[Hormonal (levonorgestrel) emergency contraception--effectiveness and mechanism of action]

Periodic abstinence and coitus interruptus are the most popular methods of contraception in Poland. Recent studies have provided us with evidence that the so-called "menstrual calendar" may be much less effective than it was believed. In these circumstances, promotion and use of safe and truly effective contraceptives is very important for Polish women. Emergency contraception (EC) is a method which could be used even in cases when other contraception methods have failed. Mechanism of action of levonorgestrel used for EC and possible disturbances in the process of implantation of the blastocyst in the endometrium, remain the source of heated discussion among medical professionals. The latest publications provide us with evidence that the use of levonorgestrel in EC neither alters endometrial receptivity nor impedes implantation. Hormonal EC effectiveness is another hot topic of gynecological endocrinology and statistics. There is, however, no better, safer, and more ethically accepted method of preventing unwanted pregnancy for patients in need of postcoital contraception.

Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis

BACKGROUND

Emergency contraception can prevent unintended pregnancies, but current methods are only effective if used as soon as possible after sexual intercourse and before ovulation. We compared the efficacy and safety of ulipristal acetate with levonorgestrel for emergency contraception.

METHODS

Women with regular menstrual cycles who presented to a participating family planning clinic requesting emergency contraception within 5 days of unprotected sexual intercourse were eligible for enrolment in this randomised, multicentre, non-inferiority trial. 2221 women were randomly assigned to receive a single, supervised dose of 30 mg ulipristal acetate (n=1104) or 1.5 mg levonorgestrel (n=1117) orally. Allocation was by block randomisation stratified by centre and time from unprotected sexual intercourse to treatment, with allocation concealment by identical opaque boxes labelled with a unique treatment number. Participants were masked to treatment assignment whereas investigators were not. Follow-up was done 5-7 days after expected onset of next menses. The primary endpoint was pregnancy rate in women who received emergency contraception within 72 h of unprotected sexual intercourse, with a non-inferiority margin of 1% point difference between groups (limit of 1.6 for odds ratio). Analysis was done on the efficacy-evaluable population, which excluded women lost to follow-up, those aged over 35 years, women with unknown follow-up pregnancy status, and those who had re-enrolled in the study. Additionally, we undertook a meta-analysis of our trial and an earlier study to assess the efficacy of ulipristal acetate compared with levonorgestrel. This trial is registered with ClinicalTrials.gov, number NCT00551616.

FINDINGS

In the efficacy-evaluable population, 1696 women received emergency contraception within 72 h of sexual intercourse (ulipristal acetate, n=844; levonorgestrel, n=852). There were 15 pregnancies in the ulipristal acetate group (1.8%, 95% CI 1.0-3.0) and 22 in the levonorgestrel group (2.6%, 1.7-3.9; odds ratio [OR] 0.68, 95% CI 0.35-1.31). In 203 women who received emergency contraception between 72 h and 120 h after sexual intercourse, there were three pregnancies, all of which were in the levonorgestrel group. The most frequent adverse event was headache (ulipristal acetate, 213 events [19.3%] in 1104 women; levonorgestrel, 211 events [18.9%] in 1117 women). Two serious adverse events were judged possibly related to use of emergency contraception; a case of dizziness in the ulipristal acetate group and a molar pregnancy in the levonorgestrel group. In the meta-analysis (0-72 h), there were 22 (1.4%) pregnancies in 1617 women in the ulipristal acetate group and 35 (2.2%) in 1625 women in the levonorgestrel group (OR 0.58, 0.33-0.99; p=0.046).

INTERPRETATION

Ulipristal acetate provides women and health-care providers with an effective alternative for emergency contraception that can be used up to 5 days after unprotected sexual intercourse.

FUNDING

HRA Pharma.

Pharmacokinetics and pharmacodynamics of sterylglucoside-modified liposomes for levonorgestrel delivery via nasal route

For emergency contraceptive, the rapid delivery of levonorgestrel (LNG) to plasma is desirable, furthermore, a sustained delivery of LNG along with rapid absorption will be necessary. The pharmacokinetics and pharmacodynamics of LNG entrapped in different kinds of liposome formulations via nasal administration in rats were evaluated and compared with LNG suspension via the oral route. The relative bioavailabilities of these liposome formulations via nasal administration were 100% or higher than 100%. The Cmax and Tmax values of sterylglucoside (SG) and chitosan-contained formulations by nasal administration were 416.84 ng/mL and 1.02 hr, 227.97 ng/mL and 2.02 hr, respectively, compared with that of 334.94 ng/mL and 1.89 hr of oral suspension. Fully 100% contraception was observed for all the formulations. SG could promote the absorption of LNG via the nasal route and may provide a rapid onset of action of LNG for emergency contraception. Chitosan could retain LNG in the nasal cavity for long contact time to sustain delivery of LNG. The rapid onset and sustained delivery of LNG can be achieved via the nasal route using liposomes as the vehicle.

Hormonal emergency contraception: a clinical primer

Unintended and teenage pregnancies are major public health concerns in the United States. Emergency contraception is used to prevent pregnancy after failure of a contraceptive method or after unprotected intercourse. Expanded use of emergency contraception has the potential to reduce unintended pregnancy and induced abortions, while reducing state and federal healthcare expenditures. The recent approval of Plan B as an over-the-counter medication for individuals over 18 years of age should improve access to this medication. However, there are still widespread misconceptions about the mechanisms and implications of emergency contraception. Expanded access to emergency contraception is associated with increased use, but not associated with decreased efficacy, increased sexual risk-taking behavior, or less consistent use of traditional birth control methods. This review is designed to provide clinicians with information regarding the use of emergency contraception for reproductive age patients. It includes a brief description of methods of use, mechanisms of action, and side effect profiles of the most commonly used methods of emergency contraception, levonorgestrel and the Yuzpe method.

Contraception for women with epilepsy

Antiepileptic drugs that induce hepatic enzyme activity may alter the metabolism of most hormonal methods of contraception, and this affects the contraceptive regime. This effect should be considered in the choice of both the treatment of the epilepsy and the choice of contraceptive method. This review considers these interactions and offers advice about their management.

Characteristics of women seeking emergency contraception in general practice

The aim of this study was to profile the users of emergency contraception (EC) attending general practices and a general practice out-of-hours co-operative service using a pre-piloted questionnaire. Questionnaires were offered to 171 women and completed by 144 (84.2%). Mean age was 24.4 years (Standard Deviation = 6.7, range 14 to 51). Most were single, 116 (80.6%). Those who had no regular partner at the time of seeking EC were more likely to have > or =6 lifetime sexual partners than those in stable relationships (OR: 3.5; CI: 1.14-10.86, p < 0.03). At the time of seeking EC 121 (84.0%) were using some method of contraception. Ninety-three (64.6%) presented within 24 hours of sexual intercourse. Concerns about condoms were the commonest reason for seeking EC. For 55 (38.2%) this was their first time to use EC. Thirty-three (22.9%) were drunk at the time of intercourse.

American Academy of Pediatrics Committee on Adolescence. Emergency contraception

Teen birth rates in the United States have declined during the last decade but remain much higher than rates in other developed countries. Reduction of unintended pregnancy during adolescence and the associated negative consequences of early pregnancy and early childbearing remain public health concerns. Emergency contraception has the potential to significantly reduce teen-pregnancy rates. This policy statement provides pediatricians with a review of emergency contraception, including a definition of emergency contraception, formulations and potential adverse effects, efficacy and mechanisms of action, typical use, and safety issues, including contraindications. This review includes teens' and young adults' reported knowledge and attitudes about hormonal emergency contraception and issues of access and availability. The American Academy of Pediatrics, as well as other professional organizations, supports over-the-counter availability of emergency contraception. In previous publications, the American Academy of Pediatrics has addressed the issues of adolescent pregnancy and other methods of contraception.

Are women ready for more liberal delivery of emergency contraceptive pills?

OBJECTIVE

To investigate the knowledge, use and attitudes towards emergency contraception (EC) among women attending family planning clinics.

DESIGN

Self-administered questionnaire survey.

SETTINGS

Eight birth control clinics and three youth health care centers of The Family Planning Association of Hong Kong.

SUBJECTS

A total of 2454 women aged 15 to 53 attending the clinics between 1 November 2003 and 13 December 2003 were recruited.

RESULTS

A total of 1405 completed questionnaires were analyzed. 63.7% of women had heard of EC and 51.8% knew that they had to take it within 72 h. 15.7% had used EC before. More advertising on EC was considered desirable by 46.3% of subjects. 48.7% of subjects supported advanced provision of emergency contraceptive pills (ECPs) and 25.7% supported over-the-counter sales.

CONCLUSION

The awareness and use of EC were low in our study population. They were not ready for more liberal delivery of ECPs as less than 50% of women supported these new delivery modes and their knowledge on ECPs use was inadequate.

Effect of hormonal emergency contraception on bleeding patterns

Spotting following the use of emergency contraception is not unusual, nor is anxiety in women waiting to see if the treatment has worked. It is not known whether such spotting should bring worry or relief. We, therefore, wished to see if there was any correlation between bleeding pattern and treatment outcome. Using data from a large multicenter efficacy trial, we examined bleeding patterns post-emergency contraception. The earlier in the cycle the pills were taken, the more likely the next bleed was to be early and the less likely it was to be on time. There was no observable difference in spotting rates between women who got pregnant and those who did not. The occurrence of spotting did not influence whether the next period was lighter or heavier.

A national study examining the effect of making emergency hormonal contraception available without prescription

BACKGROUND

In January 2001, emergency hormonal contraception was made available for women over the age of 16 years directly from a pharmacist without prescription. It is of interest whether this change in the UK has led to any improvements or deterioration in the service provided for the women who need it.

METHODS

Self- completed, anonymous questionnaires were distributed to women requesting emergency hormonal contraception through a single group of pharmacies located throughout England, Wales and Scotland.

RESULTS

A total 419 women returned completed questionnaires. A greater proportion of women were able to take emergency contraception within 24 h when they obtained their tablets directly from a pharmacy without a prescription (64% versus 46%, P = 0.029). Women who obtained their drugs directly from the pharmacist were just as well informed, just as likely to arrange regular follow-up and generally preferred this system, although they disliked having to pay.

CONCLUSION

Making emergency hormonal contraception available without prescription has improved services to women who need them, but these improvements are quantitatively minimal, preventing only five additional pregnancies per 10,000 users.

Minimum effectiveness of the levonorgestrel regimen of emergency contraception

The standard method for estimating the effectiveness of emergency contraceptive pills (ECPs) uses external data to calculate the proportion of expected pregnancies averted by the treatment. Because these data may not be applicable to ECP study populations, this approach could result in substantial overestimation of effectiveness. We used data from two published randomized trials of the levonorgestrel and Yuzpe ECP regimens to calculate the minimum effectiveness of the levonorgestrel regimen. Conservatively assuming that the Yuzpe regimen was entirely ineffective in these trials, we estimate that the levonorgestrel regimen prevented at least 49% of expected pregnancies (95% confidence interval: 17%, 69%). Because physiologic data suggests that the Yuzpe regimen does, in fact, have some efficacy, the effectiveness of the levonorgestrel regimen is likely to be higher than our minimum estimate.

Training and supporting pharmacists to supply progestogen-only emergency contraception

OBJECTIVE

To describe and evaluate the training and support provided to the first cohort of community pharmacists to supply progestogen-only emergency contraception (POEC) under a Patient Group Direction (PGD) in Lambeth, Southwark and Lewisham, London.

DESIGN

The study comprised (a) a systematic analysis of written and oral data from pharmacists before and during training, and at 5 and 13-14 months after launch; (b) analysis of telephone calls to clinical support and (c) analysis of written pharmacy records.

SUBJECTS

A total of 20/22 pharmacists in the first training cohort; 6/23 pharmacists who applied but were not accepted were also followed up.

RESULTS

A formal course with role-play was a successful training method, and the course also served as a team-building exercise. Subsequent interviews demonstrated that pharmacists had understood the concept of client confidentiality and gained confidence over time in the use of the PGD. The on-call consultants received 152 calls in the first 12 months of the scheme. Over 80% of the calls concerned clinical criteria (notably including 22% that were queries about oral contraceptives). Frequency ranged from one to eight calls per week with 28% made at weekends. In over half (60%) of the calls the pharmacist was subsequently able to make a supply. Queries over client management resulted in several changes in the protocol. The primary expressed concern for all pharmacists at all time points was how clients might 'misuse' or 'abuse' the service, and this remained a concern despite the fact that it also applies to other routes of supply of POEC. However, the PGD cohort was more positive on local benefits than pharmacists who were not selected.

CONCLUSIONS

Training and support have enabled this often-underused group of professionals to participate in an extended reproductive health service. Mobile phones are an essential support tool.

Emergency contraception: increasing public awareness

This article begins by addressing misperceptions that emergency contraception is something new and untested or inherently unsafe, and that it is comparable to an abortion. It then describes efforts that are underway to increase awareness among consumers and health care providers alike.

Differences between emergency contraception users in the United States and the United Kingdom

OBJECTIVES

to characterize emergency contraception (EC) users and clinical trial participants in the United States and the United Kingdom, comparing previous EC use and awareness, contraceptive history, and experience with EC.

METHODS

We collected data from all EC seekers (n=5383) at 1 US and 2 UK clinics (9/97-8/98). We also collected detailed information from women (n=2157) enrolling in an EC trial at the first 3 clinics and 2 additional UK sites (9/97-2/00).

RESULTS

More US (16%) than UK (4%) women reported additional acts (other than in the last 5 days) of unprotected sex during the cycle in which they sought EC. Fifty-eight percent of UK trial participants had used EC previously compared to 18% in the United States. Most participants in both groups used contraception regularly and reported needing EC because of condom breaks (67% and 56%). More UK than US participants used an ongoing method of contraception (38% v 28%). US women reported more side effects at follow-up than UK women did (76% v 59%), although similar proportions would take EC again or recommend it.

CONCLUSIONS

US and UK women in our trial experienced different side effects. Researchers should use caution when presenting aggregate results from international multicenter trials. In addition, readers should be aware that such aggregate results might mask important geographical differences. More research on experience with EC and barriers to contraceptive use in the United States is needed.

Hormonal emergency contraception

In the 1960s, high-dose estrogen was identified as a highly effective emergency contraceptive but was associated with a high frequency of nausea and vomiting. The combination of low-dose estrogen and a progestin (the Yuzpe regimen) is highly effective and much better tolerated. Recently, a progestin-only regimen containing levonorgestrel was found to be more effective than the Yuzpe regimen and caused significantly less nausea and vomiting. Danazol, an antigonadotropin, is well tolerated but has questionable efficacy Mifepristone has several pharmacologic actions that make it highly effective with an adverse-effect profile similar to that of the Yuzpe regimen. Progress has been made in the last 3 years toward increasing the number of emergency contraceptives that are accessible to women in the United States, and several highly effective options are available. The most effective and well-tolerated regimen available is levonorgestrel. However, the barriers to access and low patient and provider awareness limit the impact of emergency contraception on the rate of unintended pregnancies.

Emergency contraception: Who are the users?

CONTEXT

Data collected from two community family planning services are used to discuss the characteristics of users of emergency contraception (EC).

OBJECTIVE

To investigate the characteristics of women attending for emergency contraception.

DESIGN

A descriptive survey design was used to collect data. Questionnaires were completed over a 4-week period. Data were analysed using SPSS.

SETTING

Community family planning services in South West Surrey and Newham, East London.

PARTICIPANTS

Consenting women aged 14-44 years attending for emergency contraception (n = 171).

MAIN OUTCOME MEASURES

Description of the users, the current episode and contact with contraceptive services were analysed by age.

RESULTS

The age range was 14-37 years (mean 20.2 years). A majority were smokers. Of the women, 97.7% attended the clinic within the 72-hour time frame for issuing oral EC, however only 4% came within 12 hours of intercourse; 55% said that they had used contraception. Condom breakage was the commonest reason for failure. Reasons for not using contraception included getting 'carried away' (35%), not having condoms available (22%) and having drunk alcohol (13%). Of the sample 55.6% were previous users of EC.

DISCUSSION

The study demonstrates a high incidence of sexual risk taking and need for EC, especially amongst smokers and drinkers. The message that soonest is best still requires promotion. Providers of EC must co-ordinate their services to ensure access within the 12-hour time frame in a local area.

CONCLUSION

Health professionals need to ensure that clients have appropriate information about EC and regular contraceptive methods and that user friendly provision is widely available.

Changes in providers' views and practices about emergency contraception with education

OBJECTIVE

To assess changes in the prescribing practices, knowledge, attitudes, and perceptions of health care providers after an educational program about emergency contraception.

METHODS

Health care providers completed self-administered questionnaires before and 1 year after full implementation of the project. The 102 providers who completed both questionnaires were physicians (64%) and mid-level professionals from 13 San Diego County Kaiser Permanente medical offices working in departments such as obstetrics and gynecology, primary care, and emergency medicine.

RESULTS

The frequency of prescription for emergency contraceptive pills increased significantly from baseline to follow-up. There was an increase of almost 20% in the percentage who prescribed emergency contraception at least once a year. Knowledge also improved significantly, and perceptions of barriers to prescribing emergency contraceptive pills within the health maintenance organization decreased significantly. In contrast, attitudes about emergency contraception showed little change.

CONCLUSION

This study suggests that providers who participate in in-service training and other aspects of a demonstration project show changes in perceptions, knowledge, and behavior. However, findings also suggest that significant gaps remain in knowledge about medications, side effects, and mode of action. It is likely that many providers in other health care settings also need additional information and training concerning protocols of emergency contraception provision and its modes of action and effects.

Use of hormonal emergency contraception at a university health centre over a 6 year period

This was a retrospective review of the use of emergency hormonal contraception at a university-based health centre over a 6 year period. Usage was greater than noted in previous studies. Condom problems, or not using any form of contraception, were the main reasons for requests. Users were significantly more likely to be smokers than the base population.

[Emergency contraception: a simple, safe, effective and economical method for preventing undesired pregnancy]

In the following article, the most recent knowledge on emergency contraception (EC) is reviewed. EC is defined as those contraceptive methods that may be used to prevent an unwanted pregnancy up to 3 days after unprotected intercourse, contraceptive failure or rape. In case of non-hormonal methods (IUD), the time window for pregnancy prevention goes up to 5 days after intercourse. The different regimens now available, hormonal and non-hormonal methods, indications, contraceptive effectiveness, side effects and safety profile, possible mechanisms of action and counseling strategies will be reviewed. The potential benefits on reproductive health of wide-spread knowledge and easy, non-restrictive access to this methodology are emphasized. An extensive list of recent references is enclosed.

Knowledge of emergency contraception amongst female patients attending a department of genitourinary medicine

The aim of the study was to assess the knowledge of emergency contraception amongst new female patients attending an inner-city department of genitourinary medicine. Information was also sought about use of regular contraception and demography. Three hundred and ninety nine questionnaires were suitable for analysis. Half of the sample answered that the latest a woman could take emergency contraception after unprotected sex was three days. None of the sample knew that emergency contraception could be obtained up to five days. Twenty nine per cent of the sample reported sex without contraception during the menstrual cycle preceding attendance. Women who had ever used regular contraception in the past were statistically less likely to have reported unprotected sex in the menstrual cycle preceding attendance (p=0.0000068). Professional women were statistically less likely to have reported unprotected sex in the menstrual cycle preceding the clinic visit. Fourteen per cent of the sample had genital warts at this first clinic visit, 10 per cent had Chlamydia trachomatis, seven per cent had herpes simplex infection, six per cent had gonococcal infection and five per cent had trichomonal infection. Women who reported unprotected sex during the preceding menstrual cycle were not statistically more likely to have a sexually transmitted infection at this first clinic visit. A large number of women attending departments of genitourinary medicine are at risk of both pregnancy and also sexually transmitted infection. Staff working in all areas of sexual health need to have a good knowledge of both contraception and sexually transmitted infections in order to educate the clients on both aspects of unprotected sex.

Pregnancy prevention using emergency contraception: efficacy, attitudes, and limitations to use

Emergency contraception, also called postcoital contraception, is the use of hormonal or mechanical methods to prevent pregnancy after an episode of unprotected intercourse. Although a number of methods of emergency contraception exist, its use in the United States is not widespread. This report reviews studies on the efficacy of hormonal methods of emergency contraception, as well as the literature on women's and physicians' knowledge of and attitudes toward this method of preventing pregnancy. Articles were selected for this review from a MEDLINE search using the term "postcoital contraception." These studies show that a variety of hormonal regimens are effective in reducing the chance of pregnancy when administered within 72 hours of an episode of unprotected intercourse. Failure rates range from 0%-4.66%, depending on the regimen and the study, although some controversy exists about how to calculate efficacy. Recent studies indicate that mifepristone (RU486) may be more effective than other methods, with fewer side effects. However, the more significant issue surrounding emergency contraception may be the reasons for its infrequent use in this country. A number of limitations to use have been identified in the literature, including lack of knowledge of the method among patients and physicians, inadequate counseling, and fears that widespread use of emergency contraceptives would lead to less consistent use of other methods of contraception.

Sexual assault: the physician's role in prevention and treatment

Rape is a crime which occurs to over 12 million women. It has a substantial impact on the physical, psychological and social health of the victim. It is defined as the carnal knowledge of a person forcibly and against their will and includes successful and unsuccessful assaults. In this sense, the terms rape and sexual assault are used interchangeably. Physicians should responsibly counsel patients when appropriate concerning prevention of sexual assault and should be knowledgeable about the acute medical and psychological management of a sexual assault victim, including the collection of evidence. This article provides basic information regarding examination, evidence collection and treatment.

The effects of self-administering emergency contraception

BACKGROUND

Emergency postcoital contraception prevents pregnancy, but it must be prescribed by a doctor and taken within 72 hours of intercourse. It has been proposed that emergency contraception be made available without a prescription. We undertook a study to learn how women might behave if given a supply of emergency contraceptive pills to keep at home.

METHODS

We assigned 553 women to be given a replaceable supply of hormonal emergency contraceptive pills to take home (the treatment group) and 530 women to use emergency contraception obtained by visiting a doctor (the control group). The frequency of use of emergency contraception, the use of other contraceptives, and the incidence of unwanted pregnancy were determined in both groups of women one year later.

RESULTS

The results for 549 women in the treatment group and 522 women in the control group were available for analysis. Three hundred seventy-nine of the women in the treatment group (69 percent) and 326 of the women in the control group (62 percent) contributed detailed information at follow-up. One hundred eighty of the women in the treatment group (47 percent) used emergency contraception at least once. Among those who returned the study questionnaire, 98 percent used emergency contraception correctly. There were no serious adverse effects. Eighty-seven women in the control group (27 percent) used emergency contraception at least once (P<0.001 for the comparison with the treatment group). The women in the treatment group were not more likely to use emergency contraception repeatedly. Their use of other methods of contraception was no different from that of the women in the control group. There were 18 unintended pregnancies in the treatment group and 25 in the control group (relative risk, 0.7; 95 percent confidence interval, 0.4 to 1.2).

CONCLUSIONS

Making emergency contraception more easily obtainable does no harm and may reduce the rate of unwanted pregnancies.

Pharmacokinetics and pharmacodynamics of 7alpha-methyl-19-nortestosterone after intramuscular administration in healthy men

7alpha-Methyl-19-nortestosterone (MENT) is a potent synthetic androgen that is resistant to 5alpha-reductases and therefore less prone to over-stimulate the prostate. It is a good candidate for implant administration in long-term androgen replacement therapy for hypogonadal men or as part of a male contraceptive system. To investigate the pharmacokinetics of MENT after i.m. administration, single i.m. injections of 2, 4 or 8 mg of micronized MENT were given in aqueous suspension to 18 healthy men in two clinics. Blood was sampled frequently for 8 h and 1, 2, 3, 4 and 9 days after the injections. Serum MENT concentrations were determined by radioimmunoassay. Peak MENT concentrations were dose-dependent and were reached about 1-2 h after the injections. Doubling the dose of MENT resulted in an increase of 60% in peak serum MENT concentrations. The mean +/- SE clearance rate was 1790 +/- 140 l/day. The antigonadotrophic activity of MENT was investigated by giving six consecutive daily i.m. injections of 1, 2 or 4 mg of MENT to 24 healthy men in two clinics. Blood was sampled before each injection and up to 24 days after the last injection. Serum testosterone and gonadotrophin concentrations (determined by radioimmunoassay and fluoroimmunoassay respectively) decreased in a dose-dependent and statistically significant manner. The highest dose caused a 74% fall in testosterone, a 70% fall in luteinizing hormone, and a 57% fall in follicle stimulating hormone concentrations. MENT injections did not cause any side-effects. The results show that MENT is a potent antigonadotrophic agent in men.

Knowledge and use of hormonal emergency contraception in Finland

We studied the knowledge and use of hormonal emergency contraception (EC) in Finland by mailing a questionnaire to a national sample of 3000 women aged 18-44 years (response rate 74%). Ten percent of the women aged under 25 and 4% of all respondents had sometimes used EC. Unmarried women were more likely to report having used hormonal EC than were married women, and nulliparous women reported more use than did parous women. However, no statistically significant difference in EC use among women with or without previous abortion history was observed. Older women were less aware of EC than of other methods; only one-third of the women aged over 35 knew about this method. Current contraceptive practices were otherwise similar among ever-users and never-users of EC, but EC users more commonly reported using condom together with oral contraceptives or IUD. Nobody reported using EC as her only contraceptive method. Our findings suggest that EC is appropriately used in Finland, but more information about use of the method is still needed.

Emergency hormonal contraception usage in genitourinary medicine clinic attenders

OBJECTIVE

To assess the indications for usage of emergency hormonal contraception amongst a population of London genitourinary medicine clinic attenders.

METHODS

In a prospective study, 150 consecutive women receiving emergency hormonal contraception (EHC) were enrolled. The attending doctor completed a questionnaire of patient details and prescribed EHC with prophylactic prochlorperazine. Follow-up was arranged three weeks later, at which time outcomes and side-effects of therapy were recorded. For those women who did not reattended as planned case notes were reviewed at three months.

RESULTS

Of 150 women surveyed, 100 (66%) reported contraceptive method failure, 48 (32%) had used no contraception at the time of last sexual intercourse and two requested EHC after sexual assault. Ninety three (62%) reported condom failure, 7 (5%) oral contraceptive pill failure. Seventy five (50%) had used EHC before (range 1-10 times). Seventy one (47%) women reattended within three months. Five (3.3%) of the 150 women were pregnant; none of these cases had experienced nausea or vomiting whilst taking EHC. Side-effects were reported by 22 (31%) of the 71 patients who reattended. Nine (6%) women had been followed-up in the family planning advisory clinic. Of the 71 women who reattended, 39 (55%) reported that their preferred future method of contraception would be condoms. Of the 150 women 19 (13%) underwent tests for sexually transmissible infections within one month of presentation.

CONCLUSIONS

EHC usage in this population was associated with a failure rate of at least 3.3% and an overall side effect rate of 31%. Despite requests for emergency contraception because of condom failure many elected to continue using condoms as their preferred method of contraception. The majority of women (53%) did not return for follow-up or family planning advice, and so we believe that future contraceptive plans must be addressed at the time EHC is prescribed.

[Extrauterine pregnancy after hormonal postcoital contraception]

Postcoital contraception with estrogen-gestagen-combinations is a highly effective emergency measure in cases of unprotected sexual intercourse at midcycle. Pregnancies after hormonal postcoital contraception are rare and ectopic pregnancies are said to be an extreme rarity. At the Department of Obstetrics and Gynecology of the Philipps-University Marburg we could observe two women with ectopic pregnancies after administration of a ethinyestradiol-levonorgestrel combination (Tetragynon, Schering, Berlin). Both patients were operated by pelviscopy. We could not found a clear causal relationship between the administration of hormonal postcoital contraception and ectopic pregnancies, because both women had intrauterine operations in her history and therefore a certain level of tubal damage could not ruled out. Nevertheless, in cases of hormonal postcoital contraception a follow-up check after 3 weeks should be done and it should be kept in mind that ectopic pregnancies may occur, especially in patients with risk factors.

Postcoital contraception. Has its day come?

Although postcoital contraception might aid in reducing the occurrence of some unintended pregnancies, it is seldom used. This review summarizes the development of postcoital methods, focusing on the Yuzpe regimen, the most widely used emergency contraceptive in the United States. The article discusses its mechanism of action, safety, side effects, and effectiveness. Reasons for its limited use are discussed, as are recent findings that RU 486 may be a superior postcoital agent. Finally, a protocol for integrating the Yuzpe method into nurse-midwifery practice is presented.

Emergency contraception alters progesterone-associated endometrial protein in serum and uterine luminal fluid

OBJECTIVE

To evaluate the effect of high-dose oral contraceptives on serum and uterine luminal fluid progesterone-associated endometrial protein in the luteal phase.

METHODS

Five ovulatory women participated in the study. In a control cycle, serum and uterine lavage samples were collected on luteal day 11. In the next cycle, on luteal day 9, the participants were given two 50-micrograms ethinyl estradiol-norgestrel tablets, repeated 12 hours later. Serum and uterine lavage samples were collected 48 hours (luteal day 11) after the last dose and analyzed by two-dimensional polyacrylamide gel electrophoresis and radioimmunoassays of the serum.

RESULTS

Progesterone-associated endometrial protein levels were lower in sera from treated compared with control cycles. Analysis of serum levels of this protein by two-dimensional polyacrylamide gel electrophoresis did not reveal bands corresponding to the known size and charge characteristics (27 kd and pI of 4.9) in either control or treatment samples. On the other hand, in uterine lavage samples, a complete suppression of the 27-kd, pI-4.9 species was evident after treatment.

CONCLUSION

High-dose ethinyl estradiol-norgestrel emergency contraception effectively suppresses progesterone-associated endometrial protein in the midluteal uterus, potentially altering the endometrial environment unfavorably and affecting the survival of the early embryo.