Emergency Contraceptive Pills: Fast Facts for Health Care Providers in Crisis Settings

This document was co-developed with the Inter-Agency Working Group on Reproductive Health in Crises (IAWG)

 

About emergency contraception (EC): Emergency contraceptive pills (ECPs) can be used to prevent pregnancy after sex when a regular method is seen to have failed, no method was used, or sex was forced. They are safe and effective for all women and girls of reproductive age. Health care providers should offer EC to women and girls any time they report having unprotected sex or having been sexually assaulted.

 

Emergency contraception does not have any effects after fertilization and cannot stop or interfere with an established pregnancy.

 

Timeframe for using ECPs: ECPs can be used to prevent pregnancy for up to 120 hours (five days) after unprotected sex, but are more effective the sooner they are taken. Therefore, making ECPs easily accessible to women and girls is critical.

ECP regimens: Several types of pills are packaged and labeled specifically for use as emergency contraception (referred to as “dedicated” ECPs). The dose is: 1 tablet of levonorgestrel 1.5 mg; or 2 tablets of levonorgestrel 0.75 mg, labeled to be taken twice 12 hours apart (but both pills can safely be taken together as soon after unprotected sex as possible).

Many regular oral contraceptive pills can also be used to make EC. The dose is: Estrogen (100-120mcg ethinyl estradiol (EE)) and progestin (0.50-0.60mg levonorgestrel (LNG) or 1.0-1.2 mg norgestrel (NG)), followed by the same dose 12 hours later. Any brand of oral contraceptives that provides the correct amount of estrogen and progestin can be used. This regimen is not as effective as the dedicated levonorgestrel ECPs and causes more side effects. Therefore it should not be the first choice if dedicated levonorgestrel ECPs are available. Progestin-only pills labeled for daily oral contraceptive use can also be used to make emergency contraception. The dose is: 1.5 mg levonorgestrel.

EMERGENCY CONTRACEPTIVE PILL REGIMENS
COMMON BRAND NAMES HOW MUCH EACH PILL CONTAINS FIRST DOSE: TAKE AS SOON AS POSSIBLE, UP TO 120 HOURS SECOND DOSE: TAKE 12 HOURS LATER
Levonelle, NorLevo, Plan B, Postinor-2, Postpill, Pregnon, Vikela LNG 1.5mg OR LNG 0.75mg LNG 1.5mg: Take 1 tablet LNG 0.75mg: Take 2 tablets 0 tablets
Eugynon 50, Fertilan, Neogynon, Noral, Nordiol, Ovidon, Ovral, Ovran, Tetragynon/PC-4, Preven, E-Gen-C, Neo-Primovlar 4 EE 0.05mg AND LNG 0.25mg OR EE 0.05mg AND NG 0.5mg Take 2 tablets Take 2 tablets
Lo/Femenal, Microgynon, Nordete, Ovral L, Rigevidon EE 0.03mg AND LNG 0.15mg OR EE 0.03mg AND NG 0.3mg Take 4 tablets Take 4 tablets
Microlut, Microval, Norgestron, Ovrette LNG 1.5 mg LNG 1.5 mg (40 or 50 pills) 0 tablets

 

How ECPs work: ECPs work by preventing pregnancy. They delay or prevent ovulation or stop the egg and sperm from meeting. ECPs do not have any effects after fertilization and cannot terminate or interfere with an established pregnancy.

Safety of ECPs: Research shows that ECPs are safe for all women and girls of reproductive age, even for women who are advised not to use combined oral contraceptives for ongoing contraception. ECPs have been found to be safe for adolescents, with no contraindications and no lasting side effects. They have no medically serious complications, do not affect future fertility, and are not harmful if taken during pregnancy accidentally. Side effects may include altered bleeding patterns, nausea, headache, abdominal pain, breast tenderness, dizziness, and fatigue. These effects are not serious and last only a short time.

Repeated use of ECPs: ECPs remain safe and effective in preventing pregnancy if taken more than once, even within the same menstrual cycle (although using a regular, ongoing method is recommended as the most effective way to prevent pregnancy). The World Health Organization’s 2015 Medical Eligibility Criteria (MEC) states that “there are no restrictions on repeated use” of ECPs. Levonorgestrel ECPs do not need to be taken more than once every 24 hours if the women has unprotected sex more than once during that time.

Post-rape care: EC should routinely be offered as part of comprehensive care to sexual assault survivors to prevent the psychological and physical consequences of a pregnancy from rape. EC should be provided along with other care as indicated in the World Health Organization/United Nations High Commissioner for Refugees’ Clinical Management of Rape Survivors.

Privacy: It is critical to ensure that a woman’s privacy is respected when discussing or providing ECPs.

Clinical screening: You do not need to administer any examinations or laboratory tests before providing ECPs.

Follow up: ECPs do not prevent transmission of sexually transmitted infections (STIs); therefore, women who are at risk of STIs should always use a barrier method, such as a condom. After taking ECPs, women should use a regular contraceptive method to prevent a future pregnancy. Women can begin hormonal methods (including oral contraceptives, injectables, implants, and the levonorgestrel IUD) either immediately after taking ECPs or after their next menstrual period; if they wait, a barrier method such as condoms should be used during this time.

Pregnancy management: If a woman who has used ECPs later finds she is pregnant, she should seek medical care. Pregnancy following use of ECPs may occur if the ECPs failed, if the woman was already pregnant before taking ECPs, or if she had additional unprotected sex after taking ECPs. Whether she chooses to continue the pregnancy or seek abortion, she should know that ECPs have no known adverse effects on a pregnancy.

Are ECPs available in my setting? ECPs are legal and approved for distribution in many countries. Where dedicated EC products are not available, as is often the case in crisis settings, ECPs can be provided using a large number of daily oral contraceptive pills. The quantities of pills to provide are listed in the table above. For more information about ECPs, see also the Inter-agency Field Manual on Reproductive Health in Humanitarian Settings.

 

iawg-logo

Hosted by Women’s Refugee Commission
122 E. 42nd Street
New York, NY 10168
www.iawg.net

Emergency Contraceptive Pills: Fast Facts for Decision-Makers and Program Managers in Crisis-Affected Settings

This document was co-developed with the Inter-Agency Working Group on Reproductive Health in Crises (IAWG)

 

Emergency contraception (EC) provides women and girls with the opportunity to avoid unplanned pregnancy when a regular method is seen to have failed, no method was used, or sex was forced.

EC is a vital option for women and girls in crisis-affected settings. Women living in crisis settings, such as countries or regions affected by conflicts and natural disasters, face particular challenges that make access to EC essential. Regular contraceptive supplies can be disrupted when a crisis strikes, while sexual assault and transactional sex can often rise; both of these factors result in an increased need for EC. Moreover, the especially harsh living conditions in most crisis-affected settings make pregnancy and childbirth even more difficult and life-threatening. Women’s ability to access a full range of contraceptive methods, including EC pills (ECPs), is critical to preventing unintended pregnancy and its consequences. ECPs are extremely safe and should therefore be available to women directly from health facilities, including pharmacies, without a prescription.

About EC

Types of ECPs: Several types of pills are packaged and labeled specifically for use as emergency contraceptive pills (referred to as “dedicated” ECPs). Levonorgestrel ECPs are the most commonly available method.1

Where dedicated EC products are not available, as is often the case in crisis settings, oral contraceptives – regular birth control pills – can be used as EC. While less effective and more likely to cause side effects, this regimen offers critical EC access for women without access to dedicated ECPs. It is generally considered legally acceptable to take a drug, such as daily oral contraceptive pills, “off-label” (in other words, in a way other than the product’s offers label specifies). Any brand of combined oral contraceptives can be used as long as it provides the correct dosage of hormones.2

Safety of ECPs: Research shows that ECPs are safe for all women and girls of reproductive age, even for women who are advised not to use combined oral contraceptives for ongoing contraception. ECPs have been found to be safe for adolescents, with no contraindications and no lasting side effects. They have no medically serious complications, do not affect future fertility, and are not harmful if taken inadvertently during pregnancy. Side effects, such as menstrual irregularities and nausea, are not serious and last only a short time. For these reasons, women should be able to obtain ECPs without a doctor’s prescription.

How ECPs work: ECPs work by preventing pregnancy before it begins. They delay or prevent the release of an egg (ovulation) or stop the egg and sperm from meeting. ECPs do not have any effects after fertilization and cannot terminate or interfere with an established pregnancy.

Timeframe for using ECPs: ECPs can be used to prevent pregnancy for up to 120 hours (five days) after unprotected sex. ECPs are more effective the sooner they are taken, so prompt access is critical.

Repeated use of ECPs: ECPs remain safe and effective in preventing pregnancy if taken more than once, even in the same menstrual cycle (although using a regular, ongoing method is the most effective way to prevent pregnancy and only condoms can prevent the spread of sexually transmitted infections). The World Health Organization’s 2015 Medical Eligibility Criteria states that “there are no restrictions on repeated use” of ECPs.

Post-rape care: EC should routinely be offered as part of comprehensive care to sexual assault survivors to prevent the traumatic psychological and physical consequences of a pregnancy from rape. EC should be provided along with post-exposure prophylaxis and other health, psychological, and social supports.

What do international health organizations say about ECPs? The World Health Organization’s Essential Medicines List includes levonorgestrel ECPs. The International Federation of Gynecology and Obstetrics (FIGO) recommends that “emergency contraception be easily available and accessible at all times to all women.” Leading global health organizations’ endorsements of EC reflect confidence not only in EC’s safety and efficacy, but also in the belief that greater access to EC is vital.

How to ensure that women in crisis-affected settings have access to EC

EC was identified as a critical need in crisis settings in the early 1990s and ECPs have since been integrated into the Inter-agency Field Manual on Reproductive Health in Humanitarian Settings and the Inter-agency Reproductive Health Kits, as well as other emergency health kits. However, assessments show that women still have little access to EC in crisis situations. There is an urgent need to make EC available at the outset of humanitarian crises as well as in long-term crisis settings.

Are ECPs available in my country? Dedicated ECPs are legal and approved for sales and distribution in most countries. However, a number of crisis-affected countries do not have a dedicated ECP product registered. To find out which dedicated ECPs are available in your country, see www.cecinfo.org/country-by-country-information/status-availability-database/.

What if my country does not have a dedicated EC product? If a dedicated EC product is not available, ECPs may be brought into your country in RH Kits or through special licensing agreements. In addition, EC can be provided using regular oral contraceptive pills. Any brand of oral contraceptive pills can be used as long as the correct dose of hormones is provided. To find out the correct regimen of oral contraceptive pills that should be taken for EC, see ec.princeton.edu/worldwide/ to search by brand name or country.

How can my country or my program access ECPs? There are a number of ways to procure ECPs depending on your setting. In many crisis settings, RH Kits are available. Dedicated ECPs are included in Kit 3 (post-rape treatment) and Kit 4 (oral and injectable contraception), and regular oral contraceptive pills (which can also be used as EC) are also included in Kit 4. Dedicated ECPs can also be purchased from UNFPA through the AccessRH catalog, accessible at myaccessrh.org. For more information about forecasting for ECPs, see the resources footnoted below.3,4 Depending on the country, ECPs may be accessed through the public sector, social marketing organizations, and/or directly from private commercial outlets; see www.cecinfo.org/country-by-country-information/status-availability-database/.

How can decision-makers increase women’s access to EC in crisis settings?

  • Register at least one dedicated ECP product through the national regulatory system.
  • Include EC in family planning guidelines, guidance on post-rape care, and national essential medicines lists.
  • Include EC in public, private, and NGO procurement and supply systems. EC should also be incorporated into national contraceptive security strategies and their corresponding tools, such as the national FP register.
  • Reduce barriers to obtaining EC; for instance, make ECPs available without a prescription from pharmacies and health facilities and incorporate community-based distribution of EC into national and organizational protocols.
  • Ensure that all EC methods are included in pre-service provider training and ongoing professional development for pharmacists, doctors, nurses, and midwives. EC training can be provided in short formats, such as slide decks.
  • Promote public education of EC to increase community-level knowledge. Behavior change communication (BCC) to raise awareness about EC use and availability can include interpersonal communication, community sensitization, mass media campaigns, and new communications technologies and social media efforts.
  • Track and reduce provider stock-outs of EC.
  • Address poor quality and counterfeit EC products where they exist.

Reproductive health care, including emergency contraception, is an essential component of any humanitarian response. Women and girls in crisis settings have particular needs and it is important to make programs and services acceptable, accessible and appropriate for those in emergency situations.

Notes and References

1 Most levonorgestrel ECPs available in crisis settings include 2 tablets of LNG 0.75. They are labeled to be taken 12 hours apart but can be safely taken together as soon after unprotected sex as possible. Regimens with the full dose combined into a single pill are also available.

2 This regimen includes estrogen (100-120mcg ethinyl estradiol (EE)) and progestin (0.50-0.60mg levonorgestrel (LNG) or 1.0-1.2 mg norgestrel (NG)) followed by the same dose 12 hours later. Alternatively, progestin-only pills labeled for daily oral contraceptive use can be used to make EC. The dose is 1.5 mg of levonorgestrel (40 or 50 pills). See ec.princeton.edu/worldwide for more information.

3 Contraceptive Security Brief. Emergency Contraceptive Pills: Supply Chain Considerations USAID | Deliver Project. May 2012. Web site: http://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=17548&lid=3.

4 “A Forecasting Guide for New & Underused Methods of Family Planning: What to Do When There Is No Trend Data?” Web site: http://irh.org/projects/new_underused_methods/.

 

iawg-logo

Hosted by Women’s Refugee Commission
122 E. 42nd Street
New York, NY 10168
www.iawg.net

Repeated Use of Emergency Contraceptive Pills: The Facts

Emergency contraceptive pills (ECPs) can reduce the risk of pregnancy after unprotected sexual intercourse when a woman believes that her regular contraceptive method has failed, no method was used, or sex was forced. This fact sheet addresses both levonorgestrel (LNG) ECPs, which are the most commonly used EC method throughout the world, and ulipristal acetate (UPA) ECPs, for which less evidence exists.

The research shows that ECPs are extremely safe, even when used repeatedly. Compared with the potential health risks of pregnancy, taking ECPs to prevent unintended pregnancy is much safer. Women should be able to access and use ECPs as many times as they need. However, ongoing methods of contraception are more effective than ECPs. Only barrier methods, such as condoms, protect against HIV and sexually transmitted infections (STIs).

Are ECPs safe when used repeatedly?

Although ECPs are labeled for single use, use more than once even in the same menstrual cycle does not pose any known health risks. Repeat use of ECPs is classified as Level 1 in the World Health Organization’s Medical Eligibility Criteria (Level 1 indicates “a condition for which there is no restriction for the use of the contraceptive method”).1,2

ECPs pose no risk of harmful overdose and have no contraindications or major drug interactions.3,4They can cause minor side effects, such as menstrual irregularities and nausea, which typically last only a short time.5 These effects are not medically harmful, and ultimately each woman should decide for herself whether they are acceptable for her.6

ECPs will not harm a fetus if a woman is already pregnant.7,8,9,10 Research also shows that LNG ECPs have no effect on future fertility.11 According to a meta-analysis of 136 studies, ECPs are not associated with an increased risk of ectopic pregnancy.12

While taking ECPs is extremely safe, pregnancy comes with known health risks; continuing a pregnancy and giving birth or resorting to unsafe abortion both present significant risks to women.

How effective are ECPs when used repeatedly?

On average, LNG ECPs reduce pregnancy by 59 to 95% for each individual act of intercourse; UPA ECPs reduce pregnancy by 85% and have been found to be comparatively more effective than LNG. The precise efficacy of ECPs depends mostly on the woman’s cycle day when ECPs are taken and how soon they are taken after unprotected sex.13,14,15,16 There is no evidence to suggest that ECPs become less effective when used repeatedly.

If a woman has unprotected sex more than once in the same menstrual cycle, should she take ECPs again?

ECPs provide contraceptive protection for only a short period of time. Women who have taken ECPs once in their cycle are still at risk of pregnancy later in that same cycle since ECPs can work by delaying ovulation.15,17 This means that if a woman has unprotected intercourse after taking EC, she is still at risk of pregnancy and should definitely consider taking ECPs again. Because both LNG and UPA remain in the body for some time after ingestion, ECPs do not need to be taken more than once every 24 hours if multiple acts of unprotected sex occur within this timeframe.18,19

Can women use ECPs as their regular or only contraceptive method?

Robust data are not yet available about the effectiveness of ECPs when used as a regular, ongoing contraceptive method, although several older studies suggest that such use of LNG ECPs is safe and may have effectiveness rates comparable to use of condoms.20 A recent study of regular UPA ECP use (either every 5 or 7 days) suggests that ovulation eventually occurred in most women; in other words, a woman may still be at risk of pregnancy.4

What do leading health organizations say about repeat use of ECPs?

The World Health Organization’s 2015 Medical Eligibility Criteria (MEC) states that “There are no restrictions on repeated use for COCs, LNG or UPA for ECPs (MEC Category 1).”1 (COCs are combined oral contraceptives, which in certain doses can be used as emergency contraception.) The American Congress of Obstetricians and Gynecologists (ACOG) states that “emergency contraception may be used more than once, even within the same menstrual cycle.”21

How common is repeated use of ECPs?

Demographic and Health Surveys (DHS) show that in many developing countries, fewer than 4% of women of reproductive age have ever used ECPs.22 From this population of ECP users, we have limited information about how many women have used them more than once; however, two studies,23,24 each conducted in Kenya and Nigeria, suggest that frequent use of ECPs is relatively uncommon.*

Recommendation

Medical research provides no basis for limiting the number of times that women use ECPs, even within the same cycle. ECPs are extremely safe; they are always safer than pregnancy. Women have many reasons for making different choices about contraception, and using ECPs is more effective than using no contraceptive method. While women should know that ECPs are less effective than ongoing contraceptive methods and do not protect against STIs, each woman can use ECPs every time she has unprotected sex and wants to avoid unwanted pregnancy.

 

* A study of women in shopping centers in Nairobi, Kenya and Lagos, Nigeria found that about one in ten women in each of these urban centers had used ECPs more than once in the past six months.23 A representative population-based survey of urban women in Kenya and Nigeria found that less than 1% of women overall had used ECPs more than once per month in the past year.24

 

References

1 World Health Organization. Medical Eligibility Criteria for contraceptive use Fifth edition 2015 http://apps.who.int/iris/bitstream/10665/172915/1/WHO_RHR_15.07_eng.pdf.

2 Halpern V, Raymond EG, Lopez LM. Repeated use of pre- and post-coital hormonal contraception for prevention of pregnancy. Cochrane Database of Systematic Reviews 2010;(1):CD007595.

3 Grimes DA, Raymond EG, Scott Jones B. Emergency contraception over-the-counter: the medical and legal imperatives. Obstetrics and Gynecology 2001;98:151-155.

4 Jesam C, Cochon L, Salvatierra A, Williams A, Kapp N, Levy-Gompel D, Brache V. A prospective, open-label, multicenter study to assess the pharmacodynamics and safety of repeated use of 30 mg of ulipristal acetate. Submitted for publication. August 2015.

5 Task Force on Post-Ovulatory Methods of Fertility Regulation. Efficacy and side effects of immediate postcoital levonorgestrel used repeatedly for contraception. Contraception 2000;61:303-8.

6 Shelton JD. Repeat emergency contraception: facing our fears. Contraception 2002;66(1):15-7.

7 De Santis M, Cavaliere AF, Straface G, Carducci B, Caruso A. Failure of the emergency contraceptive levonorgestrel and the risk of adverse effects in pregnancy and on fetal development: an observational cohort study. Fertility and Sterility 2005;84(2):296-9.

8 Zhang L, Chen J, Wang Y, Ren F, Yu W, Cheng L. Pregnancy outcome after levonorgestrel-only emergency contraception failure: a prospective cohort study. Human Reproduction 2009;24(7):1605-11.

9 Zhang L, Ye W, Yu W, Cheng L, Shen L, Yang Z. Physical and mental development of children after levonorgestrel emergency contraception exposure: a follow-up prospective cohort study. Biol Reprod 2014;91:27.

10 Levy DP, Jager M, Kapp N, Abitbol JL. Ulipristal acetate for emergency contraception: postmarketing experience after use by more than 1 million women. Contraception. 2014 May;89(5):431-3.

11 Liskin L, Rutledge AH. After contraception: Dispelling rumors about later childbearing. Population Reports. Series J: Family Planning Programs 1984;(28):J697-731.

12 Cleland K, Raymond E, Trussell J, Cheng L, Zhu H. Ectopic pregnancy and emergency contraceptive pills: a systematic review. Obstetrics and Gynecology 2010;115(6):1263-6.

13 Trussell J. Understanding contraceptive failure. Best Practice and Research Clinical Obstetrics and Gynaecology. 2009;23:199-209.

14 Dada OA, Godfrey EM, Piaggio G, von Hertzen H. A randomized, double-blind, noninferiority study to compare two regimens of levonorgestrel for emergency contraception in Nigeria. Contraception 2010;82:373-378.

15 Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, Gainer E, Ulmann A. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception 2011;84(4):363-7.

16 Creinin M, Schlaff W, Archer DF, Wan L, Frezieres R, Thomas M, Rosenberg M, Higgins J. Progesterone receptor modulator for emergency contraception: a randomized controlled trial. Obstet Gynecol. 2006 Nov;108(5):1089-97.

17 International Consortium for Emergency Contraception and International Federation of Gynecology and Obstetrics. Mechanism of Action: How do levonorgestrel-only emergency contraceptive pills (LNG ECPs) prevent pregnancy? March 2012.

18 Johansson E, Brache V, Alvarez F, Faundes A, Cochon L, Ranta S, Lovern M, Kumar N. Pharmacokinetic study of different dosing regimens of levonorgestrel for emergency contraception in healthy women. Human Reproduction 2002;17(6):1472-6.

19 Unpublished data, HRA Pharma.

20 Halpern V, Raymond EG, Lopez LM. Repeated use of pre- and post-coital hormonal contraception for prevention of pregnancy. Cochrane Database of Systematic Reviews 2010;(1):CD007595.

21 American Congress of Obstetricians and Gynecologists. Practice Bulletin #112, Emergency Contraception. May 2010. (http://www.acog.cl/descargar.php?c411869daf1970b2b4a95ea10e65c002)

22 Palermo T, Bleck J, Westley E. Knowledge and Use of Emergency Contraception: A Multicountry Analysis. International Perspectives on Sexual and Reproductive Health 2014; 40(2):79-86.

23 Chin-Quee D, L’Engle K, Otterness C, Mercer S, Chen M. Repeat Use of Emergency Contraceptive Pills in Urban Kenya and Nigeria. International Perspectives on Sexual and Reproductive Health 2014;40(3):127-34.

24 Morgan G, Keesbury J, Speizer I. Emergency Contraceptive Knowledge and Use among Urban Women in Nigeria and Kenya. Studies in Family Planning 2014;45(1):59-72.