Population-based evaluation of the effectiveness of two regimens for emergency contraception

Maximizing the effectiveness of 1.5 mg levonorgestrel for emergency contraception: The case for precoital use

Objectives

U.S. and World Health Organization Selected Practice Recommendations for Contraceptive Use state people may have an advanced supply of emergency contraception (EC) to minimize treatment delays. We sought to characterize the potential improvement in effectiveness of 1.5 mg levonorgestrel (LNG-EC) if it were taken up to a few hours before unprotected sex.

Study design

We expanded on an existing mathematical model for the maximum attainable effectiveness of LNG-EC, assuming it exclusively works to disrupt ovulation, and compared results with point estimates from nine studies when it was taken up to 72 hours after sex. We then modelled how effectiveness might have improved if subjects had taken LNG-EC up to 3 hours before sex.

Results

Taking LNG-EC immediately after sex could potentially reduce the risk of unintended pregnancy by 91%. However, population-average maximum attainable effectiveness levels ranged from just 49% to 67% when accounting for the distributions of postcoital treatment delays in the example studies. If half the subjects had taken it 3 hours before sex, then maximum effectiveness levels would have ranged from 70% to 81%.

Conclusions

At the individual level, taking LNG-EC a few hours before sex is a logical extension of Selected Practice Recommendations regarding an advanced supply of EC and, based on our modeling, should be advocated for people who can reasonably anticipate an unprotected sex act. In the absence of more clinical data, however, people should not routinely rely on precoital use of LNG-EC to prevent pregnancy unless modern, effective contraceptives are inaccessible to them.

Implications

Based on mathematical modeling, individuals who anticipate needing to take LNG-EC for an impending unprotected act of sex could further reduce their chance of an undesired pregnancy by taking it a few hours in advance.

Dispensing and practice use patterns, facilitators and barriers for uptake of ulipristal acetate emergency contraception in British Columbia: a mixed-methods study

BACKGROUND

Ulipristal acetate 30 mg became available as prescription-only emergency contraception in British Columbia, Canada, in September 2015, as an addition to over-the-counter levonorgestrel emergency contraception. In this study, we determined dispensing and practice use patterns for ulipristal acetate, as well as facilitators of and barriers to emergency contraception for physicians, pharmacists and patients in BC.

METHODS

In the quantitative component of this mixed-methods study, we examined ulipristal acetate use from September 2015 to December 2018 using a database that captures all outpatient prescription dispensations in BC (PharmaNet) and another capturing market sales numbers for all oral emergency contraception in BC (IQVIA). We analyzed the quantitative data descriptively. We conducted semistructured interviews from August to November 2019, exploring barriers and facilitators affecting the use of ulipristal acetate. We performed iterative qualitative data collection and thematic analysis guided by Michie's Theoretical Domains Framework.

RESULTS

Over the 3-year study period, 318 patients filled 368 prescriptions for ulipristal acetate. Use of this agent increased between 2015 and 2018. However, levonorgestrel use by sales (range 118 897-129 478 units/yr) was substantially higher than use of ulipristal acetate (range 128-389 units/yr). In the 39 interviews we conducted, from the perspectives of 12 patients, 12 community pharmacists, and 15 prescribers, we identified the following themes and respective theoretical domains as barriers to access: low awareness of ulipristal acetate (knowledge), beliefs and experiences related to shame and stigma (beliefs about consequences), and multiple health system barriers (reinforcement).

INTERPRETATION

Use of ulipristal acetate in BC was low compared with use of levonorgestrel emergency contraception; lack of knowledge, beliefs about consequences and health system barriers may be important impediments to expanding use of ulipristal acetate. These findings illuminate potential factors to explain low use of this agent and point to the need for additional strategies to support implementation.

Case of rupture ectopic pregnancy with emergency contraception levonorgestrel 0.075 mg in a lactating woman

Levonorgestrel emergency contraception (LNG-EC) tends to make uterus unfavorable for implantation but does not prevent embryo implantation. Emergency contraceptives pills should be used with caution among lactating women who at the same time should be monitored closely for ectopic pregnancy.

90 YEARS OF PROGESTERONE: Selective progesterone receptor modulators in gynaecological therapies

Abnormal uterine bleeding (AUB) is a chronic, debilitating and common condition affecting one in four women of reproductive age. Current treatments (conservative, medical and surgical) may be unsuitable, poorly tolerated or may result in loss of fertility. Selective progesterone receptor modulators (SPRMs) influence progesterone-regulated pathways, a hormone critical to female reproductive health and disease; therefore, SPRMs hold great potential in fulfilling an unmet need in managing gynaecological disorders. SPRMs in current clinical use include RU486 (mifepristone), which is licensed for pregnancy interruption, and CDB-2914 (ulipristal acetate), licensed for managing AUB in women with leiomyomas and in a higher dose as an emergency contraceptive. In this article, we explore the clinical journey of SPRMs and the need for further interrogation of this class of drugs with the ultimate goal of improving women's quality of life.

Validating abortion procedure coding in Canadian administrative databases

Background

The British Columbia (BC) Ministry of Health collects abortion procedure data in the Medical Services Plan (MSP) physician billings database and in the hospital information Discharge Abstracts Database (DAD). Our study seeks to validate abortion procedure coding in these databases.

Methods

Two randomized controlled trials enrolled a cohort of 1031 women undergoing abortion. The researcher collected database includes both enrollment and follow up chart review data. The study cohort was linked to MSP and DAD data to identify all abortions events captured in the administrative databases. We compared clinical chart data on abortion procedures with health administrative data. We considered a match to occur if an abortion related code was found in administrative data within 30 days of the date of the same event documented in a clinical chart.

Results

Among 1158 abortion events performed during enrollment and follow-up period, 99.1 % were found in at least one of the administrative data sources. The sensitivities for the two databases, evaluated using a gold standard, were 97.7 % (95 % confidence interval (CI): 96.6–98.5) for the MSP database and 91.9 % (95 % CI: 90.0–93.4) for the DAD.

Conclusions

Abortion events coded in the BC health administrative databases are highly accurate. Single-payer health administrative databases at the provincial level in Canada have the potential to offer valid data reflecting abortion events.

Trial registration

ClinicalTrials.gov Identifier NCT01174225, Current Controlled Trials ISRCTN19506752.