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post coital contraception (Plan B, morning after)

oral contraceptives taken within 72-120 hours (5 days) of unprotected intercourse (coitus). Indications: - prevention of unwanted pregnancy - may be less effective in obese women [17] * doxycycline (single dose) may prevent gonorrhea, Chlamydia & syphilis [25] Contraindications: - may not be effective in women > 165-175 pounds [19] Dosage: - 0.10-0.2 mg of ethinyl estradiol & - 0.50-0.60 mg of levonorgestrel (Ovral)* in each of 2 doses* separated by 12 hours. - plan B one step: levonorgestrel 1.5 mg PO once [9] (OTC) - less effective than ulipristal in women with BMI > 26 - 40 mg of piroxicam (by prescription only) added to levonorgestrel results in fewer pregnancies than levonorgestrel alone 0.2% vs 1.7% [24] - ulipristal (once) is an alternative [1] - effective in women with BMI > 26 - effective for up to 5 days after unprotected sexual intercourse [23] - doxycycline 200 mg (single dose) within 72 hours after unprotected sexual intercourse may prevent gonorrhea, Chlamydia & syphilis [25] * Ref 2 indicates both tablets may be taken in 1 dose 89% effective within 3 days; still useful up to 5 days [2] Considered safe [3] OTC soon, cost $30 or more [6] Some pharmacists may be reluctant to dispense [4] Generic Plan B FDA approved June 2009 Copper IUD are effective as emergency contraception [12] - may be inserted up to 5 days after unprotected sex [19] levonorgestrel IUD non-inferior to copper IUD [22] Monitor: - obtain pregnancy test [5] Adverse effects: - changes in menstrual bleeding may occur; generally shorter cycles if menstrual cycle within 28 days Complications: - no adverse pregnancy outcomes associated with Plan B emergency contraception [7] - routine use is not harmful, but is not the best choice [10] Mechanism of action: - does not prevent implantation [13] - levonorgestrel & mifepristone delay ovulation [13] - others may thicken cervical mucus, making it more difficult for sperm to reach the egg Notes: - FDA approve OTC plan B for women 15 years of age & older [16] - must be stocked behind the counter - Rx for patients 14 years & younger - American Academy of Pediatrics recommends OTC sale of Plan B to teenagers [14] - use doubled 2002 to 2010 - reasons for use split between unprotected sex & fear that contraception would fail [15] - intrauterine devices are most expensive to administer but most cost-effective during the first year after emergency contraception [21]

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Evital

General

contraception

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 17. American College of Physicians, Philadelphia 1998, 2015
  2. Prescriber's Letter 10(6):34 2003
  3. Prescriber's Letter 11(1):5 2004 Detail-Document#: 200107 (subscription needed) http://www.prescribersletter.com
  4. Prescriber's Letter 12(5): 2005 Pharmacist Conscience Clause Detail-Document#: 210514 (subscription needed) http://www.prescribersletter.com
  5. Raymound EG et al, Bleeding pattenrms after use of levonorgestrel emergency contraceptive pills. Contraception 2006; 73:376 PMID: 16531171
  6. Prescriber's Letter 13(10): 2006 Plan B and OTC Status Detail-Document#: 221021 (subscription needed) http://www.prescribersletter.com
  7. Zhang L et al Pregnancy outcome after levonorgestrel-only emergency contraception failure: A prospective cohort study. Hum Reprod 2009 Mar 31; [e-pub ahead of print] PMID: 19336440 http://dx.doi.org/10.1093/humrep/dep076
  8. FDA NEWS RELEASE, June 24, 2009 FDA Approves Generic Prescription-Only Version of Plan B Emergency Contraceptive for Women Ages 17 and Under http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm168870.htm
  9. Plan B One-Step - Highlights of Prescribing Information Duramed Pharmaceuticals, Inc. http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/021998lbl.pdf Plan B One-Step - New FDA-Approved One-Pill Emergency Contraceptive - Teva Pharmaceuticals http://planbonestep.com/pdfs/PlanBOneRelease_FINAL.pdf - ACOG Statement on Single-Dose EC Reformulation American College of Obsetricians and Gynecologists http://www.acog.org/from_home/publications/press_releases/nr07-15-09.cfm
  10. Prescriber's Letter 18(6): 2011 COMMENTARY: Routine Use of Emergency Contraception... Is It Safe? GUIDELINES: American College of Obstetricians and Gynecologists (ACOG). Emergency Contraception (2010) Detail-Document#: 270612 (subscription needed) http://www.prescribersletter.com
  11. Federal court order from March 2009 http://www.nyed.uscourts.gov/pub/rulings/cv/2005/05cv366mofinal.pdf
  12. Cleland K et al The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience Hum. Reprod. (2012) May 8 PMID: 22570193 http://humrep.oxfordjournals.org/content/early/2012/05/02/humrep.des140.abstract?sid=4d51eb8d-0941-4dca-b81c-45042be909d1
  13. Physician's First Watch, June 6, 2012 Massachusetts Medical Society - Belluck P Abortion Qualms on Morning-After Pill May Be Unfounded New York Times http://www.nytimes.com/2012/06/06/health/research/morning-after-pills-dont-block-implantation-science-suggests.html?_r=1 - Marions L et al. Effect of emergency contraception with levonorgestrel or mifepristone on ovarian function. Contraception 2004 May; 69:373-7. PMID: 15105059
  14. American Academy of Pediatrics Emergency Contraception: Committee on Adolescence Policy Statement: Emergency Contraception Pediatrics. November 26, 2012 PMID: 23184108 http://pediatrics.aappublications.org/content/early/2012/11/21/peds.2012-2962.full.pdf+html
  15. Daniels K et al Use of Emergency Contraception Among Women Aged 15-44: United States, 2006-2010 NCHS Data Brief. No 112. Feb 2013 http://www.cdc.gov/nchs/data/databriefs/db112.pdf
  16. FDA News Release: April 30, 2013 FDA approves Plan B One-Step emergency contraceptive without a prescription for women 15 years of age and older. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm350230.htm
  17. Reuters. Nov 26, 2013 U.S. FDA reviewing if weight limits effect of 'morning after' pill http://in.reuters.com/article/2013/11/26/us-fda-morningafter-idINBRE9AP02B20131126
  18. Langston A Emergency contraception: update and review. Semin Reprod Med. 2010 Mar;28(2):95-102 PMID: 20352558
  19. Prescriber's Letter 21(1): 2014 Emergency Contraception: Is It Effective in Heavier Women? Detail-Document#: 300108 (subscription needed) http://www.prescribersletter.com
  20. Raymond EG and Cleland K Emergency Contraception. N Engl J Med 2015; 372:1342-1348. April 2, 2015 PMID: 25830424 - Cleland K, Raymond EG, Westley E, Trussell J. Emergency contraception review: evidence-based recommendations for clinicians. Clin Obstet Gynecol. 2014 Dec;57(4):741-50 PMID: 25254919
  21. Bellows BK, Tak CR, Sanders JN, Turok DK, Schwarz EB. Cost-effectiveness of emergency contraception options over 1 year. Am J Obstet Gynecol 2018 May; 218:508.e1 PMID: 29409847
  22. Turok DK, Gero A, Simmons RG et al Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception. N Engl J Med 2021; 384:335-344. Jan 28. PMID: 33503342 https://www.nejm.org/doi/full/10.1056/NEJMoa2022141
  23. Woodhams EJ, Gilliam M. Contraception. Ann Intern Med. 2019;170:ITC18-ITC32. PMID: 30716758
  24. Li RHW et al. Oral emergency contraception with levonorgestrel plus piroxicam: A randomised double-blind placebo-controlled trial. Lancet 2023 Sep; 402:851 PMID: 37597523 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01240-0/fulltext
  25. Branswell H CDC proposes new antibiotics policy aimed at reducing STIs. STAT Health. Oct 2, 2023 https://www.statnews.com/2023/10/02/cdc-proposes-new-antibiotics-policy-aimed-at-reducing-stis/

Components

ethinyl estradiol levonorgestrel (Norplant)