Chelsea Ward, MD

Approximately 4,000 women in the United States die every year of cervical cancer. Fifty percent of women with cervical cancer have never been screened, and another 10% were not screened within the previous 5 years. Papanicolaou (Pap) testing has markedly reduced mortality from cervical cancer, helping lower it from first to 14th on the list of causes of cancer deaths in women.

New guidelines from the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology address age-appropriate screening strategies, use of cytology and high-risk human papillomavirus (HPV) testing, follow-up, age to cease screening, and the approach to the HPV-vaccinated patient.

Nearly 100% of cervical cancers are caused by HPV. "High-risk HPV" is a term used to identify approximately 15 carcinogenic HPV genotypes, including HPV 16 and HPV 18. Most HPV infections are cleared by the body within 2 years; those that remain have a higher risk of developing precancerous lesions.

Cervical intraepithelial neoplasia (CIN) are precancerous lesions found on the cervix and are classified as CIN 1, 2, or 3, depending on degree of abnormality in the epithelium. CIN 1-2 have a 10%-15% likelihood of progressing to CIN 3 and a 1%-5% risk of becoming cancer. The Bethesda system uses the nomenclature low-grade and high-grade squamous intraepithelial lesion (LSIL and HSIL), which correspond to CIN 1 and CIN 2-3, respectively.

Screening Recommendations

• Initiation of screening: Screening in adolescents and young women has led to unnecessary evaluation and overtreatment of preinvasive cervical lesions that have a high probability of regressing spontaneously.

Recommendation: Cervical cancer screening should begin at age 21 years regardless of age of sexual initiation or other risk factors.

• Periodic screening: Evidence has shown that annual screening leads to a small increase in cancers prevented, at the cost of a large excess of procedures and treatments. Most HPV infections are benign and transient, and lesions will usually regress within 2 years. At worst, these lesions are usually years from causing cancer.

Recommendation: Screening should be periodic, based on age and clinical history, regardless of previous HPV vaccination.

• Screening, 21-29 years: There is a high prevalence of HPV in this age group – mostly benign cases that will regress spontaneously. Studies show no significant difference in cancer reduction between a 2-year and 3-year screening interval. However, there is a tripling in the number of colposcopy referrals in this age group when screening occurs every 2 years.

Recommendation: Women should be screened with cytology alone every 3 years. HPV testing should not be used to screen women in this age group.

• Screening, 30-65 years: There are two types of testing that are appropriate in this age group; one is recommended over the other if available. "Co-testing" refers to the combination of cytology and HPV testing, which increases the ability to detect CIN 3 and allows for a decrease in the interval of screening because of the low risk associated with a negative screen. Co-testing also increases the ability to detect adenocarcinoma. Cytology alone is also acceptable, but there is insufficient evidence to support a longer screening interval, even with previous successive negative screens.

Recommendation: In this age range, co-test screening should be performed every 5 years, or cytology alone every 3 years.

• Screening, older than 65 years: Women who have had CIN 2+ in the past 20 years have a 5- to 10-fold greater risk of developing cervical cancer than does the general population.

Recommendation: Discontinue screening in women older than 65 years who have had no diagnosis of CIN 2+ in the previous 20 years, regardless of sexual activity. For a woman who has been diagnosed or treated for CIN 2+ or adenocarcinoma in situ, routine screening should continue for 20 years, even past age 65 years.

• Screening, women after hysterectomy: Women who have had hysterectomy with removal of the cervix who have no history of CIN 2+ should not be screened.

Management of Abnormal Results

• HPV positive, cytology negative: It is not recommended to send these women immediately for colposcopy. Instead, there are two options: Either repeat co-testing in 12 months, or perform genotype-specific HPV testing for HPV 16 alone or HPV 16/18.

If co-testing is repeated in 12 months, women testing positive on either test (HPV positive or LSIL [low-grade squamous intraepithelial lesion] or greater) should be referred for colposcopy. If genotype testing is performed, then women testing positive for HPV 16 or HPV 16/18 also should be referred for colposcopy. If genotype is negative for HPV 16 or HPV 16/18, then repeat co-testing in 12 months. This is the only situation in which genotype-specific HPV testing is recommended.

• ASC-US, HPV negative: Atypical cells of undetermined significance (ASC-US) is a cytology testing finding that is not diagnostic and is clinically ambiguous, because it doesn’t represent a specific cytologic interpretation. Studies have shown that the risk of developing precancerous lesions from ASC-US is not different enough from a negative co-test to alter management. Thus, the recommendation is to continue screening per age-specific guidelines.

• ASC-US, HPV positive; LSIL; or more severe cytologic result regardless of HPV status: Conduct a colposcopic evaluation.

The Bottom Line:

Cervical cancer screening is an essential part of well-woman care. However, new recommendations stress maximizing benefit and minimizing harm by starting screening at age 21 years and by having screening intervals that are longer than annually and are determined by a woman’s age and previous cytology results. Screening recommendations do not change based on history of HPV vaccination.

Reference

• American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer (J. Low. Genit. Tract Dis. 2012;16:175-204).

Management guidelines and algorithms can be found at www.asccp.org.

Dr. Ward is a third-year resident in the ob.gyn. residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Approximately 4,000 women in the United States die every year of cervical cancer. Fifty percent of women with cervical cancer have never been screened, and another 10% were not screened within the previous 5 years. Papanicolaou (Pap) testing has markedly reduced mortality from cervical cancer, helping lower it from first to 14th on the list of causes of cancer deaths in women.

New guidelines from the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology address age-appropriate screening strategies, use of cytology and high-risk human papillomavirus (HPV) testing, follow-up, age to cease screening, and the approach to the HPV-vaccinated patient.

Nearly 100% of cervical cancers are caused by HPV. "High-risk HPV" is a term used to identify approximately 15 carcinogenic HPV genotypes, including HPV 16 and HPV 18. Most HPV infections are cleared by the body within 2 years; those that remain have a higher risk of developing precancerous lesions.

Cervical intraepithelial neoplasia (CIN) are precancerous lesions found on the cervix and are classified as CIN 1, 2, or 3, depending on degree of abnormality in the epithelium. CIN 1-2 have a 10%-15% likelihood of progressing to CIN 3 and a 1%-5% risk of becoming cancer. The Bethesda system uses the nomenclature low-grade and high-grade squamous intraepithelial lesion (LSIL and HSIL), which correspond to CIN 1 and CIN 2-3, respectively.

Screening Recommendations

• Initiation of screening: Screening in adolescents and young women has led to unnecessary evaluation and overtreatment of preinvasive cervical lesions that have a high probability of regressing spontaneously.

Recommendation: Cervical cancer screening should begin at age 21 years regardless of age of sexual initiation or other risk factors.

• Periodic screening: Evidence has shown that annual screening leads to a small increase in cancers prevented, at the cost of a large excess of procedures and treatments. Most HPV infections are benign and transient, and lesions will usually regress within 2 years. At worst, these lesions are usually years from causing cancer.

Recommendation: Screening should be periodic, based on age and clinical history, regardless of previous HPV vaccination.

• Screening, 21-29 years: There is a high prevalence of HPV in this age group – mostly benign cases that will regress spontaneously. Studies show no significant difference in cancer reduction between a 2-year and 3-year screening interval. However, there is a tripling in the number of colposcopy referrals in this age group when screening occurs every 2 years.

Recommendation: Women should be screened with cytology alone every 3 years. HPV testing should not be used to screen women in this age group.

• Screening, 30-65 years: There are two types of testing that are appropriate in this age group; one is recommended over the other if available. "Co-testing" refers to the combination of cytology and HPV testing, which increases the ability to detect CIN 3 and allows for a decrease in the interval of screening because of the low risk associated with a negative screen. Co-testing also increases the ability to detect adenocarcinoma. Cytology alone is also acceptable, but there is insufficient evidence to support a longer screening interval, even with previous successive negative screens.

Recommendation: In this age range, co-test screening should be performed every 5 years, or cytology alone every 3 years.

• Screening, older than 65 years: Women who have had CIN 2+ in the past 20 years have a 5- to 10-fold greater risk of developing cervical cancer than does the general population.

Recommendation: Discontinue screening in women older than 65 years who have had no diagnosis of CIN 2+ in the previous 20 years, regardless of sexual activity. For a woman who has been diagnosed or treated for CIN 2+ or adenocarcinoma in situ, routine screening should continue for 20 years, even past age 65 years.

• Screening, women after hysterectomy: Women who have had hysterectomy with removal of the cervix who have no history of CIN 2+ should not be screened.

Management of Abnormal Results

• HPV positive, cytology negative: It is not recommended to send these women immediately for colposcopy. Instead, there are two options: Either repeat co-testing in 12 months, or perform genotype-specific HPV testing for HPV 16 alone or HPV 16/18.

If co-testing is repeated in 12 months, women testing positive on either test (HPV positive or LSIL [low-grade squamous intraepithelial lesion] or greater) should be referred for colposcopy. If genotype testing is performed, then women testing positive for HPV 16 or HPV 16/18 also should be referred for colposcopy. If genotype is negative for HPV 16 or HPV 16/18, then repeat co-testing in 12 months. This is the only situation in which genotype-specific HPV testing is recommended.

• ASC-US, HPV negative: Atypical cells of undetermined significance (ASC-US) is a cytology testing finding that is not diagnostic and is clinically ambiguous, because it doesn’t represent a specific cytologic interpretation. Studies have shown that the risk of developing precancerous lesions from ASC-US is not different enough from a negative co-test to alter management. Thus, the recommendation is to continue screening per age-specific guidelines.

• ASC-US, HPV positive; LSIL; or more severe cytologic result regardless of HPV status: Conduct a colposcopic evaluation.

The Bottom Line:

Cervical cancer screening is an essential part of well-woman care. However, new recommendations stress maximizing benefit and minimizing harm by starting screening at age 21 years and by having screening intervals that are longer than annually and are determined by a woman’s age and previous cytology results. Screening recommendations do not change based on history of HPV vaccination.

Reference

• American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer (J. Low. Genit. Tract Dis. 2012;16:175-204).

Management guidelines and algorithms can be found at www.asccp.org.

Dr. Ward is a third-year resident in the ob.gyn. residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Approximately 4,000 women in the United States die every year of cervical cancer. Fifty percent of women with cervical cancer have never been screened, and another 10% were not screened within the previous 5 years. Papanicolaou (Pap) testing has markedly reduced mortality from cervical cancer, helping lower it from first to 14th on the list of causes of cancer deaths in women.

New guidelines from the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology address age-appropriate screening strategies, use of cytology and high-risk human papillomavirus (HPV) testing, follow-up, age to cease screening, and the approach to the HPV-vaccinated patient.

Nearly 100% of cervical cancers are caused by HPV. "High-risk HPV" is a term used to identify approximately 15 carcinogenic HPV genotypes, including HPV 16 and HPV 18. Most HPV infections are cleared by the body within 2 years; those that remain have a higher risk of developing precancerous lesions.

Cervical intraepithelial neoplasia (CIN) are precancerous lesions found on the cervix and are classified as CIN 1, 2, or 3, depending on degree of abnormality in the epithelium. CIN 1-2 have a 10%-15% likelihood of progressing to CIN 3 and a 1%-5% risk of becoming cancer. The Bethesda system uses the nomenclature low-grade and high-grade squamous intraepithelial lesion (LSIL and HSIL), which correspond to CIN 1 and CIN 2-3, respectively.

Screening Recommendations

• Initiation of screening: Screening in adolescents and young women has led to unnecessary evaluation and overtreatment of preinvasive cervical lesions that have a high probability of regressing spontaneously.

Recommendation: Cervical cancer screening should begin at age 21 years regardless of age of sexual initiation or other risk factors.

• Periodic screening: Evidence has shown that annual screening leads to a small increase in cancers prevented, at the cost of a large excess of procedures and treatments. Most HPV infections are benign and transient, and lesions will usually regress within 2 years. At worst, these lesions are usually years from causing cancer.

Recommendation: Screening should be periodic, based on age and clinical history, regardless of previous HPV vaccination.

• Screening, 21-29 years: There is a high prevalence of HPV in this age group – mostly benign cases that will regress spontaneously. Studies show no significant difference in cancer reduction between a 2-year and 3-year screening interval. However, there is a tripling in the number of colposcopy referrals in this age group when screening occurs every 2 years.

Recommendation: Women should be screened with cytology alone every 3 years. HPV testing should not be used to screen women in this age group.

• Screening, 30-65 years: There are two types of testing that are appropriate in this age group; one is recommended over the other if available. "Co-testing" refers to the combination of cytology and HPV testing, which increases the ability to detect CIN 3 and allows for a decrease in the interval of screening because of the low risk associated with a negative screen. Co-testing also increases the ability to detect adenocarcinoma. Cytology alone is also acceptable, but there is insufficient evidence to support a longer screening interval, even with previous successive negative screens.

Recommendation: In this age range, co-test screening should be performed every 5 years, or cytology alone every 3 years.

• Screening, older than 65 years: Women who have had CIN 2+ in the past 20 years have a 5- to 10-fold greater risk of developing cervical cancer than does the general population.

Recommendation: Discontinue screening in women older than 65 years who have had no diagnosis of CIN 2+ in the previous 20 years, regardless of sexual activity. For a woman who has been diagnosed or treated for CIN 2+ or adenocarcinoma in situ, routine screening should continue for 20 years, even past age 65 years.

• Screening, women after hysterectomy: Women who have had hysterectomy with removal of the cervix who have no history of CIN 2+ should not be screened.

Management of Abnormal Results

• HPV positive, cytology negative: It is not recommended to send these women immediately for colposcopy. Instead, there are two options: Either repeat co-testing in 12 months, or perform genotype-specific HPV testing for HPV 16 alone or HPV 16/18.

If co-testing is repeated in 12 months, women testing positive on either test (HPV positive or LSIL [low-grade squamous intraepithelial lesion] or greater) should be referred for colposcopy. If genotype testing is performed, then women testing positive for HPV 16 or HPV 16/18 also should be referred for colposcopy. If genotype is negative for HPV 16 or HPV 16/18, then repeat co-testing in 12 months. This is the only situation in which genotype-specific HPV testing is recommended.

• ASC-US, HPV negative: Atypical cells of undetermined significance (ASC-US) is a cytology testing finding that is not diagnostic and is clinically ambiguous, because it doesn’t represent a specific cytologic interpretation. Studies have shown that the risk of developing precancerous lesions from ASC-US is not different enough from a negative co-test to alter management. Thus, the recommendation is to continue screening per age-specific guidelines.

• ASC-US, HPV positive; LSIL; or more severe cytologic result regardless of HPV status: Conduct a colposcopic evaluation.

The Bottom Line:

Cervical cancer screening is an essential part of well-woman care. However, new recommendations stress maximizing benefit and minimizing harm by starting screening at age 21 years and by having screening intervals that are longer than annually and are determined by a woman’s age and previous cytology results. Screening recommendations do not change based on history of HPV vaccination.

Reference

• American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer (J. Low. Genit. Tract Dis. 2012;16:175-204).

Management guidelines and algorithms can be found at www.asccp.org.

Dr. Ward is a third-year resident in the ob.gyn. residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Oral contraceptives are prescribed daily, yet emergency contraception options often are overlooked. Emergency contraception is used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. An open, informative conversation is an important way to increase awareness and knowledge to avoid unintended pregnancies.

Emergency contraception works by inhibiting or delaying ovulation and possibly by inhibiting implantation of the fertilized egg. It is effective only before a pregnancy is established – in the 5 days between intercourse and implantation of the fertilized egg – and is ineffective after implantation. There are no known risks to an established pregnancy or harm to the developing embryo, nor any increased risk for a future ectopic pregnancy.

The most commonly used regimens are combined estrogen-progestin and progestin-only pills. Ulipristal acetate, a progesterone agonist/antagonist, was approved for emergency contraception in 2010.

The estrogen-progestin regimen uses various oral contraceptive products in doses that are equal to two doses of 100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel, taken as soon as possible after intercourse, up to 72 hours, with a second dose 12 hours after the first dose.

The progestin-only regimen contains 1.5 mg levonorgestrel in single-dose or two-dose protocols and can be acquired over the counter for women age 17 years and older; patients younger than 17 years require a prescription. The manufacturers of the progestin-only regimen are phasing out the two-dose protocol, because studies have shown that taking 1.5 mg one time is equally as effective as two 0.75-mg pills 12 hours apart.

Recent studies have shown that emergency contraception is modestly effective up to 5 days after intercourse. The newest approved regimen contains 30 mg of ulipristal acetate in a single dose, and studies have shown effectiveness for up to 5 days after intercourse.

It is estimated that emergency contraception can prevent approximately 75% of pregnancies that would otherwise occur, and the levonorgestrel-only regimen is approximately 50% more effective than the combined regimen.

Side effects from emergency contraception are short term in nature, with no serious side effects. Nausea and vomiting are most common and are found more often with the estrogen-progestin regimen than with the levonorgestrel or ulipristal acetate regimens. It is recommended that an antiemetic be prescribed prophylactically if the combined regimen is given. Irregular bleeding can occur with all of the regimens during the month after treatment. Other side effects include breast tenderness, dizziness, headache, cramping, and fatigue.

There are also no health conditions that are contraindications for emergency contraception, even those that would otherwise be a contraindication for oral contraception. No clinical examination or pregnancy testing is necessary before dispensing a prescription of emergency contraception – unless the woman was a victim of assault, when further sexually transmitted disease testing and counseling are important.

Emergency contraception may be used more than once, even within the same menstrual cycle; but it is not intended and not recommended to be used as long-term contraception.

Use of a copper intrauterine device (IUD) for emergency contraception has been reported since 1976, and has pregnancy rates of 0%-0.2% if inserted within 5 days of intercourse. The advantage of insertion of the copper IUD is that it can be retained for long-term contraception. Women who meet the standard criteria for insertion of an IUD and do not have any medical indications that would prohibit them from using the copper device may choose this alternative to hormonal treatment, although the risks and costs must be considered.

Because emergency contraception delays ovulation, it is possible that a woman can become pregnant later in the menstrual cycle. Women should begin using barrier contraceptives immediately after using emergency contraception to prevent pregnancy until normal menses resumes. Long-term hormonal methods – IUD, oral, Depo-Provera, or implant – should be administered after the next menstrual period, once it is confirmed that the patient is not pregnant.

Clinical follow-up is not necessary after the administration of emergency contraception. The woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant, and see her practitioner. Evaluation is also necessary should the woman experience signs of a spontaneous abortion or ectopic pregnancy. In addition, women should be offered sexually transmitted disease screening in a follow-up appointment or at the time of administration of the emergency contraception.

The Bottom Line

Emergency contraception is underused, and the most important barrier to use is a lack of information. The levonorgestrel-only regimen is more effective than the combined regimen, with less nausea associated with it and is therefore the preferred regimen. Emergency contraception can be made available for up to 5 days after intercourse.

It is recommended that when initiating family planning or contraception discussions, emergency contraception options should be discussed and prescribed.

A list of commonly prescribed oral contraceptives that can be used for emergency contraception in the United States can be found at the following two excellent Web sites: http://ec.princeton.edu/ and http://ec.princeton.edu/questions/dose.html#dose.

References

• Emergency Contraception. ACOG Practice Bulletin 112, May 2010.

• Ella product Web site.

Dr. Ward is a first-year ob.gyn. resident at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Oral contraceptives are prescribed daily, yet emergency contraception options often are overlooked. Emergency contraception is used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. An open, informative conversation is an important way to increase awareness and knowledge to avoid unintended pregnancies.

Emergency contraception works by inhibiting or delaying ovulation and possibly by inhibiting implantation of the fertilized egg. It is effective only before a pregnancy is established – in the 5 days between intercourse and implantation of the fertilized egg – and is ineffective after implantation. There are no known risks to an established pregnancy or harm to the developing embryo, nor any increased risk for a future ectopic pregnancy.

The most commonly used regimens are combined estrogen-progestin and progestin-only pills. Ulipristal acetate, a progesterone agonist/antagonist, was approved for emergency contraception in 2010.

The estrogen-progestin regimen uses various oral contraceptive products in doses that are equal to two doses of 100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel, taken as soon as possible after intercourse, up to 72 hours, with a second dose 12 hours after the first dose.

The progestin-only regimen contains 1.5 mg levonorgestrel in single-dose or two-dose protocols and can be acquired over the counter for women age 17 years and older; patients younger than 17 years require a prescription. The manufacturers of the progestin-only regimen are phasing out the two-dose protocol, because studies have shown that taking 1.5 mg one time is equally as effective as two 0.75-mg pills 12 hours apart.

Recent studies have shown that emergency contraception is modestly effective up to 5 days after intercourse. The newest approved regimen contains 30 mg of ulipristal acetate in a single dose, and studies have shown effectiveness for up to 5 days after intercourse.

It is estimated that emergency contraception can prevent approximately 75% of pregnancies that would otherwise occur, and the levonorgestrel-only regimen is approximately 50% more effective than the combined regimen.

Side effects from emergency contraception are short term in nature, with no serious side effects. Nausea and vomiting are most common and are found more often with the estrogen-progestin regimen than with the levonorgestrel or ulipristal acetate regimens. It is recommended that an antiemetic be prescribed prophylactically if the combined regimen is given. Irregular bleeding can occur with all of the regimens during the month after treatment. Other side effects include breast tenderness, dizziness, headache, cramping, and fatigue.

There are also no health conditions that are contraindications for emergency contraception, even those that would otherwise be a contraindication for oral contraception. No clinical examination or pregnancy testing is necessary before dispensing a prescription of emergency contraception – unless the woman was a victim of assault, when further sexually transmitted disease testing and counseling are important.

Emergency contraception may be used more than once, even within the same menstrual cycle; but it is not intended and not recommended to be used as long-term contraception.

Use of a copper intrauterine device (IUD) for emergency contraception has been reported since 1976, and has pregnancy rates of 0%-0.2% if inserted within 5 days of intercourse. The advantage of insertion of the copper IUD is that it can be retained for long-term contraception. Women who meet the standard criteria for insertion of an IUD and do not have any medical indications that would prohibit them from using the copper device may choose this alternative to hormonal treatment, although the risks and costs must be considered.

Because emergency contraception delays ovulation, it is possible that a woman can become pregnant later in the menstrual cycle. Women should begin using barrier contraceptives immediately after using emergency contraception to prevent pregnancy until normal menses resumes. Long-term hormonal methods – IUD, oral, Depo-Provera, or implant – should be administered after the next menstrual period, once it is confirmed that the patient is not pregnant.

Clinical follow-up is not necessary after the administration of emergency contraception. The woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant, and see her practitioner. Evaluation is also necessary should the woman experience signs of a spontaneous abortion or ectopic pregnancy. In addition, women should be offered sexually transmitted disease screening in a follow-up appointment or at the time of administration of the emergency contraception.

The Bottom Line

Emergency contraception is underused, and the most important barrier to use is a lack of information. The levonorgestrel-only regimen is more effective than the combined regimen, with less nausea associated with it and is therefore the preferred regimen. Emergency contraception can be made available for up to 5 days after intercourse.

It is recommended that when initiating family planning or contraception discussions, emergency contraception options should be discussed and prescribed.

A list of commonly prescribed oral contraceptives that can be used for emergency contraception in the United States can be found at the following two excellent Web sites: http://ec.princeton.edu/ and http://ec.princeton.edu/questions/dose.html#dose.

References

• Emergency Contraception. ACOG Practice Bulletin 112, May 2010.

• Ella product Web site.

Dr. Ward is a first-year ob.gyn. resident at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Oral contraceptives are prescribed daily, yet emergency contraception options often are overlooked. Emergency contraception is used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. An open, informative conversation is an important way to increase awareness and knowledge to avoid unintended pregnancies.

Emergency contraception works by inhibiting or delaying ovulation and possibly by inhibiting implantation of the fertilized egg. It is effective only before a pregnancy is established – in the 5 days between intercourse and implantation of the fertilized egg – and is ineffective after implantation. There are no known risks to an established pregnancy or harm to the developing embryo, nor any increased risk for a future ectopic pregnancy.

The most commonly used regimens are combined estrogen-progestin and progestin-only pills. Ulipristal acetate, a progesterone agonist/antagonist, was approved for emergency contraception in 2010.

The estrogen-progestin regimen uses various oral contraceptive products in doses that are equal to two doses of 100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel, taken as soon as possible after intercourse, up to 72 hours, with a second dose 12 hours after the first dose.

The progestin-only regimen contains 1.5 mg levonorgestrel in single-dose or two-dose protocols and can be acquired over the counter for women age 17 years and older; patients younger than 17 years require a prescription. The manufacturers of the progestin-only regimen are phasing out the two-dose protocol, because studies have shown that taking 1.5 mg one time is equally as effective as two 0.75-mg pills 12 hours apart.

Recent studies have shown that emergency contraception is modestly effective up to 5 days after intercourse. The newest approved regimen contains 30 mg of ulipristal acetate in a single dose, and studies have shown effectiveness for up to 5 days after intercourse.

It is estimated that emergency contraception can prevent approximately 75% of pregnancies that would otherwise occur, and the levonorgestrel-only regimen is approximately 50% more effective than the combined regimen.

Side effects from emergency contraception are short term in nature, with no serious side effects. Nausea and vomiting are most common and are found more often with the estrogen-progestin regimen than with the levonorgestrel or ulipristal acetate regimens. It is recommended that an antiemetic be prescribed prophylactically if the combined regimen is given. Irregular bleeding can occur with all of the regimens during the month after treatment. Other side effects include breast tenderness, dizziness, headache, cramping, and fatigue.

There are also no health conditions that are contraindications for emergency contraception, even those that would otherwise be a contraindication for oral contraception. No clinical examination or pregnancy testing is necessary before dispensing a prescription of emergency contraception – unless the woman was a victim of assault, when further sexually transmitted disease testing and counseling are important.

Emergency contraception may be used more than once, even within the same menstrual cycle; but it is not intended and not recommended to be used as long-term contraception.

Use of a copper intrauterine device (IUD) for emergency contraception has been reported since 1976, and has pregnancy rates of 0%-0.2% if inserted within 5 days of intercourse. The advantage of insertion of the copper IUD is that it can be retained for long-term contraception. Women who meet the standard criteria for insertion of an IUD and do not have any medical indications that would prohibit them from using the copper device may choose this alternative to hormonal treatment, although the risks and costs must be considered.

Because emergency contraception delays ovulation, it is possible that a woman can become pregnant later in the menstrual cycle. Women should begin using barrier contraceptives immediately after using emergency contraception to prevent pregnancy until normal menses resumes. Long-term hormonal methods – IUD, oral, Depo-Provera, or implant – should be administered after the next menstrual period, once it is confirmed that the patient is not pregnant.

Clinical follow-up is not necessary after the administration of emergency contraception. The woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant, and see her practitioner. Evaluation is also necessary should the woman experience signs of a spontaneous abortion or ectopic pregnancy. In addition, women should be offered sexually transmitted disease screening in a follow-up appointment or at the time of administration of the emergency contraception.

The Bottom Line

Emergency contraception is underused, and the most important barrier to use is a lack of information. The levonorgestrel-only regimen is more effective than the combined regimen, with less nausea associated with it and is therefore the preferred regimen. Emergency contraception can be made available for up to 5 days after intercourse.

It is recommended that when initiating family planning or contraception discussions, emergency contraception options should be discussed and prescribed.

A list of commonly prescribed oral contraceptives that can be used for emergency contraception in the United States can be found at the following two excellent Web sites: http://ec.princeton.edu/ and http://ec.princeton.edu/questions/dose.html#dose.

References

• Emergency Contraception. ACOG Practice Bulletin 112, May 2010.

• Ella product Web site.

Dr. Ward is a first-year ob.gyn. resident at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Oral contraceptives are prescribed daily, yet emergency contraception options often are overlooked. Emergency contraception is used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. An open, informative conversation is an important way to increase awareness and knowledge to avoid unintended pregnancies.

Emergency contraception works by inhibiting or delaying ovulation and possibly by inhibiting implantation of the fertilized egg. It is effective only before a pregnancy is established – in the 5 days between intercourse and implantation of the fertilized egg – and is ineffective after implantation. There are no known risks to an established pregnancy or harm to the developing embryo, nor any increased risk for a future ectopic pregnancy.

The most commonly used regimens are combined estrogen-progestin and progestin-only pills. Ulipristal acetate, a progesterone agonist/antagonist, was approved for emergency contraception in 2010.

The estrogen-progestin regimen uses various oral contraceptive products in doses that are equal to two doses of 100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel, taken as soon as possible after intercourse, up to 72 hours, with a second dose 12 hours after the first dose.

The progestin-only regimen contains 1.5 mg levonorgestrel in single-dose or two-dose protocols and can be acquired over the counter for women age 17 years and older; patients younger than 17 years require a prescription. The manufacturers of the progestin-only regimen are phasing out the two-dose protocol, because studies have shown that taking 1.5 mg one time is equally as effective as two 0.75-mg pills 12 hours apart.

Recent studies have shown that emergency contraception is modestly effective up to 5 days after intercourse. The newest approved regimen contains 30 mg of ulipristal acetate in a single dose, and studies have shown effectiveness for up to 5 days after intercourse.

It is estimated that emergency contraception can prevent approximately 75% of pregnancies that would otherwise occur, and the levonorgestrel-only regimen is approximately 50% more effective than the combined regimen.

Side effects from emergency contraception are short term in nature, with no serious side effects. Nausea and vomiting are most common and are found more often with the estrogen-progestin regimen than with the levonorgestrel or ulipristal acetate regimens. It is recommended that an antiemetic be prescribed prophylactically if the combined regimen is given. Irregular bleeding can occur with all of the regimens during the month after treatment. Other side effects include breast tenderness, dizziness, headache, cramping, and fatigue.

There are also no health conditions that are contraindications for emergency contraception, even those that would otherwise be a contraindication for oral contraception. No clinical examination or pregnancy testing is necessary before dispensing a prescription of emergency contraception – unless the woman was a victim of assault, when further sexually transmitted disease testing and counseling are important.

Emergency contraception may be used more than once, even within the same menstrual cycle; but it is not intended and not recommended to be used as long-term contraception.

Use of a copper intrauterine device (IUD) for emergency contraception has been reported since 1976, and has pregnancy rates of 0%-0.2% if inserted within 5 days of intercourse. The advantage of insertion of the copper IUD is that it can be retained for long-term contraception. Women who meet the standard criteria for insertion of an IUD and do not have any medical indications that would prohibit them from using the copper device may choose this alternative to hormonal treatment, although the risks and costs must be considered.

Because emergency contraception delays ovulation, it is possible that a woman can become pregnant later in the menstrual cycle. Women should begin using barrier contraceptives immediately after using emergency contraception to prevent pregnancy until normal menses resumes. Long-term hormonal methods – IUD, oral, Depo-Provera, or implant – should be administered after the next menstrual period, once it is confirmed that the patient is not pregnant.

Clinical follow-up is not necessary after the administration of emergency contraception. The woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant, and see her practitioner. Evaluation is also necessary should the woman experience signs of a spontaneous abortion or ectopic pregnancy. In addition, women should be offered sexually transmitted disease screening in a follow-up appointment or at the time of administration of the emergency contraception.

The Bottom Line

Emergency contraception is underused, and the most important barrier to use is a lack of information. The levonorgestrel-only regimen is more effective than the combined regimen, with less nausea associated with it and is therefore the preferred regimen. Emergency contraception can be made available for up to 5 days after intercourse.

It is recommended that when initiating family planning or contraception discussions, emergency contraception options should be discussed and prescribed.

A list of commonly prescribed oral contraceptives that can be used for emergency contraception in the United States can be found at the following two excellent Web sites: http://ec.princeton.edu/ and http://ec.princeton.edu/questions/dose.html#dose.

References

• Emergency Contraception. ACOG Practice Bulletin 112, May 2010.

• Ella product Web site.

Dr. Ward is a first-year ob.gyn. resident at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Oral contraceptives are prescribed daily, yet emergency contraception options often are overlooked. Emergency contraception is used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. An open, informative conversation is an important way to increase awareness and knowledge to avoid unintended pregnancies.

Emergency contraception works by inhibiting or delaying ovulation and possibly by inhibiting implantation of the fertilized egg. It is effective only before a pregnancy is established – in the 5 days between intercourse and implantation of the fertilized egg – and is ineffective after implantation. There are no known risks to an established pregnancy or harm to the developing embryo, nor any increased risk for a future ectopic pregnancy.

The most commonly used regimens are combined estrogen-progestin and progestin-only pills. Ulipristal acetate, a progesterone agonist/antagonist, was approved for emergency contraception in 2010.

The estrogen-progestin regimen uses various oral contraceptive products in doses that are equal to two doses of 100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel, taken as soon as possible after intercourse, up to 72 hours, with a second dose 12 hours after the first dose.

The progestin-only regimen contains 1.5 mg levonorgestrel in single-dose or two-dose protocols and can be acquired over the counter for women age 17 years and older; patients younger than 17 years require a prescription. The manufacturers of the progestin-only regimen are phasing out the two-dose protocol, because studies have shown that taking 1.5 mg one time is equally as effective as two 0.75-mg pills 12 hours apart.

Recent studies have shown that emergency contraception is modestly effective up to 5 days after intercourse. The newest approved regimen contains 30 mg of ulipristal acetate in a single dose, and studies have shown effectiveness for up to 5 days after intercourse.

It is estimated that emergency contraception can prevent approximately 75% of pregnancies that would otherwise occur, and the levonorgestrel-only regimen is approximately 50% more effective than the combined regimen.

Side effects from emergency contraception are short term in nature, with no serious side effects. Nausea and vomiting are most common and are found more often with the estrogen-progestin regimen than with the levonorgestrel or ulipristal acetate regimens. It is recommended that an antiemetic be prescribed prophylactically if the combined regimen is given. Irregular bleeding can occur with all of the regimens during the month after treatment. Other side effects include breast tenderness, dizziness, headache, cramping, and fatigue.

There are also no health conditions that are contraindications for emergency contraception, even those that would otherwise be a contraindication for oral contraception. No clinical examination or pregnancy testing is necessary before dispensing a prescription of emergency contraception – unless the woman was a victim of assault, when further sexually transmitted disease testing and counseling are important.

Emergency contraception may be used more than once, even within the same menstrual cycle; but it is not intended and not recommended to be used as long-term contraception.

Use of a copper intrauterine device (IUD) for emergency contraception has been reported since 1976, and has pregnancy rates of 0%-0.2% if inserted within 5 days of intercourse. The advantage of insertion of the copper IUD is that it can be retained for long-term contraception. Women who meet the standard criteria for insertion of an IUD and do not have any medical indications that would prohibit them from using the copper device may choose this alternative to hormonal treatment, although the risks and costs must be considered.

Because emergency contraception delays ovulation, it is possible that a woman can become pregnant later in the menstrual cycle. Women should begin using barrier contraceptives immediately after using emergency contraception to prevent pregnancy until normal menses resumes. Long-term hormonal methods – IUD, oral, Depo-Provera, or implant – should be administered after the next menstrual period, once it is confirmed that the patient is not pregnant.

Clinical follow-up is not necessary after the administration of emergency contraception. The woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant, and see her practitioner. Evaluation is also necessary should the woman experience signs of a spontaneous abortion or ectopic pregnancy. In addition, women should be offered sexually transmitted disease screening in a follow-up appointment or at the time of administration of the emergency contraception.

The Bottom Line

Emergency contraception is underused, and the most important barrier to use is a lack of information. The levonorgestrel-only regimen is more effective than the combined regimen, with less nausea associated with it and is therefore the preferred regimen. Emergency contraception can be made available for up to 5 days after intercourse.

It is recommended that when initiating family planning or contraception discussions, emergency contraception options should be discussed and prescribed.

A list of commonly prescribed oral contraceptives that can be used for emergency contraception in the United States can be found at the following two excellent Web sites: http://ec.princeton.edu/ and http://ec.princeton.edu/questions/dose.html#dose.

References

• Emergency Contraception. ACOG Practice Bulletin 112, May 2010.

• Ella product Web site.

Dr. Ward is a first-year ob.gyn. resident at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Oral contraceptives are prescribed daily, yet emergency contraception options often are overlooked. Emergency contraception is used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. An open, informative conversation is an important way to increase awareness and knowledge to avoid unintended pregnancies.

Emergency contraception works by inhibiting or delaying ovulation and possibly by inhibiting implantation of the fertilized egg. It is effective only before a pregnancy is established – in the 5 days between intercourse and implantation of the fertilized egg – and is ineffective after implantation. There are no known risks to an established pregnancy or harm to the developing embryo, nor any increased risk for a future ectopic pregnancy.

The most commonly used regimens are combined estrogen-progestin and progestin-only pills. Ulipristal acetate, a progesterone agonist/antagonist, was approved for emergency contraception in 2010.

The estrogen-progestin regimen uses various oral contraceptive products in doses that are equal to two doses of 100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel, taken as soon as possible after intercourse, up to 72 hours, with a second dose 12 hours after the first dose.

The progestin-only regimen contains 1.5 mg levonorgestrel in single-dose or two-dose protocols and can be acquired over the counter for women age 17 years and older; patients younger than 17 years require a prescription. The manufacturers of the progestin-only regimen are phasing out the two-dose protocol, because studies have shown that taking 1.5 mg one time is equally as effective as two 0.75-mg pills 12 hours apart.

Recent studies have shown that emergency contraception is modestly effective up to 5 days after intercourse. The newest approved regimen contains 30 mg of ulipristal acetate in a single dose, and studies have shown effectiveness for up to 5 days after intercourse.

It is estimated that emergency contraception can prevent approximately 75% of pregnancies that would otherwise occur, and the levonorgestrel-only regimen is approximately 50% more effective than the combined regimen.

Side effects from emergency contraception are short term in nature, with no serious side effects. Nausea and vomiting are most common and are found more often with the estrogen-progestin regimen than with the levonorgestrel or ulipristal acetate regimens. It is recommended that an antiemetic be prescribed prophylactically if the combined regimen is given. Irregular bleeding can occur with all of the regimens during the month after treatment. Other side effects include breast tenderness, dizziness, headache, cramping, and fatigue.

There are also no health conditions that are contraindications for emergency contraception, even those that would otherwise be a contraindication for oral contraception. No clinical examination or pregnancy testing is necessary before dispensing a prescription of emergency contraception – unless the woman was a victim of assault, when further sexually transmitted disease testing and counseling are important.

Emergency contraception may be used more than once, even within the same menstrual cycle; but it is not intended and not recommended to be used as long-term contraception.

Use of a copper intrauterine device (IUD) for emergency contraception has been reported since 1976, and has pregnancy rates of 0%-0.2% if inserted within 5 days of intercourse. The advantage of insertion of the copper IUD is that it can be retained for long-term contraception. Women who meet the standard criteria for insertion of an IUD and do not have any medical indications that would prohibit them from using the copper device may choose this alternative to hormonal treatment, although the risks and costs must be considered.

Because emergency contraception delays ovulation, it is possible that a woman can become pregnant later in the menstrual cycle. Women should begin using barrier contraceptives immediately after using emergency contraception to prevent pregnancy until normal menses resumes. Long-term hormonal methods – IUD, oral, Depo-Provera, or implant – should be administered after the next menstrual period, once it is confirmed that the patient is not pregnant.

Clinical follow-up is not necessary after the administration of emergency contraception. The woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant, and see her practitioner. Evaluation is also necessary should the woman experience signs of a spontaneous abortion or ectopic pregnancy. In addition, women should be offered sexually transmitted disease screening in a follow-up appointment or at the time of administration of the emergency contraception.

The Bottom Line

Emergency contraception is underused, and the most important barrier to use is a lack of information. The levonorgestrel-only regimen is more effective than the combined regimen, with less nausea associated with it and is therefore the preferred regimen. Emergency contraception can be made available for up to 5 days after intercourse.

It is recommended that when initiating family planning or contraception discussions, emergency contraception options should be discussed and prescribed.

A list of commonly prescribed oral contraceptives that can be used for emergency contraception in the United States can be found at the following two excellent Web sites: http://ec.princeton.edu/ and http://ec.princeton.edu/questions/dose.html#dose.

References

• Emergency Contraception. ACOG Practice Bulletin 112, May 2010.

• Ella product Web site.

Dr. Ward is a first-year ob.gyn. resident at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Oral contraceptives are prescribed daily, yet emergency contraception options often are overlooked. Emergency contraception is used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. An open, informative conversation is an important way to increase awareness and knowledge to avoid unintended pregnancies.

Emergency contraception works by inhibiting or delaying ovulation and possibly by inhibiting implantation of the fertilized egg. It is effective only before a pregnancy is established – in the 5 days between intercourse and implantation of the fertilized egg – and is ineffective after implantation. There are no known risks to an established pregnancy or harm to the developing embryo, nor any increased risk for a future ectopic pregnancy.

The most commonly used regimens are combined estrogen-progestin and progestin-only pills. Ulipristal acetate, a progesterone agonist/antagonist, was approved for emergency contraception in 2010.

The estrogen-progestin regimen uses various oral contraceptive products in doses that are equal to two doses of 100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel, taken as soon as possible after intercourse, up to 72 hours, with a second dose 12 hours after the first dose.

The progestin-only regimen contains 1.5 mg levonorgestrel in single-dose or two-dose protocols and can be acquired over the counter for women age 17 years and older; patients younger than 17 years require a prescription. The manufacturers of the progestin-only regimen are phasing out the two-dose protocol, because studies have shown that taking 1.5 mg one time is equally as effective as two 0.75-mg pills 12 hours apart.

Recent studies have shown that emergency contraception is modestly effective up to 5 days after intercourse. The newest approved regimen contains 30 mg of ulipristal acetate in a single dose, and studies have shown effectiveness for up to 5 days after intercourse.

It is estimated that emergency contraception can prevent approximately 75% of pregnancies that would otherwise occur, and the levonorgestrel-only regimen is approximately 50% more effective than the combined regimen.

Side effects from emergency contraception are short term in nature, with no serious side effects. Nausea and vomiting are most common and are found more often with the estrogen-progestin regimen than with the levonorgestrel or ulipristal acetate regimens. It is recommended that an antiemetic be prescribed prophylactically if the combined regimen is given. Irregular bleeding can occur with all of the regimens during the month after treatment. Other side effects include breast tenderness, dizziness, headache, cramping, and fatigue.

There are also no health conditions that are contraindications for emergency contraception, even those that would otherwise be a contraindication for oral contraception. No clinical examination or pregnancy testing is necessary before dispensing a prescription of emergency contraception – unless the woman was a victim of assault, when further sexually transmitted disease testing and counseling are important.

Emergency contraception may be used more than once, even within the same menstrual cycle; but it is not intended and not recommended to be used as long-term contraception.

Use of a copper intrauterine device (IUD) for emergency contraception has been reported since 1976, and has pregnancy rates of 0%-0.2% if inserted within 5 days of intercourse. The advantage of insertion of the copper IUD is that it can be retained for long-term contraception. Women who meet the standard criteria for insertion of an IUD and do not have any medical indications that would prohibit them from using the copper device may choose this alternative to hormonal treatment, although the risks and costs must be considered.

Because emergency contraception delays ovulation, it is possible that a woman can become pregnant later in the menstrual cycle. Women should begin using barrier contraceptives immediately after using emergency contraception to prevent pregnancy until normal menses resumes. Long-term hormonal methods – IUD, oral, Depo-Provera, or implant – should be administered after the next menstrual period, once it is confirmed that the patient is not pregnant.

Clinical follow-up is not necessary after the administration of emergency contraception. The woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant, and see her practitioner. Evaluation is also necessary should the woman experience signs of a spontaneous abortion or ectopic pregnancy. In addition, women should be offered sexually transmitted disease screening in a follow-up appointment or at the time of administration of the emergency contraception.

The Bottom Line

Emergency contraception is underused, and the most important barrier to use is a lack of information. The levonorgestrel-only regimen is more effective than the combined regimen, with less nausea associated with it and is therefore the preferred regimen. Emergency contraception can be made available for up to 5 days after intercourse.

It is recommended that when initiating family planning or contraception discussions, emergency contraception options should be discussed and prescribed.

A list of commonly prescribed oral contraceptives that can be used for emergency contraception in the United States can be found at the following two excellent Web sites: http://ec.princeton.edu/ and http://ec.princeton.edu/questions/dose.html#dose.

References

• Emergency Contraception. ACOG Practice Bulletin 112, May 2010.

• Ella product Web site.

Dr. Ward is a first-year ob.gyn. resident at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Oral contraceptives are prescribed daily, yet emergency contraception options often are overlooked. Emergency contraception is used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. An open, informative conversation is an important way to increase awareness and knowledge to avoid unintended pregnancies.

Emergency contraception works by inhibiting or delaying ovulation and possibly by inhibiting implantation of the fertilized egg. It is effective only before a pregnancy is established – in the 5 days between intercourse and implantation of the fertilized egg – and is ineffective after implantation. There are no known risks to an established pregnancy or harm to the developing embryo, nor any increased risk for a future ectopic pregnancy.

The most commonly used regimens are combined estrogen-progestin and progestin-only pills. Ulipristal acetate, a progesterone agonist/antagonist, was approved for emergency contraception in 2010.

The estrogen-progestin regimen uses various oral contraceptive products in doses that are equal to two doses of 100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel, taken as soon as possible after intercourse, up to 72 hours, with a second dose 12 hours after the first dose.

The progestin-only regimen contains 1.5 mg levonorgestrel in single-dose or two-dose protocols and can be acquired over the counter for women age 17 years and older; patients younger than 17 years require a prescription. The manufacturers of the progestin-only regimen are phasing out the two-dose protocol, because studies have shown that taking 1.5 mg one time is equally as effective as two 0.75-mg pills 12 hours apart.

Recent studies have shown that emergency contraception is modestly effective up to 5 days after intercourse. The newest approved regimen contains 30 mg of ulipristal acetate in a single dose, and studies have shown effectiveness for up to 5 days after intercourse.

It is estimated that emergency contraception can prevent approximately 75% of pregnancies that would otherwise occur, and the levonorgestrel-only regimen is approximately 50% more effective than the combined regimen.

Side effects from emergency contraception are short term in nature, with no serious side effects. Nausea and vomiting are most common and are found more often with the estrogen-progestin regimen than with the levonorgestrel or ulipristal acetate regimens. It is recommended that an antiemetic be prescribed prophylactically if the combined regimen is given. Irregular bleeding can occur with all of the regimens during the month after treatment. Other side effects include breast tenderness, dizziness, headache, cramping, and fatigue.

There are also no health conditions that are contraindications for emergency contraception, even those that would otherwise be a contraindication for oral contraception. No clinical examination or pregnancy testing is necessary before dispensing a prescription of emergency contraception – unless the woman was a victim of assault, when further sexually transmitted disease testing and counseling are important.

Emergency contraception may be used more than once, even within the same menstrual cycle; but it is not intended and not recommended to be used as long-term contraception.

Use of a copper intrauterine device (IUD) for emergency contraception has been reported since 1976, and has pregnancy rates of 0%-0.2% if inserted within 5 days of intercourse. The advantage of insertion of the copper IUD is that it can be retained for long-term contraception. Women who meet the standard criteria for insertion of an IUD and do not have any medical indications that would prohibit them from using the copper device may choose this alternative to hormonal treatment, although the risks and costs must be considered.

Because emergency contraception delays ovulation, it is possible that a woman can become pregnant later in the menstrual cycle. Women should begin using barrier contraceptives immediately after using emergency contraception to prevent pregnancy until normal menses resumes. Long-term hormonal methods – IUD, oral, Depo-Provera, or implant – should be administered after the next menstrual period, once it is confirmed that the patient is not pregnant.

Clinical follow-up is not necessary after the administration of emergency contraception. The woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant, and see her practitioner. Evaluation is also necessary should the woman experience signs of a spontaneous abortion or ectopic pregnancy. In addition, women should be offered sexually transmitted disease screening in a follow-up appointment or at the time of administration of the emergency contraception.

The Bottom Line

Emergency contraception is underused, and the most important barrier to use is a lack of information. The levonorgestrel-only regimen is more effective than the combined regimen, with less nausea associated with it and is therefore the preferred regimen. Emergency contraception can be made available for up to 5 days after intercourse.

It is recommended that when initiating family planning or contraception discussions, emergency contraception options should be discussed and prescribed.

A list of commonly prescribed oral contraceptives that can be used for emergency contraception in the United States can be found at the following two excellent Web sites: http://ec.princeton.edu/ and http://ec.princeton.edu/questions/dose.html#dose.

References

• Emergency Contraception. ACOG Practice Bulletin 112, May 2010.

• Ella product Web site.

Dr. Ward is a first-year ob.gyn. resident at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.

Oral contraceptives are prescribed daily, yet emergency contraception options often are overlooked. Emergency contraception is used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. An open, informative conversation is an important way to increase awareness and knowledge to avoid unintended pregnancies.

Emergency contraception works by inhibiting or delaying ovulation and possibly by inhibiting implantation of the fertilized egg. It is effective only before a pregnancy is established – in the 5 days between intercourse and implantation of the fertilized egg – and is ineffective after implantation. There are no known risks to an established pregnancy or harm to the developing embryo, nor any increased risk for a future ectopic pregnancy.

The most commonly used regimens are combined estrogen-progestin and progestin-only pills. Ulipristal acetate, a progesterone agonist/antagonist, was approved for emergency contraception in 2010.

The estrogen-progestin regimen uses various oral contraceptive products in doses that are equal to two doses of 100 mcg of ethinyl estradiol plus 0.5 mg of levonorgestrel, taken as soon as possible after intercourse, up to 72 hours, with a second dose 12 hours after the first dose.

The progestin-only regimen contains 1.5 mg levonorgestrel in single-dose or two-dose protocols and can be acquired over the counter for women age 17 years and older; patients younger than 17 years require a prescription. The manufacturers of the progestin-only regimen are phasing out the two-dose protocol, because studies have shown that taking 1.5 mg one time is equally as effective as two 0.75-mg pills 12 hours apart.

Recent studies have shown that emergency contraception is modestly effective up to 5 days after intercourse. The newest approved regimen contains 30 mg of ulipristal acetate in a single dose, and studies have shown effectiveness for up to 5 days after intercourse.

It is estimated that emergency contraception can prevent approximately 75% of pregnancies that would otherwise occur, and the levonorgestrel-only regimen is approximately 50% more effective than the combined regimen.

Side effects from emergency contraception are short term in nature, with no serious side effects. Nausea and vomiting are most common and are found more often with the estrogen-progestin regimen than with the levonorgestrel or ulipristal acetate regimens. It is recommended that an antiemetic be prescribed prophylactically if the combined regimen is given. Irregular bleeding can occur with all of the regimens during the month after treatment. Other side effects include breast tenderness, dizziness, headache, cramping, and fatigue.

There are also no health conditions that are contraindications for emergency contraception, even those that would otherwise be a contraindication for oral contraception. No clinical examination or pregnancy testing is necessary before dispensing a prescription of emergency contraception – unless the woman was a victim of assault, when further sexually transmitted disease testing and counseling are important.

Emergency contraception may be used more than once, even within the same menstrual cycle; but it is not intended and not recommended to be used as long-term contraception.

Use of a copper intrauterine device (IUD) for emergency contraception has been reported since 1976, and has pregnancy rates of 0%-0.2% if inserted within 5 days of intercourse. The advantage of insertion of the copper IUD is that it can be retained for long-term contraception. Women who meet the standard criteria for insertion of an IUD and do not have any medical indications that would prohibit them from using the copper device may choose this alternative to hormonal treatment, although the risks and costs must be considered.

Because emergency contraception delays ovulation, it is possible that a woman can become pregnant later in the menstrual cycle. Women should begin using barrier contraceptives immediately after using emergency contraception to prevent pregnancy until normal menses resumes. Long-term hormonal methods – IUD, oral, Depo-Provera, or implant – should be administered after the next menstrual period, once it is confirmed that the patient is not pregnant.

Clinical follow-up is not necessary after the administration of emergency contraception. The woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant, and see her practitioner. Evaluation is also necessary should the woman experience signs of a spontaneous abortion or ectopic pregnancy. In addition, women should be offered sexually transmitted disease screening in a follow-up appointment or at the time of administration of the emergency contraception.

The Bottom Line

Emergency contraception is underused, and the most important barrier to use is a lack of information. The levonorgestrel-only regimen is more effective than the combined regimen, with less nausea associated with it and is therefore the preferred regimen. Emergency contraception can be made available for up to 5 days after intercourse.

It is recommended that when initiating family planning or contraception discussions, emergency contraception options should be discussed and prescribed.

A list of commonly prescribed oral contraceptives that can be used for emergency contraception in the United States can be found at the following two excellent Web sites: http://ec.princeton.edu/ and http://ec.princeton.edu/questions/dose.html#dose.

References

• Emergency Contraception. ACOG Practice Bulletin 112, May 2010.

• Ella product Web site.

Dr. Ward is a first-year ob.gyn. resident at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.