | | Effectiveness of Yuzpe is |
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Recommencing contraception following prescription of emergency contraception
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Combined oral contraceptive
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These can be recommenced the following day, and once seven active tablets have been taken, contraceptive protection is considered to be adequate.
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Progesterone only oral contraceptives
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The minipill can be recommenced the following day and after three consecutive minipills no alternative (i.e. barrier) contraception will be required.
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Implanon, Depo-Provera and Intrauterine Contraceptive Devices (IUCD)
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These cannot be used until the next normal period, or until pregnancy is absolutely excluded. This may take three weeks.
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Review
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A woman should be asked to return for review and pregnancy testing if:
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- her period is light, associated with persistent spotting, excessive or unusual pain or
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- her period is more than one week late
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- or there has been more than one episode of unprotected sex in one cycle
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- or contraceptive review is required
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- or she has developed any symptoms consistent with an STI (e.g. unusual vaginal discharge / pain)
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- or she is considered to be at risk for STIs or unplanned pregnancy
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- and/or she has reason for concern
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Review visit
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- Record client's menstrual data and perform a pregnancy test if indicated
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- Discuss ongoing contraception options
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Emergency contraception failure
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Advise client on available options:
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- Should she decide to continue the pregnancy, she should be reassured that there are no known teratogenic effects following the use of emergency contraception;
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- There may be a higher percentage of ectopic pregnancies 'emergency contraception failure' cases than in the general population. The possibility of ectopic pregnancy should be investigated.
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Prescription
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- Women's health nurse practitioners should check the client's medical history, medication history and history of allergies when prescribing medications.
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- They should also ensure that the patient understands the drug regimen and inform them of possible adverse reactions.
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- Details of the prescription should be recorded in the client's file. All relevant fields on the medication order chart should be completed. This includes the name of the prescriber, the commencement date, the dose, the frequency, the date and time of prescribing, and the prescriber's name.
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- Women's health nurse practitioners should utilise the current prescribing information regarding the following medication and ensure that the patient is aware of appropriate storage required for the medication.
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Levonorgestrel
| Levonorgestrel 1.5mg (2 X 750mcg) (eg Postinor-2™)
1 tablet as soon as possible (less than or equal to 72 hours) after unprotected intercourse, then 1 tablet 12 hours following first dose; vomiting <2 hours after dosing, see doctor for possible additional tablet. Can be taken with or without food.
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| Yuzpe method
| Levonorgestrel 500mcg and Ethinyloestradiol 100mcg
| | 2 doses 12 hours apart, each given with metoclopramide 10mg. Take with or without food. |
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Levonorgestrel
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Levonorgestrel 1.5mg (Postinor-2™) is the current preferred method of emergency contraception. It is the only TGA registered product for emergency contraception. It is now available over the counter from a pharmacist. Women's health nurse practitioners who have gained permission to store and dispense this drug from their practice are able to provide this medication to eligible women.
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- 1.5mg levornogestrel may be given as Postinor-2™ or the dose can be made up from levenorgestrel minipills. 50 X 30mcg pills may be given as a divided dose given 12 hours apart. This method should only be used if Postinor-2™ is not available.
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Yuzpe method
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This method should only be used if there is no possibility of the woman obtaining the levenorgestrel method. A spare dose is given in case of vomiting. Each of the two doses may be achieved by using any of the following regimens.
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- 4 each of: Nordette™ or Microgynon™ 30 or Monopheme™ or Levlen™
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- 4 each of: Triphasil™ or Triquilar™ or Tripheme™ or Logynon™ (last 10 active pills in the pack)
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- 5 each of Loette™or Microgynon™ 20
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Instructions to be given are to take one metoclopramide tablet (10mg) then half an hour later one dose of hormone. Repeat sequence 12 hours later. Take spare tablets if vomiting occurs within two hours of either dose.
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Referral
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Referral to a medical practitioner should be considered if:
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- the woman wishes to have an IUCD inserted
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- or the woman elects to use IUCD, Implanon™ or Depo-Provera™ for her ongoing contraceptive needs
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Referral to a centre such as CASA House should be offered if the woman has experienced sexual assault.
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Links to consumer information
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- Family Planning Victoria: Emergency Contraception
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- MIMS Consumer medicine Information: Prostinor 2
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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