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Contraception Corner

Increasing Use of Emergency Contraception

Barbara Clark, RN, MSN, MPH; Beth Jordan, MD

Even with the recent approval of over-the-counter (OTC) sales, many patients still do not take advantage of emergency contraception (EC). With this major barrier to access removed, it is now up to physicians to bridge the information gap.

The US Food and Drug Administration recently approved OTC sales of EC to women aged 18 years and older. Several types of EC are currently available to US women: combination (estrogen/progestin) oral contraceptives (COCs), progestin-only pills, and the copper-bearing intrauterine device (IUD). Combination OCs have been used for EC for more than 25 years, but have now largely been replaced by the dedicated, progestin-only EC product. When used correctly, progestin-only EC and COCs prevent approximately 89% and 74% of pregnancies, respectively.1,2 Both types can cause side effects; the most common of these, nausea and vomiting, can be relieved by taking antinausea medication 1 hour before taking EC. In addition, EC can also cause a delay in menses, abdominal pain, breast tenderness, headache, dizziness, and fatigue.

Traditionally, the progestin-only EC or COCs were taken in two doses, 12 hours apart, 3 to 5 days after unprotected intercourse. However, research shows that taking the progestin-only pills in a single dose is equally effective, causes no additional side effects, and is easier for the patient.3 When used as EC, COCs still require a divided dose.4

The copper-bearing IUD is at least 99% effective if inserted within 5 days after unprotected intercourse. However, this method is contraindicated in women at risk for sexually transmitted infections at the time of insertion.5 Side effects include bleeding and cramping for a few days postinsertion.

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ADVANCE PROVISION


The sooner EC is used, the more effective it is; therefore, having advance EC (AEC) allows women to use it immediately after unprotected intercourse.4 In addition, women are more likely to use EC when they have it on hand. A study of 2,117 women aged 15 to 24 years found that those with AEC were almost twice as likely to use EC than those who only had access to EC through pharmacies or clinics (P < .001).6 Other studies had similar findings.7,8 In all studies, the frequency of unprotected intercourse was comparable between the AEC and EC groups.

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EFFECT ON SEXUAL ACTIVITY

According to Trussell et al,9 about half of all unintended pregnancies could be prevented if EC were easily accessible and used. However, some policymakers fear that if EC is too readily available, women may abandon regular contraception and engage in more unprotected sexual intercourse.10 Research contradicts this belief.7,8,11 For instance, in a study of adolescent mothers (Hispanic, 83%; black, 16%), researchers found no significant differences in reported primary contraception use (odds ratio [OR] = 0.77, confidence interval [CI] = 0.47-1.25) or condom use (OR = 0.71, 95% CI = 0.32-1.57) between those receiving education only versus AEC.11

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EDUCATION

Most women aged 18 to 44 years (66%) have heard about EC, but only 1% to 2% have used it. Adolescents and minorities are less likely to know about EC or use it.12,13 Consequently, it is important for physicians to take advantage of the materials available to them and educate patients about obtaining and using EC and AEC—both pills and the copper-bearing IUD. Resources include Web sites, handouts, and hotlines (1-888-NOT-2-LATE [1-888-668-2528]) that can answer all patient questions.14-16

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CONCLUSION

Emergency contraception can prevent unintended pregnancies, and has not been shown to increase the incidence of unprotected sex. The main obstacle to broader use is now lack of patient knowledge. Over-the-counter availability will expand access, particularly in terms of promoting AEC, but only patient education can help to get this modality into the hands of women who need it.

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Barbara Clark, RN, MSN, MPH, is a freelance writer in Arlington, Va. Beth Jordan, MD, is medical director, Association of Reproductive Health Professionals, Washington, DC.

References

1. Trussell J, Raymond EG. Emergency contraception: a cost-effective approach to preventing unintended pregnancy [the Emergency Contraception Web site]. September 2006. Available at: http://ec.princeton.edu/questions/ec-review.pdf. Accessed September 26, 2006.
2. Trussell J, Ellertson C, Stewart F. The effectiveness of the Yuzpe regimen of emergency contraception. Fam Plann Perspect. 1996;28(2):58-64.
3. von Hertzen H, Piaggio G, Ding J, et al. Low-dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002;360(9348):1803-1810.
4. Piaggio G, von Hertzen H, Grimes DA, Van Look PF. Timing of emergency contraception with levonorgestrel or the Yuzpe regimen. Task Force on Postovulatory Methods of Fertility Regulation. Lancet. 1999;353(9154):721.
5. Trussell J, Ellertson C. Efficacy of emergency contraception. Fertility Control Reviews. 1995;4(2):8-11.
6. Raine TR, Harper CC, Rocca CH, et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA. 2005;293(1):54-62.
7. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women’s sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol. 2004;17(2):87-96.
8. Raine T, Harper C, Leon K, Darney P. Emergency contraception: advance provision in a young, high-risk clinic population. Obstet Gynecol. 2000;96(1):1-7.
9. Trussell J, Stewart F, Guest F, Hatcher RA. Emergency contraceptive pills: a simple proposal to reduce unintended pregnancies. Fam Plann Perspect. 1992;24(6):269-273.
10. Harvey SM, Beckman LJ, Sherman C, Petitti D. Women’s experience and satisfaction with emergency contraception. Fam Plann Perspect. 1999;31(5):237-240,260.
11. Belzer M, Yoshida E, Tejirian T, Tucker D, Chung K, Sanchez K. Advanced supply of emergency contraception for adolescent mothers increased utilization without reducing condom or primary contraception use. J Adolesc Health. 2003;32(2):122-123.
12. Cohall AT, Dickerson D, Vaughan R, Cohall R. Inner-city adolescents’ awareness of emergency contraception. J Am Med Womens Assoc. 1998;53(5 suppl 2):258-261.
13. Kaiser Family Foundation. Is the Secret Getting Out? 1997 National Surveys of Americans and Health Care Providers on Emergency Contraception. Menlo Park, Calif: The Henry J Kaiser Family Foundation; 1997.
14. Emergency contraception has tremendous potential in the fight to reduce unintended pregnancy. Guttmacher Institute Web site. Available at: http://www.guttmacher.org/media/presskits/2005/05/06/ec.html. Accessed September 19, 2006.
15. Emergency contraception. American College of Obstetricians and Gynecologists Web site. Available at: http://www.acog.org/departments/dept_notice.cfm?recno=18&bulletin=1077. Accessed September 19, 2006.
16. The Emergency Contraception Web site. Available at: http://ec.princeton.edu/references/index.html#PUB. Accessed September 19, 2006.

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