Updated estimates of the effectiveness of the Yuzpe regimen of emergency contraception

Emergency contraception in the emergency department

BACKGROUND

On June 24, 2022, the Supreme Court overturned Roe v. Wade, which will limit legal abortion in many areas of the U.S., making the need for effective emergency contraception even more critical.

METHODS

This narrative review focuses on the approach to providing safe and effective emergency contraception in the emergency department (ED) with a focus on agents that are used in the U. S.; however, many of the agents discussed are also available and utilized in other countries.

RESULTS

Emergency contraception methods included in this review are, ulipristal, levonorgestrel, combined oral contraceptive pills, and copper intrauterine devices (IUDs).

CONCLUSION

The efficacy of products used for emergency contraception depend on patient and temporal factors. Emergency physicians must have an understanding of the optimal use of these agents to prevent unwanted pregnancy, particularly in the setting of restricted abortion access.

Trends in emergency contraception awareness among women and girls in 28 sub-Saharan countries

Background

Studies have shown that emergency contraception (EC) remains underutilised in preventing unintended pregnancy in sub-Saharan Africa (SSA). Small-scale surveys have attributed EC underutilisation to gaps in EC awareness among SSA women and girls. However, limited studies have explored trends in EC awareness in SSA. We address this gap by examining trends in EC awareness using data from 28 SSA countries. Our analysis was disaggregated by age distribution, place of residence, level of education, and wealth to show differences in EC awareness trend.

Methods

We analysed the Demographic and Health Surveys (DHS) data of 1,030,029 women aged 15 to 49 on emergency contraception awareness. EC awareness was defined as having ever heard of special pills to prevent pregnancy within 3 days after unprotected sexual intercourse. Frequencies and percentages were used to summarise trends in EC awareness between years 2000 and 2019.

Results

Overall, there was an upward shift in the level of EC awareness in all countries, except in Burkina Faso, Niger, Chad, and Ethiopia. While some countries recorded a significant upward trend in EC awareness, others recorded just a slight increase. Women in Kenya, Ghana, Gabon, and Cameroon had the highest upward shift in EC awareness. For example, only 28% of women were aware of EC in Ghana in 2003, but in 2014, 64% of women knew about EC, an increase of over 36 percentage points. Increase in EC awareness was starker among women aged 20–24 years, those who resided in urban areas, had higher education, and belong to the highest wealth quintile, than those aged 15–19, in rural areas, with no formal education and belonging to the lowest wealth quintile.

Conclusion

Our analysis shows that the level of EC awareness has increased substantially in most SSA countries. However, EC awareness still differs widely within and between SSA countries. Intervention to improve EC awareness should focus on women aged 15 to 19, those with no formal education, residing in rural areas, and within the lowest quintile, especially, in countries such as Chad, Niger, Burkina Faso, and Ethiopia where level of EC is low with lagging progress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12067-y.

The safety of available and emerging options for emergency contraception

INTRODUCTION

Emergency contraception (EC) is a way to significantly reduce the chance of becoming pregnant after an episode of unprotected intercourse. Considerable data support the safety of all available and emerging options for EC. Areas covered: This review presents a comprehensive summary of the literature regarding the safety of EC as well as directions for further study. PubMed was searched for all relevant studies published prior to June 2017. Expertopinion: All available methods of EC (i.e., ulipristal acetate pills, levonorgestrel pills, and the copper-IUD), carry only mild side effects and serious adverse events are essentially unknown. The copper IUD has the highest efficacy of EC methods. Given the excellent safety profiles of mifepristone and the levonorgestrel IUD, research is ongoing related to use of these products for EC.

Practice Bulletin No. 152: Emergency Contraception

Emergency contraception, also known as postcoital contraception, is therapy used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. Common indications for emergency contraception include contraceptive failure (eg, condom breakage or missed doses of oral contraceptives) and failure to use any form of contraception (). Although oral emergency contraception was first described in the medical literature in the 1960s, the U.S. Food and Drug Administration (FDA) approved the first dedicated product for emergency contraception in 1998. Since then, several new products have been introduced. Methods of emergency contraception include oral administration of combined estrogen-progestin, progestin only, or selective progesterone receptor modulators and insertion of a copper intrauterine device (IUD). Many women are unaware of the existence of emergency contraception, misunderstand its use and safety, or do not use it when a need arises (). The purpose of this Practice Bulletin is to review the evidence for the efficacy and safety of available methods of emergency contraception and to increase awareness of these methods among obstetrician-gynecologists and other gynecologic providers.

Emergency contraception: What is new?

Unintended pregnancy rates remain high throughout the World and increase the risk of poor maternal and infant outcomes. Most of unintended pregnancies occur in women who were not using contraception or who became pregnant despite the reported use of contraception. Women who have had recent unprotected intercourse including those who have had another form of contraception fail are potential candidates for this intervention. Currently used emergency contraceptive methods are pills that contain combined estrogen-progesterone, only progestin, antiprogestins and copper intrauterine devices. The most common form of this type of contraception is oral progestin-only pills (levonorgestrel). The most effective method is copper intrauterine devices followed by anti-progestins and oral progestin-only pills. The major pathogenesis of oral emergency contraceptives is the prevention or delay of ovulation. Although conception is possible on only a few days of the cycle, emergency contraception is offered when indicated without regard to the timing of the menstrual cycle because of uncertainty in the timing of the ovulation. Levonorgestrel and E/P regimes are most effective as soon as possible after unprotected sexual intercourse. A linear relationship has been shown between effectiveness and the time of dose. The effectiveness continues for 120 h, but it is recommended to be used within 72 h after intercourse. Intrauterine devices may prevent pregnancy when 5 d after ovulation.

Knowledge, attitude and practice of emergency contraception on nursing personnel

INTRODUCTION

Emergency Contraception is a grossly underu-tilized option of prevention of pregnancy. It is a safe and effective method which can prevent unintended pregnancies, unsafe abortions and unwanted childbirth. Knowledge and attitude of Nursing personnel who are both service providers and health educators to the community can influence the contraceptive behavior of the people exposed to them. A few studies done in our country indicate that their awareness regarding EC is low.

AIM

To explore the knowledge, attitude and practice of EC amongst Nursing Personnel in a medical college hospital.

MATERIALS AND METHODS

In this study, 185 nursing personnel participated. A predesigned, pretested questionnaire was used to collect their responses regarding knowledge, attitude and practice of EC. Descriptive analysis of data was done. Results : Out of the total, 52.43% of the participants had good knowledge regarding the general information of EC, 51.35% had positive attitude towards EC, 47.56% had expressed willingness to use EC if indicated whereas only 22.7% had ever used EC. 72.97% had expressed willingness to attend awareness programmes on EC. Conclusion :Even though knowledge and attitude towards EC among the participants was marginally good they had many misconceptions regarding specific aspects like mode of action, indications and timing of administration. More awareness programmes would definitely clear their misconceptions and apprehensions and encourage Nursing Personnel to personally use and promote EC to others.

Community pharmacist perception and attitude toward ethical issues at community pharmacy setting in central Saudi Arabia

OBJECTIVE

The purpose of this study is to identify the community pharmacist perceptions and attitudes toward ethical issues at community pharmacy setting in Saudi Arabia.

METHOD

A cross-sectional, descriptive, and qualitative survey of community pharmacists was conducted and the survey questions were pre-tested by a pharmacist with extensive experience in ethical issues. Based on the result of a pilot study the questionnaire was used with some modifications and the final questionnaire was sent to the participants by handing over in person, mail or Email.

RESULTS

45.7% Often discuss ethical issues with their patients, while only 2.1% never discuss it. 40.6% often record the ethical concern whereas only 1.9% of them never do so. 31.5% reported that patients initiate ethical issues.

DISCUSSION

28.3% of the pharmacists initiate the discussion. The barriers that limit discussing ethical issues with their patients were lack of time due to other obligations assigned to the community pharmacist (69.2%), lack of reliable resources (10.7%), not interested in the subject (10.1%), lack of knowledge on ethical issues (4.8%), and other reasons (5.3%). Recourses are books (37.7%), internet web sites (31.1%), and brochures (26.8%). Only a minority of respondents had access to computer databases (15.8%) and other resources (1.3%). Most perceived ethical problems were: being asked for hormonal contraception, dispensing a drug for unreported indication (69.2%), dispensing dose of medicine for a child that is outside the SNF limits (68.9%), unwanted professional behavior about controlled drugs (66.6%), a colleague insisting on unethical behavior (65.0%), a colleague has done something unethical for the first time (64.7%), suspecting that a child is being abused (63.3%) prescribing on private scripts for suspected medications of possible abuse (60.7%) and terminally ill patient asks for a diagnosis or prognosis (52.9%).

CONCLUSION

The findings of this study assured the need of Saudi health authorities to implement a code of ethics for pharmacy practicing to cover all aspects of ethical issues.

Prevention of unintended pregnancy: a focus on long-acting reversible contraception

This article summarizes the literature regarding the epidemiology and prevention of unintended pregnancy in the United States. Because of the Affordable Care Act and its accompanying contraceptive provision, there is a need for more primary care clinicians to provide family planning services. Office-based interventions to incorporate family planning services in primary care are presented, including clinical tools and electronic health record use. Special attention is paid to long-acting reversible contraceptive methods (the subdermal implant and intrauterine devices); these highly effective and safe methods have the greatest potential to decrease the rate of unintended pregnancy, but have been underused.

"I'll see what I can do": What adolescents experience when requesting emergency contraception

PURPOSE

To understand the experiences of adolescent females when they try to obtain emergency contraception (EC) from pharmacies.

METHODS

Female callers, posing as 17-year-old adolescents, used standardized scripts to telephone 943 pharmacies in five United States cities. Two investigators independently coded qualitative data from these calls. Codes were discussed and a thematic analysis was conducted. Investigator, expert, and informant triangulation were used to ensure data credibility.

RESULTS

Four major themes emerged. First, ethical terms (personal or religious) were used to explain institutional pharmacy policies on EC availability. Second, there was confusion about the dispensing regulations regarding EC, given recent changes in United States policies. Third, pharmacy staff often introduced false barriers to EC access. In some cases, pharmacy staff used these barriers as justification for refusing to dispense EC; however, in other cases, pharmacy staff helped the adolescents overcome these false barriers. Finally, the degree of confidentiality in providing EC was unpredictable, with some pharmacies guaranteeing strict confidentiality and others explicitly telling adolescents, incorrectly, that their parents had to be informed.

CONCLUSIONS

Adolescents requesting EC from pharmacies are often explained pharmacy policies in ethics-laden terms, and confidentiality is not always guaranteed. They are told of false barriers to EC access, and there is confusion concerning the evolving policies regarding EC dispensing. It is important for clinicians, pharmacy staff and others to be aware of these experiences as they work to help improve adolescents' access to EC.

Knowledge, attitude, and practice about Emergency Contraception among health staff in Bushehr state, south of Iran

Emergency Contraception (EC) is used within a few days of unprotected sex to prevent an unintended pregnancy. About one quarter of pregnancies in south of Iran are unintended. EC is important option that women can use after unprotected sex or contraceptive failure for preventing of unplanned pregnancies and adverse maternal and perinatal health outcomes. Health staff have influence on women’s contraceptive behavior and their knowledge and attitudes about EC can affect women’s contraceptive behaviors. Data are lacking about the knowledge, attitude and practice of hormonal EC method among health staff in Bushehr state, south of Iran. A cross-sectional study using self administered questionnaire was conducted. A sample of 170 health staff were surveyed. The mean age of respondents was 30.6±5.1. Overall 6.5% of participants had poor knowledge, 25.2% moderate knowledge, 68.3% good knowledge about EC. Half of participants had positive and half had negative attitude towards the EC method. Midwives and family health workers were more knowledgeable (p<0.05) and more frequently counseled women about EC than general practitioners (GPs) (p<0.001). The most cited reason for EC prescriptions were rupture condom and none use of contraception. Our findings showed despite of majority of health staff had good knowledge about EC, their knowledge about the indications for prescription of EC and its side effects was inadequate. The educational efforts for health staff should be focused more on the specific aspects of EC method. GPs also should be more involved in family planning program.

Emergency contraception

There have been numerous attempts to control fertility after unprotected sexual intercourse (UPSI). From very bizarre methods like the vaginal application of Coca Cola to the more serious attempts using calcium antagonists influencing fertility parameters in sperm to hormonal methods or intrauterine devices. So far, hormonal methods preventing or delaying ovulation have proved to be the most popular starting with the combination of ethinyl estradiol and levonorgestrel (LNG), known as the Yuzpe regimen. The first dose had to be taken within 72 hours of UPSI, a second one 12 hours later. Later on, LNG alone, at first in a regimen similar to the Yuzpe method (2 × 0.75 mg 12 hours apart) showed to be more successful, eventually resulting in the development of a 1.5 mg LNG pill that combined good efficacy with a high ease of use. Several efficacious and easy to use methods for emergency contraception (EC) are available on the market today with the most widely spread being LNG in a single dose of 1.5 mg (given as one tablet of 1.5 mg or 2 tablets of 0.75 mg each) for administration up to 3 days (according to WHO up to 5 days) after UPSI. Its limitations are the non-optimal efficacy which is decreasing the later the drug is taken and the fact that it is only approved for up to 72 hours after UPSI. This regimen has no effect on the endometrium, corpus luteum function and implantation, is not abortive and don't harm the fetus if accidentally taken in early pregnancy. It has no impact on the rate of ectopic pregnancies. It has become the standard method used up to this day in most countries. Since the mid 1970s copper IUDs have been used for EC, which show a high efficacy. Their disadvantages lie in the fact that EC is considered an off label use for most IUDs (not for the GynFix copper IUD in the European Union) and that they might not be acceptable for every patient. Furthermore IUD-insertion is an invasive procedure and it is required trained providers and sterilized facilities. Mifepristone in the dosages of 10 or 25 mg is used with good results as an emergency contraceptive in China for up to 120 hours after UPSI, but has never received any significant consideration in Western countries. While high doses of mifepristone has an effect on endometrial receptivity and will inhibit ovulation if given in the follicular phase and prevent implantation if given in the early luteal phase, low doses such as 10 mg has no impact on the endometrium. Mifepristone does not increase the rate of ectopic pregnancies. The most recent development is the approval of the selective progesterone receptor modulator ulipristal acetate (UPA) in the dosage of 30 mg for EC up to 5 days after UPSI, combining the safe and easy application of the single dose LNG pill with an even higher efficacy. It has shown to be more efficacious than LNG and can be used for up to 120 hours after UPSI; the difference in efficacy is highest for 0-24 hours, followed by 0-72 hours following UPSI. No VTE has been reported following UPA-administration or any progesterone receptor modulator. No effect on endometrium, corpus luteum function and implantation has been observed with doses used for EC. Independent of the substance it should be noted that, if there is a choice, the intake of an oral emergency contraceptive pill should happen as soon as possible after the risk situation. A pre-existing pregnancy must be excluded. Possible contraindications and drug interactions must be considered according to the individual special product informations.

Emerging options for emergency contraception

Emergency post-coital contraception (EC) is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD) and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method), and less commonly, mifepristone. Some options are available over-the-counter, while others require provider prescription or placement. There are no absolute contraindications to the use of emergency contraceptive pills, with the exception of ulipristal acetate and mifepristone. This article reviews the mechanisms of action, efficacy, safety, side effects, clinical considerations, and patient preferences with respect to EC usage. The decision of which regimen to use is influenced by local availability, cost, and patient preference.

Emergency contraception

OBJECTIVE

To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting.

OPTIONS

The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed.

OUTCOMES

Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception.

EVIDENCE

Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed.

VALUES

The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1).

BENEFITS, HARMS, AND COSTS

These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1. Hormonal emergency contraception may be effective if used up to 5 days after unprotected intercourse. (II-2) 2. The earlier hormonal emergency contraception is used, the more effective it is. (II-2) 3. A copper IUD can be effective emergency contraception if used within 7 days after intercourse. (II-2) 4. Levonorgestrel emergency contraception regimens are more effective and cause fewer side effects than the Yuzpe regimen. (I) 5. Levonorgestrel emergency contraception single dose (1.5 mg) and the 2-dose levonorgestrel regimen (0.75 mg 12 hours apart) have similar efficacy with no difference in side effects. (I) 6. Of the hormonal emergency contraception regimens available in Canada, levonorgestrel-only is the drug of choice. (I) 7. A pregnancy that results from failure of emergency contraception need not be terminated (I) Recommendations 1. Emergency contraception should be used as soon as possible after unprotected sexual intercourse. (II-2A) 2. Emergency contraception should be offered to women if unprotected intercourse has occurred within the time it is known to be effective (5 days for hormonal methods and up to 7 days for a copper IUD). (II-2B) 3. Women should be evaluated for pregnancy if menses have not begun within 21 days following emergency contraception treatment. (III-A) 4. During physician visits for periodic health examinations or reproductive health concerns, any woman in the reproductive age group who has not been sterilized may be counselled about emergency contraception in advance with detailed information about how and when to use it. (III-C).

Conception probabilities at different days of menstrual cycle in Chinese women

OBJECTIVE

To investigate the conception probability among Chinese women.

DESIGN

Prospective observational study.

SETTING

Clinics in hospitals and family planning institutes in 10 provinces and cities.

PATIENT(S)

A total of 851 healthy married women aged 18-35 years with normal menstrual cycles who wish to have babies and with no contraception.

INTERVENTION(S)

Urinary LH was measured around days of expected ovulation for 7 days. The Barrett and Marshall model was used for calculation of conception probabilities on each cycle day from day -5 to day +1 in women with multiple episodes of intercourse.

MAIN OUTCOME MEASURE(S)

Pregnancies in 1, 3, and >or=6 months.

RESULT(S)

A total of 851 women with 2,055 cycles were analyzed. In 489 cycles there was only one episode of intercourse. A total of 601 pregnancies occurred. The conception probabilities from days in relation to ovulation -5 to +1 for a single episode of intercourse were 0.216, 0.102, 0.236, 0.233, 0.388, 0.293, and 0.386, respectively, and for multiple episodes they were 0.254, 0.271, 0.293, 0.365, 0.315, and 0.284, respectively, with the peak value at day -1. Recalculation of the efficacy of emergency contraception with low-dose mifepristone with the present conception probabilities showed higher efficacy.

CONCLUSION(S)

Conception probabilities among Chinese women are different from those in the literature. Further comparative studies are needed to confirm an ethnic difference.

Reasons for requesting emergency contraception: A survey of 506 Italian women

OBJECTIVE

To evaluate the reason for requesting emergency contraception (EC), previous use of contraceptive methods and provision route in a Family Planning Clinic in Italy.

METHODS

Women requesting EC were interviewed, through a questionnaire containing questions on demographic characteristics, about their reasons for requesting EC, their prior contraceptive use, their reasons for not using an effective contraceptive method (or possible reasons for its failure) and specifically about the so-called 'provision route' (i.e. whether and where they had previously requested EC receiving a negative response).

RESULTS

Almost 70% of all women requesting EC were aged between 18 and 25 years. Some 80% of all women were in a stable relationship with their partner, with fewer than 20% having had an occasional intercourse. The vast majority of women (83%) reported prior use of a modern contraceptive method, i.e. 64% with a condom, 27% for combined oral contraceptives and 1.1% for the intrauterine device (IUD). In addition, 15% of the women had used more than one method (oral pills and condoms). Concerning the reasons for requesting EC, condom breakage or slipping was the most frequently cited (64%), followed by totally unprotected intercourse (28%), failed withdrawal (5%) and forgetting one or more pill (only 1.1%).

CONCLUSIONS

More than one-third of the women interviewed had previously used an emergency contraceptive modality; although no one did so more than four times. Therefore, it can be inferred that-at least in the present series-EC had not been used as a routine contraceptive method. Finally, it seems clear that in Italy, even in large cities, information about the availability, proper usage and mechanism of action is lacking. This seems due to information being spread by word of mouth between peers and friends, with more formal communication channels lagging behind.

Barriers to adolescents' getting emergency contraception through pharmacy access in California: differences by language and region

CONTEXT

In California, emergency contraception is available without a prescription to females younger than 18 through pharmacy access. Timely access to the method is critical to reduce the rate of unintended pregnancy among adolescents, particularly Latinas.

METHODS

In 2005-2006, researchers posing as English- and Spanish-speaking females-who said they either were 15 and had had unprotected intercourse last night or were 18 and had had unprotected sex four days ago-called 115 pharmacy-access pharmacies in California. Each pharmacy received one call using each scenario; a call was considered successful if the caller was told she could come in to obtain the method. Chi-square tests were used to assess differences between subgroups. In-depth interviews with 22 providers and pharmacists were also conducted, and emergent themes were identified.

RESULTS

Thirty-six percent of all calls were successful. Spanish speakers were less successful than English speakers (24% vs. 48%), and callers to rural pharmacies were less successful than callers to urban ones (27% vs. 44%). Although rural pharmacies were more likely to offer Spanish-language services, Spanish-speaking callers to these pharmacies were the least successful of all callers (17%). Spanish speakers were also less successful than English speakers when calling urban pharmacies (30% vs. 57%). Interviews suggested that little cooperation existed between pharmacists and clinicians and that dispensing the method at clinics was a favorable option for adolescents.

CONCLUSIONS

Adolescents face significant barriers to obtaining emergency contraception, but the expansion of Spanish-language services at pharmacies and greater collaboration between providers and pharmacists could improve access.

Emergency contraception: the state of the art

Emergency contraception, otherwise known as post-coital contraception, is part of the continuum of contraceptive methods that women and couples can use for pregnancy prevention. Although emergency contraception should not be used as a regular, plan-ahead contraceptive method, it gives a woman one last-ditch effort to prevent unwanted pregnancy. This paper reviews the history of emergency contraception, the need for further studies, and results of studies conducted at the World Health Organization. Various methods used for emergency contraception are discussed, as well as their efficacies and side effects.

Pharmacy students' knowledge, attitudes, and behaviors regarding emergency contraception

OBJECTIVES

To determine pharmacy students' knowledge, attitudes, and behaviors regarding emergency contraception.

METHODS

A cross-sectional survey was conducted among a convenience sample of students prior to a regular class period. The 16-item survey instrument included both multiple-choice and true/false questions to assess knowledge and Likert-type scale questions regarding attitudes and behaviors. Frequency and descriptive statistics were calculated for all variables.

RESULTS

Three hundred one pharmacy students were surveyed. Eighty-seven percent knew that Plan B had been approved by the Food and Drug Administration (FDA) for nonprescription use, yet 33% believed that it worked by disrupting a newly implanted ovum. On a scale from 1-5 on which 5 = strongly agree, the mean item score was 1.5 for whether nonprescription emergency contraception should be available without counseling by a pharmacist, yet only 26.7% believed they were competent instructing patients on the use of emergency contraception.

CONCLUSIONS

Additional education is needed to prepare pharmacy students to provide informed pharmaceutical care to patients seeking emergency contraception, especially given the passage of legislation making the pharmacy the point of access for some emergency contraception products.

Understanding contraceptive failure

Contraceptive failure is a major source of unintended pregnancy. This chapter will review sources of data and measurement of contraceptive failure, summarize results from the literature on the risks of contraceptive failure during typical and perfect use for available methods of contraception, provide a tool for communicating risks of contraceptive failure to clients, examine determinants of contraceptive failure, and identify methodological pitfalls in the published literature.

Emergency contraception: a review

Emergency contraception (EC), also known as 'the morning after pill', or post-coital contraception, is a modality of preventing the establishment of a pregnancy after unprotected intercourse. Both a hormonal and an intrauterine form are available. Modern hormonal EC, with low side effects, was first proposed by Yuzpe in 1974. More recently, a new regimen, consisting of levonorgestrel administered alone, was introduced and found in clinical trials to be more effective (if taken as early as possible), and associated with less side effects than the Yuzpe regimen, which it has gradually replaced. The WHO developed another regimen based on the use of the selective progesterone receptor modulator (antiprogestin) mifepristone and conducted trials with different dosages. Intrauterine EC was first proposed by Lippes in 1976. It has the advantage of being applicable for almost a week and the disadvantage of a greater complexity. In addition, this modality is solely interceptive, acting by preventing implantation. Pregnancy rates reported following EC using an intrauterine device with more than 300 mm2 of copper are consistently low (0.1-0.2%).

Arkansas pharmacists' perceptions toward emergency contraception and nonprescription Plan B

Objective

This study describes Arkansas pharmacists’ knowledge, attitudes, and beliefs regarding emergency contraception.

Methods

A cross-sectional survey was conducted among a convenience sample of pharmacists prior to a continuing education lecture. The 16-item survey included multiple choice and true/false questions to assess knowledge in addition to Likert-type scale questions regarding attitudes and beliefs. Frequency and descriptive statistics were calculated for all variables.

Results

Eighty-eight pharmacists completed the survey. A majority (73%) knew that Plan B had been FDA-approved for nonprescription use yet 42% believed that it works by disrupting a newly implanted ovum. On a scale from 1-5 where 5=strongly agree, the mean item score was 3.2 for whether emergency contraception should be available for nonprescription use with counseling and 1.6 for nonprescription use without counseling. When asked what they would do if presented with a request for emergency contraception, 45.8% indicated they would dispense the drug, 22.9% would refer the patient to another pharmacist or pharmacy, 3.6% would refuse to dispense, and 27.7% were not sure. Almost half (48.6%) did not believe they were competent instructing patients on the use of emergency contraception.

Conclusions

The results show that pharmacists could benefit from additional training on emergency contraception.

Patients' emergency contraception comprehension, usage, and view of the emergency department role for emergency contraception

Female Emergency Department (ED) patients were surveyed to determine their comprehension of the concept of emergency contraception (EC), to assess how often they had used EC in comparison to other forms of contraception, and to learn which patients want the ED to provide EC services. Most of the 761 respondents were aged < 35 years (62.1%), never married (42.9%), had been pregnant at least once (70.2%), had never had an abortion (76.1%), had never used EC (90.6%), and had sex with a man within the past month (70.7%). Respondents were 2.5 times more likely to have had an abortion than to have used EC; 85.3% could not correctly answer two questions that assessed comprehension of the concept of EC; 43.1% wanted the ED to offer EC, 55.6% to provide information about EC, and 52.6% to refer patients for EC. Younger patients, those who attended religious services infrequently, patients who had ever used EC, and those at risk of pregnancy were more likely to want the ED to provide EC services.

Emergency contraception, myths and facts

Emergency contraception has the potential to reduce the United States unintended pregnancy rate by half. This article discusses the evidence on the safety and efficacy of emergency contraception, its side effects, as well as its mechanisms of action. Emergency contraception availability presents many opportunities for enhanced contraceptive care, beyond the obvious lapse in condom use, and evidence is lacking for contraindications to this expanded role. This article concludes that clinicians caring for women of reproductive age should recognize the importance of ready access to this medication to help prevent unintended pregnancies.

Advance provision of emergency contraception for pregnancy prevention (full review)

BACKGROUND

Emergency contraception can prevent pregnancy when taken after unprotected intercourse. Obtaining emergency contraception within the recommended time frame is difficult for many women. Advance provision, in which women receive a supply of emergency contraception before unprotected sex, could circumvent some obstacles to timely use.

OBJECTIVES

To summarize randomized controlled trials evaluating advance provision of emergency contraception to explore effects on pregnancy rates, sexually transmitted infections, and sexual and contraceptive behaviors.

SEARCH STRATEGY

In August 2006, we searched CENTRAL, EMBASE, POPLINE, MEDLINE via PubMed, and a specialized emergency contraception article database. We also searched reference lists and contacted experts to identify additional published or unpublished trials.

SELECTION CRITERIA

We included randomized controlled trials comparing advance provision and standard access, which was defined as any of the following: counseling which may or may not have included information about emergency contraception, or provision of emergency contraception on request at a clinic or pharmacy.

DATA COLLECTION AND ANALYSIS

We evaluated all identified titles and abstracts found for potential inclusion. Two reviewers independently abstracted data and assessed study quality. We entered and analyzed data using RevMan 4.2.8. We calculated odds ratios with 95% confidence intervals for dichotomous data and weighted mean differences with 95% confidence intervals for continuous data.

MAIN RESULTS

Eight randomized controlled trials met our criteria for inclusion, representing 6389 patients in the United States, China and India. Advance provision did not decrease pregnancy rates (OR 1.0; 95% CI: 0.78 to 1.29 in studies for which we included twelve month follow-up data; OR 0.91; 95% CI: 0.69 to 1.19 in studies for which we included six month follow-up data; OR 0.49; 95% CI: 0.09 to 2.74 in a study with three month follow up data), despite increased use (single use: OR 2.52; 95% CI 1.72 to 3.70; multiple use: OR 4.13; 95% CI 1.77 to 9.63) and faster use (weighted mean difference (WMD) -14.6 hours; 95% CI -16.77 to -12.4 hours). Advance provision did not lead to increased rates of sexually transmitted infections (OR 0.99; 95% CI 0.73 to 1.34), increased frequency of unprotected intercourse, nor changes in contraceptive methods. Women who received emergency contraception in advance were equally as likely to use condoms as other women.

AUTHORS' CONCLUSIONS

Advance provision of emergency contraception did not reduce pregnancy rates when compared to conventional provision. Advance provision does not negatively impact sexual and reproductive health behaviors and outcomes. Women should have easy access to emergency contraception, because it can decrease the chance of pregnancy. However, the interventions tested thus far have not reduced overall pregnancy rates in the populations studied.

Texas community pharmacists' willingness to participate in pharmacist-initiated emergency contraception

OBJECTIVES

To determine Texas community pharmacists' knowledge about and experience with emergency contraception (EC), their perceptions about and willingness to participate in pharmacist-initiated emergency contraception (PIEC), and whether their willingness is influenced by their background characteristics or experience with EC.

DESIGN

Cross-sectional study.

SETTING

Texas in November through December 2004.

PARTICIPANTS

300 community pharmacists.

INTERVENTIONS

Mailed questionnaire consisting of 40 questions divided into three SECTIONS: experience with EC, perceptions about PIEC, and background information.

MAIN OUTCOME MEASURES

Pharmacists' perceptions and behaviors regarding EC and PIEC, and their willingness to participate in PIEC. Bivariate analysis to assess background characteristics and experience with EC in relation to willingness to participate in PIEC; multiple regression to identify predictors of willingness to participate in PIEC.

RESULTS

With a usable response rate of 51%, results indicate that most pharmacists (91.2%) had heard of EC, while 45.2% kept EC in stock. More than one half (57.8%) had dispensed EC, and 95.5% were aware that EC is most effective when taken within 72 hours. Some 27.4% were opposed to dispensing EC, primarily because of religious (86.1%) and moral (80.6%) beliefs. Most (57.7%) believed that there should be a minimum age (mean +/- SD, 17.25 +/- 1.93 years) for patients receiving EC. Less than one half (46.7%) had heard of PIEC. Although pharmacists agreed (3.42 +/- 1.38) that PIEC would enhance the role of community pharmacists, they were unwilling (2.71 +/- 1.54) to participate in PIEC. Significant predictors of willingness to participate in PIEC included background characteristics, experience with EC, as well as benefits and barriers associated with PIEC. A regression analysis indicated that these significant predictors accounted for 58.6% of the total variance in willingness to participate in PIEC.

CONCLUSION

A majority of Texas community pharmacists were quite knowledgeable about and aware of EC, but fewer had actually dispensed EC. Most had not heard of PIEC before study participation, and their perceptions relating to PIEC were generally unfavorable. Potential barriers to PIEC outnumbered potential benefits for most pharmacists. Findings indicate that Texas community pharmacists were not willing to become involved in PIEC at the time of this study.

Trends in knowledge of emergency contraception among women in California, 1999–2004

OBJECTIVE

To examine trends in knowledge of emergency contraception (EC) and determine whether disparities in knowledge have persisted over time.

STUDY DESIGN

This study is based on 6 years of the California Women's Health Survey, a population-based telephone survey. We examine predictors of EC knowledge among 11,998 women age 18-44.

RESULTS

Between 1999 and 2004, the percentage of women aware of EC increased from 40-57%. Despite this increase, disparities in EC knowledge based on women's age, race/ethnicity, and socioeconomic status persist. Foreign-born Hispanic women, women whose income falls below the poverty level, and women who did not complete high school reported the lowest levels of EC knowledge in 2004.

CONCLUSIONS

Education efforts may increase overall knowledge of the method. However, efforts must tailor these messages to women who may be outside the reach of traditional media and remain unaware of EC.

The determinants and circumstances of use of emergency contraceptive pills in France in the context of direct pharmacy access

BACKGROUND

In France, the 1999 introduction of a dedicated emergency contraceptive pill (ECP) available without a prescription has resulted in a 72% increase in its use over the past 5 years, especially among younger women.

METHODS

We used a population-based health survey conducted in 1999 and in 2004 to examine the changes in the determinants of lifetime ECP use among women aged between 15 and 24 years. We also explored the determinants and circumstances of recent use of ECPs in 2004 among women aged between 15 and 44 years who are at risk for unplanned pregnancy.

RESULTS

In 1999, 14.6% of women aged between 15 and 24 years had ever used ECPs; this proportion rose to 31.7% in 2004. Results show consistent patterns of lifetime ECP use in 1999 and in 2004, with greater use among higher-educated women and women living in large cities. In 2004, 22% of women were using no contraceptive at the time they used ECPs and 84% resumed use of a regular contraceptive after ECP use. However, 5.5% had unprotected intercourse after taking ECPs in the same menstrual cycle and in the next.

CONCLUSION

Despite direct pharmacy access, differences in ECP use remain by social and residential status. Emergency contraceptive pills were used as a backup method in case of contraceptive failure and did not impede the use of subsequent regular contraception.

Current issues in emergency contraception: an overview for providers

Emergency contraception has the potential to greatly reduce the number of unintended pregnancies occurring each year in the United States. Emergency contraception is a safe and effective intervention to which all women should have easy access in the event of an act of unprotected intercourse. Methods of emergency contraception include combined hormone oral contraceptive pills, progestin-only oral contraceptive pills, a dedicated progestin-only emergency contraceptive product, and insertion of a copper intrauterine device. Barriers exist to the increased use of emergency contraception, including the prescription-only status of all of the methods and lack of accurate knowledge on the part of health care providers and consumers. This article provides an overview of the clinical management of emergency contraception.

Hormonal contraception: recent advances and controversies

This document will outline new delivery systems and contraceptive formulations, summarize recent advances in emergency contraception, and review the effects of hormonal contraception on cancer risks, cardiovascular disease, and bone.

Birth control within reach: a national survey on women's attitudes toward and interest in pharmacy access to hormonal contraception

OBJECTIVE

This survey was conducted to better understand women's experiences with hormonal contraception and their interest in and attitudes toward gaining direct access to oral contraception (OC), patch, ring or emergency contraception (EC) in pharmacies.

METHOD

A nationally representative telephone survey of 811 women aged 18-44 years who were at risk for unintended pregnancy was conducted in the United States.

RESULTS

It was found that 68% of women in the United States said they would use pharmacy access to OC, patch, ring and/or EC. Likely users include women not using contraception who would begin using hormonal contraceptives (41%) if they were available directly in pharmacies, and OC, patch or ring users who were interested in obtaining their method this way (66%). Over half of the women (55%) said they would be more likely to use EC if they were available directly in pharmacies. Interest in pharmacy access is higher among uninsured and low-income women. Support for pharmacy access hinges on pharmacist screening, with 63% of women agreeing that OC, patch and ring should be available without prescription if pharmacists screen women for medically safe use.

CONCLUSION

Most women in the United States believe that hormonal contraception should be available without prescription and would personally use pharmacy access. Seventeen to 22 million women constitute the potential market for pharmacy access to hormonal contraceptives in the United States. Women's enthusiasm for pharmacy access suggests that the pharmacy is an important site for the provision of sexual health education, screening and supplies.

Acceptance and use of emergency contraception with standardized counseling intervention: results of a randomized controlled trial

OBJECTIVE

The objective of this work was to evaluate the acceptance, use and recall of an optional advance prescription for emergency contraception (EC).

MATERIALS AND METHODS

This study used as randomized controlled trial evaluating contraceptive counseling intervention with women aged 16-44 years who were at risk for unintended pregnancy (N=737). Intervention participants (n=365) received contraceptive counseling with optional advance EC prescription. Control women (n=372) received no contraceptive or EC counseling. Among intervention participants, initial acceptance and use of EC in first 2 months were evaluated. Among all participants, differences were evaluated between recall of EC discussion and use of EC.

RESULTS

Among 365 intervention women, 336 received EC counseling and 51% of these 336 accepted advance EC prescription. At 2 months, among the women who had accepted EC, 6% had filled and used their prescription and 8% had filled but not used their prescription. At 12 months, intervention women were significantly more likely than controls to recall talking about EC (33% vs. 5%) and obtaining a prescription (38% vs. 6%), but there were no differences in the use of EC (6% vs. 6%).

CONCLUSION

When the option is available for EC counseling, approximately half of women accepted advance prescription for EC. However, few women who received information and/or an advance prescription remembered discussing EC, filled the prescription or used EC over 12 months.

Hormonal contraception in adolescents: special considerations

With the rates of unintended pregnancies in teenagers remaining high, it is crucial to present adolescents with all of the contraceptive options available to them. While barrier methods, for example, male condoms, are easily accessible and do not have adverse effects, their use must be consistent and correct with each act of intercourse. Hormonal contraception affords much better efficacy in preventing pregnancy when used with full compliance. Oral contraceptives are a popular method of contraception among adolescents and offer many non-contraceptive benefits along with the prevention of pregnancy. They have very few significant adverse effects, which are outweighed by the significant morbidity associated with teenage pregnancies, and can be used by most adolescent females. However, their minor bothersome effects do contribute to the high discontinuation rates seen. In addition, many girls find it difficult to remember to take a pill every day, leading to higher failure rates in teenagers than in adult women. The advent of long-acting, progestogen (progestin)-only methods, such as injectables and implantables, has been generally accepted by adolescents and these methods have proven to be more efficacious by avoiding the need for daily compliance. However, progestogen-only methods cause irregular bleeding and amenorrhea, which is not acceptable to many teenagers. In addition, the most widely used implant was taken off the market a few years ago and newer forms are not yet widely accessible. Other novel methods are currently available, including the transdermal patch and the vaginal ring. Both are combinations of estrogen and progestogen and have similar efficacy and adverse effect profiles to oral contraceptives. Their use may be associated with greater compliance by adolescents because they also do not require adherence to a daily regimen. However, there may be some drawbacks with these newer methods, for example, visibility of the patch and difficulty with insertion of the vaginal ring. When regular contraceptive modalities fail, emergency contraception is available. Choices include combination oral contraceptives, progestogen-only pills, mifepristone, or placement of a copper-releasing intrauterine device. These methods can be very useful for preventing pregnancy in adolescents as long as adolescents are aware of their existence and have easy access to them.