A prospective, open-label, single arm, multicentre study to evaluate efficacy, safety and acceptability of pericoital oral contraception using levonorgestrel 1.5 mg

Acceptability of an on-demand pericoital oral contraceptive pill: a systematic scoping review

BACKGROUND

Access to an on-demand pericoital oral contraceptive pill - used to prevent pregnancy within a defined window around sexual intercourse - could offer women more reproductive agency. A contraceptive with this indication is not currently available in any market. This review aims to understand international user appeal for an on-demand pericoital oral contraceptive pill.

METHODS

Systematic scoping review, comprising 30 peer-reviewed papers published between 2014-2023.

RESULTS

Data from 30 papers reporting on research from 16 countries across five World Health Organisation regions suggests widespread user appeal for on-demand oral contraceptive pills that can be used peri- or post-coitally, especially among women who are younger, more educated or who have less frequent sex. Women of varying age, wealth, employment or relationship status, and with different prior experience of using modern contraceptives, were also interested. Women identified clear rationale for use and preference of these types of product: close alignment with women's sexual lives that comprised unplanned, spontaneous or occasional sex; perceived convenience and effectiveness; discreet use of pills to negotiate contextual circumstances that constrained their reproductive agency. Factors inhibiting use included knowledge barriers and attitudes of service providers, a lack of knowledge and misinformation among end-users, women's dislike of menstrual side effects and myths related to the effects of hormone content on future fertility.

CONCLUSIONS

Introduction of an on-demand pericoital oral contraceptive pill could expand contraceptive choice for diverse women experiencing unmet need for modern contraception and constrained sexual and reproductive agency. Priorities for future research include: broadening the geographical scope of evidence to include SE Asia and the Pacific, and international rural and peri-urban settings; documenting the perspectives of adolescents and unmarried young people; identifying opportunities for innovation in the supply channels to enhance appropriate, affordable access to on-demand oral contraceptives; and unpacking how to bring new pericoital contraceptives to the market in a variety of international settings.

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.

Feasibility and Acceptability of LNG 1.5 mg as an On-Demand Pericoital Contraceptive in Ghana

Globally, there is a need for more family planning method options as currently, available options do not adequately meet the needs of women, specifically those who have infrequent sex. Levonorgestrel (LNG) 1.5 mg is widely available as emergency contraception pills (ECP), and recent research has shown that certain women take it as their main form of contraception. Furthermore, limited studies have found repeat, on-demand use safe and efficacious. This 12-month prospective, single-arm, interventional study in Ghana tested whether a single LNG 1.5 mg on-demand or pericoital ("around the time of sex") dose contraceptive was acceptable to women who have infrequent sex and if pharmacy provision was feasible. The study sample (1,890) comprised women of reproductive age recruited from urban areas, having infrequent sex (i.e., coital frequency ≤ 6× per month), and not using any other modern methods except condoms or ECP at the time of study inclusion. Results indicated that there is demand and acceptability for a pericoital pill and that pharmacy provision is feasible. Furthermore, precoital use of the pill had high levels of satisfaction and was popular with new users. Adding LNG 1.5 mg for pericoital use to the family planning method mix has the potential to address an important segment of the population currently underserved, decrease unwanted pregnancies, and increase modern contraceptive prevalence rates.

A systematic review and meta-analysis of the prevalence and association between levonorgestrel and ectopic pregnancy

BACKGROUND

The use of levonorgestrel emergency oral contraceptives (EOCs) is one of the factors that may be associated with ectopic pregnancy. We aimed to investigate the incidence of ectopic pregnancy in EOC users and the association between EOCs and ectopic pregnancy.

RESEARCH DESIGN AND METHODS

We searched for articles that provided the incidence of and the association between levonorgestrel EOCs and ectopic pregnancy in women of reproductive ages in CINAHL Complete, Medline, OpenDissertations, Scopus, Science Direct, and Thai Journal Online. The risk of bias was assessed by Risk Of Bias In Non-randomized Studies or Risk of Bias 2. A meta-analysis was conducted using the random-effects model.

RESULTS

We retrieved 1839 nonredundant articles from the systematic search. The meta-analysis showed that the prevalence of ectopic pregnancy was not statistically different from zero (pooled prevalence estimate = 0.029%; 95%CI: -0.006, 0.065; N = 9; I2 = 0) and rare. In addition, levonorgestrel EOCs increased the risk of ectopic pregnancy (OR = 6.17; 95%CI: 3.78, 10.08; N = 5; I2 = 43%).

CONCLUSIONS

Women with extrauterine or ectopic pregnancy had higher odds of using levonorgestrel emergency oral contraceptives than those with intrauterine pregnancy. However, the prevalence of ectopic pregnancy is rare.

Optimizing the pipeline of multipurpose prevention technologies: opportunities across women's reproductive lifespans

HIV/AIDS and maternal mortality are the two leading causes of death among women of reproductive age in sub-Saharan Africa. A growing body of research investigates opportunities for multipurpose prevention technologies (MPTs) that prevent unintended pregnancy, HIV, and/or other sexually transmitted infections (STIs) with a single product. More than two dozen MPTs are currently in development, most of them combining contraception with HIV pre-exposure prophylaxis, with or without protection from other STIs. If successful, such MPTs could offer women benefits at multiple levels: greater motivation for effective use; lower product administration burden; accelerated integration of HIV, STI, and reproductive health services; and opportunities to circumvent stigma by using contraception as a "fig leaf" for HIV and/or STI prevention. However, even if women find respite from product burden, lack of motivation, and/or stigma in contraceptive-containing MPTs, their use of MPTs will be interrupted, often multiple times, over the reproductive lifecourse due to desire for pregnancy, pregnancy and breastfeeding, menopause, and changes in risk. Interruptions to the benefits of MPTs could be avoided by combining HIV/STI prevention with other life-stage-appropriate reproductive health products. New product concepts could include combining prenatal supplements with HIV and STI prevention, emergency contraception with HIV post-exposure prophylaxis, or hormone replacement therapies for menopause with HIV and STI prevention. Research is needed to optimize the MPT pipeline based on the populations underserved by available options and the capacity of resource-constrained health systems to deliver novel preventative healthcare products.

Society of Family Planning Clinical Recommendation: Emergency contraception

Emergency contraception (EC) refers to several contraceptive options that can be used within a few days after unprotected or under protected intercourse or sexual assault to reduce the risk of pregnancy. Current EC options available in the United States include the copper intrauterine device (IUD), levonorgestrel (LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way, Take Action), and oral ulipristal acetate (UPA) (ella). These clinical recommendations review the indications, effectiveness, safety, and side effects of emergency contraceptive methods; considerations for the use of EC by specific patient populations and in specific clinical circumstances and current barriers to emergency contraceptive access. Further research is needed to evaluate the effectiveness of LNG IUDs for emergency contraceptive use; address the effects of repeated use of UPA at different times in the same menstrual cycle; assess the impact on ovulation of initiating or reinitiating different regimens of regular hormonal contraception following UPA use; and elucidate effective emergency contraceptive pill options by body mass indices or weight.

Feasibility of e-commerce pharmacy provision and acceptability of levonorgestrel 1.5 mg for pericoital use in urban and peri-urban settings in Kenya: a prospective cohort study

INTRODUCTION

An 'on-demand' contraceptive pill may suit women having infrequent sex. We assessed the feasibility of e-commerce pharmacy provision and acceptability of levonorgestrel (LNG) 1.5 mg for pericoital use in Kenya.

METHODS

A 12-month prospective, single-arm, open-label, interventional study conducted from August 2020 to August 2021. A total of 897 women aged 18-49 years at risk of pregnancy and having infrequent sex (ie, six times or fewer coital frequency/month) were screened and enrolled. We undertook univariate and bivariate analysis on multiple data points: enrolment dataset, bimonthly surveys, extended survey around 6-month follow-up, and e-commerce pharmacy sales log.

RESULTS

A total of 2291 pericoital LNG 1.5 mg pill doses were dispensed to 300 women over a 12-month period mainly via the USSD (Unstructured Supplementary Service Data) platform. Of the 266 women who obtained the pill and completed the survey, most (83%) were satisfied/very satisfied with e-commerce platform services, citing convenience and ease of use. The pill was also acceptable. Of the 266 women who used it at least once, 94% were satisfied/very satisfied, likely to continue using and would recommend it to others; 86% used it within 24 hours before/after sex as recommended and most of the time they had sex; and 147 (55%) experienced side effects, mainly nausea, headache, changes in menstrual pattern, cramps and dizziness that were mild and tolerable.

CONCLUSIONS

E-commerce pharmacy provision of LNG 1.5 mg for pericoital use is feasible. In addition, a pericoital LNG 1.5 mg pill is acceptable among women having infrequent sex and could potentially address their unmet family planning needs.

Dynamics of Emergency Contraceptive Use in Accra, Ghana

Recent data suggest increasing rates of emergency contraception (EC) use in Ghana, particularly in urban areas. In 2018, we collected survey data from 3,703 sexually experienced women aged 16-44 years living in low-income settlements of Accra. We estimated the prevalence of lifetime and current EC use. Multivariate logistic regression was used to assess factors associated with current use of EC. Retrospective monthly calendar data on contraceptive use were analyzed to identify patterns of EC use, including repeat and continuous use, and uptake of other contraceptive methods in the months following EC use. Nearly 15 percent of women had ever used EC. About half of recent EC users (52 percent) used EC for at least four months cumulatively within a 12-month window. There was no evidence of adoption of other modern methods in the months after using EC. Our results suggest that EC is a common method for pregnancy prevention in Accra, particularly among young, unmarried, highly educated women. Counseling on effective EC use and strategies that promote equitable access should be prioritized.

A Systematic Review and Meta-analysis of the Adverse Effects of Levonorgestrel Emergency Oral Contraceptive

INTRODUCTION

The levonorgestrel oral emergency contraceptive is well tolerated and effective, however its use is still limited, mainly due to safety concerns.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize current evidence regarding the adverse events, and their prevalence, reported during the use of oral levonorgestrel emergency contraceptives.

METHODS

Four electronic databases and the US FDA Adverse Event Reporting System (FAERS) Public Dashboard were searched. Studies that reported or investigated safety outcomes or adverse reactions during the use of levonorgestrel as an emergency oral contraceptive were included. Data on study design, demographics of levonorgestrel and the control cohort, and reported adverse effects were extracted.

RESULTS

A total of 47 articles were included in this systematic review, from which it was shown that most of the adverse reactions were common and not serious. Uncommon adverse reactions identified included anorexia, ectopic pregnancy, exanthema, chloasma, miscarriage, and weight gain. Multiple serious adverse events, including convulsion, ectopic pregnancy, febrile neutropenia, stroke, abdominal hernia, anaphylaxis, cancer, ovarian cyst rupture, serious infections, and suicidal ideation, were reported. In addition, the prevalence of adverse events after a levonorgestrel 0.75 mg two-dose regimen and a levonorgestrel 1.5 mg single-dose regimen were not statistically different (p > 0.05).

CONCLUSIONS

The most common adverse effects of levonorgestrel were not serious. This systematic review shows that data regarding the adverse reactions of repeated use of levonorgestrel are scarce. Studies on the multiple uses of levonorgestrel emergency contraception are still required to ensure its safety.

Overview of modern contraception

The large-scale initiatives to address the global unmet needs for family planning (FP) have gathered and compelled scientists, providers, program managers, and other stakeholders (including users) to re-examine the various methods of modern contraception, focusing on those that are proven to be more effective (long-acting reversible contraceptives and permanent methods), historically more widely used (oral contraceptives, condoms), and in development (male hormonal contraception). Implementing FP programs requires an understanding of the human rights principles underpinning the delivery of contraceptive services, the various indicators related to demand, need, and use (demand satisfied, unmet need, and contraceptive prevalence), and its effectiveness (perfect or correct use and typical use), which will be presented in this article. Tools and guidance documents developed using the best available evidence have also been listed in this review article. This issue will also look at new initiatives about providing care (self-care), and key population groups (post-pregnancy and adolescence). The clinical use of the methods should go hand in hand with the programmatic initiatives to ensure that women, men, or couple take up the appropriate method of choice and continue using these based on their reproductive health goals.

Self-care provision of contraception: Evidence and insights from contraceptive injectable self-administration

As new reproductive health products become available, women increasingly want to take a participatory role in their health. New developments and formulations of contraceptive products provide an opportunity to support this evolving trend toward self-care. Self-care, as defined by the World Health Organization (WHO), highlights the ability of individuals to promote health, prevent disease, and manage their own health with or without the support of a health care provider. The recently released WHO Guidelines on Self-Care Interventions for Health: Sexual and Reproductive Health and Rights included new self-care recommendations related to use of family planning, including self-injection of injectable contraceptives and over-the-counter provision of oral contraceptive pills. This paper focuses on the research evidence of self-administration (self-injection) of subcutaneous depot medroxyprogesterone acetate (DMPA-SC), and the practical experience of providers, women, and family planning programs adopting self-injection practices. We also explore the role of self-care in the provision of other contraceptives.

Clinical Pharmacology of Hormonal Emergency Contraceptive Pills

Emergency contraceptives play a major role in preventing unwanted pregnancy. The use of emergency contraceptives is characterized by myths and lack of knowledge by both health professionals and users. The main objective of this paper is to summarize the clinical pharmacology of hormonal methods of emergency contraception. A literature review was done to describe in detail the mechanism of action, efficacy, pharmacokinetics, safety profile, and drug interactions of hormonal emergency contraceptive pills. This information is useful to healthcare professionals and users to fully understand how hormonal emergency contraceptive methods work.

Pericoital contraception

PURPOSE OF REVIEW

To evaluate the literature on repeat use of emergency contraception and pericoital approaches to contraception.

RECENT FINDINGS

Women are very interested in an oral, on-demand contraceptive option, were one available. Ulipristal acetate and a combination of levonorgestrel (LNG) and meloxicam (a cyclo-oxygenase-2 inhibitor) both appear to be more effective at disrupting ovulation than LNG alone. Recent advisories from the United Kingdom regarding daily dosing of ulipristal for fibroids emphasize the need for more safety data.

SUMMARY

Repeat pericoital dosing of 1.5-mg LNG is approximately as effective as other on-demand contraceptive methods and is overall very safe. The most common side effect is irregular bleeding. Repeat on-demand ulipristal acetate or meloxicam/other cyclo-oxygenase-2 inhibitors have potential as an on-demand option either alone or in combination but have not been evaluated for contraceptive efficacy in a large-scale study. Given the high unmet need for contraception, even among women with access to available options, there is a distinct need for options that address needs of women who are interested in an on-demand option. On-demand oral contraception has the potential to expand the convenience of contraceptive options and overall contraceptive use.

State of emergency contraception in the U.S., 2018

Emergency contraception is indicated in instances of unprotected sexual intercourse, including reproductive coercion, sexual assault, and contraceptive failure. It plays a role in averting unintended pregnancies due to inconsistent use or non-use of contraception. Options for emergency contraception vary by efficacy as well as accessibility within the U.S. This paper provides an overview of levonorgestrel (Plan B One-Step and generic counterparts), ulipristal acetate (sold as ella), and the copper intrauterine device (IUD, sold as ParaGard), including the mechanisms of action, administration, efficacy, drug interactions, safety, side effects, advantages, and drawbacks. It will also review current misconceptions about emergency contraception and access for subpopulations, including adolescents, immigrants, survivors of sexual assault, rural populations, and military/veteran women. This paper will address barriers such as gaps in knowledge, and financial, health systems, and practice barriers. Continuing areas of research, including the impact of body weight on the efficacy of emergency contraceptive pills and potential interactions between ulipristal acetate and ongoing hormonal contraceptives, are also addressed.