Emergency Contraceptive Pills (ECP)

The Contraceptive Epidemiology

Worldwide, 922 million women of reproductive age (or their partners) are contraceptive users.  Among the 1.9 billion women of reproductive age (15-49 years) living in the world, 1.1 billion have a need for family planning, that is, they are either current users of contraceptives. Of them, 842 million use modern methods of contraception and 80 million use traditional methods or, have an unmet need for family planning.  Also, 190 million women want to avoid pregnancy but, do not use any contraceptive method.  Among the women of reproductive age (15-49 years), 779 million contraceptive users are married & 143 million users are unmarried women.  In these 143 million unmarried women, the most common method has been seen to be the use of the pill at 26.1%.

Female sterilization and male condom have been seen to be the two most common methods used worldwide. Female sterilization is the most common contraceptive method used worldwide. In 2019, 23.7 per cent of women, that is 219 million women, were using contraception in the form of female sterilization. Three other methods having more than 100 million users worldwide are the male condom (189 million), IUD (159 million) and the pill (151 million). Overall, 45.2 per cent of contraceptive users rely on permanent or long-acting methods (female and male sterilization, IUD, implant), 46.1 per cent on a short-acting method (such as male condom, the pill, injectable and other modern methods) and 8.7 per cent on traditional methods (withdrawal, rhythm methods and other traditional methods).

Contraceptive Usage per Region

In Eastern and South-Eastern Asia, IUD is the most common contraceptive method used (18.6 per cent of women rely on this method), followed closely by male condom (17.0 per cent). In Europe and Northern America, the pill and male condom are the most commonly used methods (17.8 and 14.6 per cent of women, respectively), while in Latin America and the Caribbean it is female sterilization and the pill (16.0 and 14.9 per cent, respectively). In Oceania, the dominant method is the pill (16.9 per cent) and in Central and Southern Asia it is female sterilization (21.8 per cent of women rely on this method). In Northern Africa and Western Asia, the two most common methods are the pill (10.5 per cent) and IUD (9.5 per cent). Sub-Saharan Africa is the only region in which injectable are the dominant method with a prevalence of 9.6 per cent among women of reproductive age.

Even though the prevalence of some methods, such as female sterilization and IUD, have decreased on a global level, the overall number of women using these methods has grown due to population growth. The number of women relying on female sterilization has increased between 1994 and 2019 from 195 million to 219 million and the number of women relying on IUD has risen from 133 million to 159 million. The largest increases have been recorded in the numbers of women relying on male condoms (from 64 million to 189 million), on injectable (from 17 million to 74 million) and on pills (from 97 million to 151 million). It is important that population growth amongst women of reproductive age is taken into account in order to adequately plan for the provision of family planning services, including contraceptive methods.

In at least 1 out of every 5 countries, a single method accounts for 50 per cent or more of all contraceptive use. In those countries where one method constitutes half or more of all use, the dominant methods include the pill (13 countries), IUD, injectable and male condom (6 countries each), female sterilization (4 countries) and a traditional method (3 countries).

The contraceptive pill and male condom are commonly used methods in majority of countries. The pill is used by over 20 per cent of women of reproductive age in 27 countries worldwide, with the highest prevalence in European countries. Short-acting contraceptive methods are more common in sub-Saharan Africa and Europe. Overall, short-acting methods, such as the pill, injectable and male condom, constitute more than half of all contraceptive methods used in 125 countries. It has also been seen that methods designed to be used by women account for most contraceptive use.

Emergency Contraception

Like other forms of birth control, emergency contraception stops one from getting pregnant. The difference is that it can be taken after intercourse. Emergency contraception is different from drugs used to end a pregnancy. If someone is already pregnant, it will have no effect as a contraceptive method. Emergency contraception does not induce abortions. Emergency contraception can work well, but it’s not a substitute for regular birth control. Regular birth control works better, has fewer side effects, and costs less. Emergency contraception refers to methods of contraception that can be used to prevent pregnancy after sexual intercourse. These are recommended for use within 5 days but are more effective the sooner they are used after the act of intercourse. Emergency contraception can prevent up to over 95% of pregnancies when taken within 5 days after intercourse.  It can be used in the following situations: unprotected intercourse, concerns about possible contraceptive failure, incorrect use of contraceptives, and sexual assault if without contraception coverage. As the name suggests, emergency birth control is for emergencies and not something to use all the time.

The emergency contraceptive pill regimens recommended by WHO are:

  • Ulipristal acetate,
  • Levonorgestrel,

Combined oral contraceptives (COCs) consisting of ethinyl estradiol plus levonorgestrel.

Emergency Contraceptive Pills (ECP)

Mechanism of action of Emergency Contraceptive Pills

Emergency contraceptive pills prevent pregnancy by preventing or delaying ovulation and they do not induce an abortion. Emergency contraception cannot interrupt an established pregnancy or harm a developing embryo.

Who & in what situations to use Emergency Contraceptive Pills

Any woman or girl of reproductive age may need emergency contraception to avoid an unwanted pregnancy. There are no absolute medical contraindications to the use of emergency contraception. There are no age limits for the use of emergency contraception.

Emergency contraception can be used in a number of situations following sexual intercourse. These include:

  1. When no contraceptive has been used.
  2. Sexual assault when the woman was not protected by an effective contraceptive method.
  3. When there is concern of possible contraceptive failure, from improper or incorrect use, such as:
    • condom breakage, slippage, or incorrect use
    • 3 or more consecutively missed combined oral contraceptive pills or 3 days late during the first week of the cycle
    • more than 3 hours late from the usual time of intake of the progestogen-only pill (minipill), or more than 27 hours after the previous pill
    • more than 12 hours late from the usual time of intake of the desogestrel-containing pill (0.75 mg) or more than 36 hours after the previous pill
    • more than 2 weeks late for the norethisterone enanthate progestogen-only injection
    • more than 4 weeks late for the depot-medroxyprogesterone acetate (DMPA) progestogen-only injection
    • more than 7 days late for the combined injectable contraceptive
    • dislodgment, breakage, tearing, or early removal of a diaphragm or cervical cap
    • failed withdrawal (e.g. ejaculation in the vagina or on external genitalia)
    • failure of a spermicide tablet or film to melt before intercourse
    • miscalculation of the abstinence period, or failure to abstain or use a barrier method on the fertile days of the cycle when using fertility awareness based methods
    • Expulsion of an intrauterine contraceptive device (IUD) or hormonal contraceptive implant.

Following use of ECPs, women or girls may resume or initiate a regular method of contraception as follows:

  • If a copper IUD is used for emergency contraception, no additional contraceptive protection is needed.
  • Following administration of ECPs with levonorgestrel or combined oral contraceptive pills, women or girls may resume their contraceptive method, or start any contraceptive method immediately, including a copper-bearing IUD.
  • Following use of ECPs with ulipristal acetate, women or girls may resume or start any progestogen containing method (either combined hormonal contraception or progestogen only contraceptives) on the 6th day after taking ulipristal acetate.
  • They can have an levonorgestrel -IUD inserted immediately if it can be determined they are not pregnant. They can have the copper IUD inserted immediately.

What are the Emergency Contraceptive Pills Available

The 3 types of emergency contraceptive pills are:

  1. ECPs containing Ulipristal Acetate: It is a nonhormonal pill. It contains ulipristal, a nonhormonal drug that blocks the effects of key hormones necessary for conception. It is available only by prescription.
  2. ECPs containing Levonorgestrel: These contain a hormone called levonorgestrel. Levonorgestrel pills are specifically packaged as emergency contraception and do not require a prescription.
  3. Combined oral contraceptive pills: These can also be used as emergency contraception, but more than one pill has to be taken at a time to prevent pregnancy. This approach works, but it is less effective and more likely to cause nausea than levonorgestrel pills.

Emergency contraception pills and combined oral contraceptive pills dosage

As per WHO guidelines, dosage recommendations for emergency contraceptive pills are:

  • ECPs with Ulipristal Acetate, taken as a single dose of 30 mg;
  • ECPs with Levonorgestrel taken as a single dose of 1.5 mg, OR alternatively,
  • Levonorgestrel taken in 2 doses of 0.75 mg each, 12 hours apart.
  • Combined oral contraceptive pills, taken as a split dose, one dose of 100 μg of ethinyl estradiol plus 0.50 mg of Levonorgestrel, followed by a second dose of 100 μg of ethinyl estradiol plus 0.50 mg of Levonorgestrel 12 hours later. (Yuzpe method)

Many studies and meta analyses have showed that women who used ECPs with Ulipristal Acetate had a pregnancy rate of 1.2%. Studies have shown that ECPs with Levonorgestrel had a pregnancy rate of 1.2% to 2.1%. Ideally, ECPs with Ulipristal Acetate, ECPs with Levonorgestrel or Combined oral contraceptive pills should be taken as early as possible after unprotected intercourse, within 120 hours. ECPs with Ulipristal Acetate are more effective between 72–120 hours after unprotected intercourse than other ECPs.

Side Effects & Restrictions

Side effects from the use of ECPs are similar to those of oral contraceptive pills like nausea and vomiting, slight irregular vaginal bleeding, and fatigue. Side effects are not common, they are mild, and normally resolve without further medications or interventions. If vomiting occurs within 2 hours of taking a dose, the dose should be repeated. ECPs with Levonorgestrel or with Ulipristal Acetate are preferable to Combined oral contraceptive pills because they cause less nausea and vomiting. Routine use of anti-emetics before taking ECPs is not recommended. Drugs used for emergency contraception do not harm future fertility and, there is no delay in the return to fertility after taking ECPs.

There are no restrictions for the medical eligibility of who can use ECPs. Some women, however, use ECPs repeatedly for any of the reasons stated above, or as their main method of contraception. In such situations, further counseling needs to be given on what other and more regular contraceptive options may be more appropriate and more effective. Frequent and repeated ECP use may be harmful for women with conditions classified as medical eligibility criteria (MEC) category 2, 3, or 4 for combined hormonal contraception or Progestin-only contraceptives. Frequent use of emergency contraception can result in increased side-effects, such as menstrual irregularities, although their repeated use poses no known health risks.

Emergency contraceptive pills were found to be less effective in obese women (whose body mass index is more than 30 kg/m2), but there are no safety concerns. Obese women should not be denied access to emergency contraception when they need it. Counseling for use of emergency contraceptive pills should include options for using regular contraception and advice on how to use methods correctly in case of perceived method failure.

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