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SUMOLLY ANAK DAVID

21ST JANUARY 2009


 Emergency contraception (also known as
postcoital contraception and the morning-after
pill) typically refers to the administration of
drugs to prevent pregnancy in women who
have had recent unprotected intercourse
(including sexual assault), or to those who have
had a failure of another method of
contraception ( missed OCP, expulsion of IUD,
burst, split, dislodge condoms)

ref: Baiden et al. 2002


 The length of menstrual cycle is 28 days
 Each cycle consists of the :
i) Menstrual phase (days 1-5)
ii) Follicular phase (days 1-13)
iii) Ovulatory phase (days 10-18)
iv) Luteal phase (days 15-28)
 The mechanism of action is uncertain and may vary
depending upon the day of the cycle the drug is administered.
Emergency contraceptives may act by inhibiting or delaying
ovulation, interfering with fertilization or tubal transport,
preventing implantation by altering endometrial receptivity, or
possibly causing regression of the corpus luteum.
 Since these drugs are administered within hours of intercourse
and implantation does not occur until approximately five to
seven days after ovulation, use of emergency contraception
does not interrupt pregnancy or harm a developing embryo
 EC is effective only in the first few days following intercourse
before the ovum is released from the ovary and before the
sperm fertilizes the ovum.
 HORMONE
◦ Progestin only EC
◦ Combined progestin-estrogen EC
 INTRA-UTERINE CONTRACEPTIVE DEVICE
 inhibit the pre-ovulatory luteinizing hormone
(LH) surge, impeding follicular development
and maturation and/or the release of the egg
 may interfere with sperm motility by thickening
the cervical mucus, which prevents sperm from
reaching the egg, thus inhibiting fertilization
 Recommended dose is 0.75mg taken within 72
hour and the second dose 12H later, though a
single dose of 1.5mg have been used
1. Suppress the midcycle peak of luteinizing and
folicle-stimulating hormone - only able to
suppress ovulation in half of the cycle
2. Produce hostile cervical mucus - prevent
sperm penetration
3. Reduce cilia motion in the fallopian tube and
decrease motility of the uterus and oviduct,
thus inhibiting ova and sperm transport.
4. Reducing the size and number of endometrial
glands, thus inhibiting implantation
Ref: (Donna & Siri 2006
 Quantity and quality of breast milk do not seem
harmed (In contrast, combined oral contraceptives can
slightly reduce milk production.)
 No estrogen side effects. Do not increase risk of
estrogen-related complications such as heart attack or
stroke.
 effective during breastfeeding (start 6 weeks after
childbirth).
 Even less risk of progestin-related side effects, such as
acne and weight gain, than with combined oral
contraceptives.
 May help prevent:
– Benign breast disease,
– Endometrial and ovarian cancer,
– Pelvic inflammatory disease.
ref: Robert 1997
 Involved the use of levonorgesterol
 Effective if dose is taken within 72 hours (3

days) of unprotected sexual intercourse.


 1.5mg as a single dose within 72 H
 If vomiting occurs within 3 hours, a

replacement dose can be given


Common side effects:
 Irregular menstrual
periods
 Headache Serious side effects:
 Breast pain
 Bleeding that lasts a
 Upset stomach

 Dizziness
long time
 Lack of menstrual
 Acne

 Increased hair growth periods


(medline)  Severe stomach pain
 Yuzpe regimen consists of combined oral
contraceptives—estrogen and progestin,
taken within 72 hours (three days) of
unprotected intercourse, followed by a
second dose 12 hours later
 Nausea and vomiting are the major side

effects of the regimen


A) The estrogen inhibits FSH release,
therefore follicle development.
B) The progesterone inhibits LH release,
therefore ovulation, and makes cervical
mucus inhospitable for sperm.
 Together, they make the endometrium

unsuitable for implantation.


(Rang et al 2003)
Advantage
 Reduced

dysmenorhea,
 Depression menorrhagia
 Reduced risk of
 Mood disturbance
 Nausea & vomiting pelvic
inflammatory
 Headache
disease (c/t IUD)
 Breast tenderness
 Change in body
weight
 Fluid retention
 doubling or tripling of the incidence of
◦ stroke,
◦ myocardial infarction,
◦ venous thromboembolism (VTE)
 Use of COC confers some risk of VTE, about 3-6 times
that of non-users. While data are limited, evidence
suggests that there is no increased risk of VTE
among women who use progesterone -only methods
or combined injectable contraceptives
(Saadatnia & Tajmirriahi 2007).

◦ breast cancer in women under the age of 35


 A copper intrauterine device placed within 120
hours of unprotected intercourse can also be
used as a form of emergency contraception
 provides continuing contraception after the initial
event.
 T-shaped polyethylene frame with 380 mm2 of
exposed surface consisting of fine copper wire
 effect of copper may be related to in utero
oxidation with release of copper ions. Copper ions
may inhibit transtubal sperm migration, thus
preventing zygote formation
 A intrauterine device is a T-
shaped piece of plastic
placed inside the uterus.
 The piece of plastic contains
copper or a synthetic
progesterone hormone that
prevents pregnancy.
 e.g. Copper-T 380A (ParaGard),
Progestrone T (Progestasert),
Levonorgestrel (Mirena)
 The progesterone intrauterine device releases a constant low
dose of a synthetic hormone continually throughout the day.
 Both the progesterone IUD and copper IUD prevent
pregnancy in one of two ways:
- The released progesterone or copper creates
changes in the cervical mucus and inside the
uterus that kills sperm or makes them immobile.
- Changes the lining of the uterus, preventing
implantation should fertilization occur
 Mood changes
 Acne
 Headaches
 Breast tenderness
 Pelvic pain
 Cramping
 Increased bleeding
during menstruation
 Nausea
 have or ever had cancer in the uterus or
cervix
 have unexplained vaginal bleeding
 may be pregnant
 have pelvic inflammatory disease
 have a history of ectopic pregnancy
 have Gonorrhea or Chlamydia
 are not in a mutually monogamous
relationship
METHOD SIDE EFFECT CONTRAINDICAT EFFICACY
ION
PROGESTERONE Nausea 20%, 89%.
ONLY vomiting 5%
Headache, abd
pain
Breast tenderness

COMBINED Nausea 50% 35 yo 75%


PROESTERON- Vomiting 20% Smoke ,
ESTROGEN Breast tenderness migraine
Weight changes High BP
spotting Thrombosis
Heart attack,
stroke
Breastfeeding
IUD Heavy menses Pregnant 99%
dysmenorrhea Std
Pelvic infection Previous ectopic
 Progestin only
◦ 2 pills within 120h
Estinor®, Postinor ®, postinor-2
50 pills within 120h
microlut 35
 Progestin + estrogen (the first 21 pill only)
◦ 2 pills within 120h and another 2 12H later
 eugynon ®, neogynon ®, nordiol
◦ 4 pills within 120H & 12H later
microgynon®, riget®, nordette®, rigevidon®
◦ 5 pills within 120h and 12h Later
 loette®
ref: IPPF.com
hhtp//www.uptodate.com
British National Formulary (BNF). 2005. BMJ
Publishing Group Ltd, London.
Donna S. & Siri, L.K. 2006. Progestin-only oral
contraceptive. The handbook of contraception: A
guide for practical management. Humana Press.
Wells, B.G. 2006. Gynecologic and Obstetric
disorders (Contraception). In: Wells, B.G., DiPiro,
J.T., Schwinghammer, T.L. & Hamilton, C.W.
Pharmacotherapy handbook. Boston: McGrawHill
MIMS. 2005. CMPMedica Pacific Ltd, Hong Kong
Pharmacotherapy Handbook 6th Edition.
Elizabeth Wesley. Emergency Contraception: A
Global Overview. Supplement 2 1998
Robert, A.H. 1997. Progestin-only oral
contraceptive. The essentials of
contraceptive technology.
Saadatnia, M. & Tajmirriahi, M. 2007.
Hormonal Contraceptives as a risk factor
for cerebral venous and sinus thrombosis.
Acta Neurologica Scandinavica 115(5) :
295-300.