Contraception: Emergency Emergency contraception is a way of preventing pregnancy after unprotected sex or when contraception has failed. It is also called the “morning after pill”, although a woman does not need to wait until the morning after to take it. It is not intended for use as a regular way of preventing pregnancy. There are two main types of emergency contraception – the emergency hormonal contraceptive pill (ECP) and the intrauterine contraceptive device (IUD). A copper IUD inserted within five days of unprotected intercourse has almost 100% effectiveness but must be fitted by a doctor. It has the advantage of providing long-term contraception and being effective for heavier women. When should the ECP be taken? The ECP is approved to be taken up to 72 hours after unprotected sex (three days) in New Zealand. According to the World Health Organization it can be used up to five days after unprotected sex; however, failure rates are higher. The ECP is most effective if taken within 12–24 hours. Pregnancy rates of between 0.7% and 1.6% have been reported when the ECP is taken within 72 hours. The effectiveness of the ECP appears reduced in women with a BMI of 30 or more and these women are best referred to a doctor for a post-coital IUD. Who can sell the ECP? Only pharmacists who have successfully completed an education programme accredited by the Pharmacy Council to become providers of emergency hormonal contraception may supply the ECP. Pharmacists who have not completed this training may not sell the ECP and must instead direct women wanting the ECP to a pharmacy where an accredited pharmacist is working (or to her doctor or a family planning clinic). Pharmacies may display an ECP decal to advertise the ECP is available from an accredited pharmacist practising there. Refer to the Pharmacy Council of New Zealand website (www.pharmacycouncil.org.nz) for the nine standards prescribed by the council for the non-prescription supply by pharmacists of the levonorgestrel ECP. Nurses who have competency in the field of sexual and reproductive health may also provide the ECP. Women seeking the ECP should be spoken to in a private area where the conversation cannot be overheard by others. All necessary advice and information should be provided in an appropriate manner. Pharmacists must attend to the request for the ECP personally, and not just oversee the sale. Details of the sale should be recorded; however, it is optional for the woman to supply identifying details. The ECP may be sold to women of any age and should be sold directly to the woman requiring it; unless unusual circumstances prevent direct supply and then it may be supplied to another person. Reasonable efforts must be made by the pharmacist to inform the woman about the limitations of the ECP as an ongoing method of contraception, and refer her to the appropriate health professional if further investigations or long-term contraception is required. Pharmacists must advise the woman buying the ECP that it is not 100% effective and to seek further advice from a doctor or family planning clinic if her next period is lighter than usual, late or different in any way, or if any other unusual bleeding or lower abdominal pain occurs. The ECP may also be supplied to women for future use. When would emergency contraception be used? Pregnancy is most likely to occur if intercourse happens up to five to seven days before, or one day after ovulation. This is because some sperm can survive up to seven days (average three to four days) inside a woman, whereas the ovum (egg) has a life span of only about 12–24 hours. However, many women have irregular cycles or are unsure of the date of their last period, so, unless they have periods like clockwork, or are taking a contraceptive pill, it is best to assume unprotected sex on any day of the cycle might result in pregnancy. Emergency contraception should also be considered with incorrect use, dislodgement or breakage of a barrier method (condom or diaphragm), part or complete expulsion of an IUD, vomiting or diarrhoea while on a contraceptive pill, a missed Depo Provera injection, or with missed contraceptive pills (as outlined below). Emergency contraception should be made available to any woman who feels she needs it. Missed contraceptive pills With the combined oral contraceptive pill (OCP) data sheets consider a “missed pill” to be one that is taken more than 12 hours later than the usual time. However, research has shown that this advice is very conservative and that contraceptive efficacy is only compromised when missing two pills in a row. The loss of efficacy also depends on which week of hormone pills is involved. • Efficacy is compromised if two or more pills are missed from the first seven TREATMENT OPTIONS Category Examples Comments Emergency Contraceptive Pill Antiemetics [PHARMACIST ONLY] (Accredited ECP pharmacists) eg, levonorgestrel 1.5mg (Postinor-1) [PRESCRIPTION] (Except when sold by accredited ECP pharmacists for the treatment of nausea associated with emergency contraception) eg, prochlorperazine (Antinaus) The tablet should be taken as soon as possible (and no later than 72 hours) after unprotected sex. Readminister if vomiting occurs within three hours of the dose. Up to 10 tablets may be supplied without prescription for nausea associated with the ECP. READY, SET, LEARN! Page 42 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION active tablets in a packet. • If two or more pills are missed from the last seven active tablets in a packet, emergency contraception is not needed provided that the pill-free break is omitted. • As long as the hormone pills in the first and last week have been taken correctly, there is no concern about missed pills in the middle week of the combined pill packet. With the progesterone-only pill (POP), the pills are taken continuously and within a strict time frame, so for most POPs, a missed pill is defined as one or more pills taken three or more hours late, or missed altogether. The ECP should be considered if this has occurred along with sexual intercourse. For both types of contraceptive pills, when pills have been missed, additional means of contraception (ie, condoms) are required until contraceptive effectiveness is re-established. For combined OCPs this is recommended for seven days and for most POPs, at least two days. How does the ECP work? • The ECP prevents pregnancy by: »» interfering with the mobility of sperm »» delaying ovulation (the release of the egg from an ovary) until sperm are no longer active »» changing the lining of the uterus (corpus luteum) so a fertilised egg cannot implant and develop. • The ECP cannot interrupt or harm an established pregnancy. • The ECP can be used more than once in a menstrual cycle. Warnings • Do not give the ECP to women who are allergic to levonorgestrel or any inactive substances used in the manufacture of the tablet. • Consider an increased dose of ECP for women taking medications that induce hepatic enzymes (eg, carbamazepine, phenytoin, topiramate, St John’s wort, rifampicin, rifabutin, ritonavir), or with malabsorption syndromes. Discuss or refer to a doctor or family planning clinic. • The ECP is considered safe to take while breastfeeding, although a women should talk further with a doctor or a pharmacist if she is concerned. • If the woman vomits within three hours of taking the ECP, she should be referred to the pharmacist, her doctor or a family planning clinic for advice and further tablets. • Around 25% of women taking the ECP feel nauseous and 5% may vomit. Taking the medicine with food may help. The pharmacist supplying the ECP may also sell up to 10 prochlorperazine tablets to prevent nausea and vomiting associated with taking the ECP. • Advise women that their next period may be later or earlier than usual, or there may be spotting or irregular bleeding before their period occurs. She should see her doctor if her next period is late or lighter than usual. Refer to PHARMACIST All customers seeking the ECP must be referred to a pharmacist, who should then refer a woman to a doctor or family planning clinic if she: • has severe liver disease, severe hypertension, diabetes, stroke, heart disease, or a past history of breast cancer and the pharmacist is not comfortable supplying the ECP. • is pregnant, thinks she is pregnant or her period is late or unusual. • has a period that is more than five days late, is unusually light or heavy, or is painful. • has a BMI of 30 or more • is at risk of contracting a sexually transmitted infection (this can be screened for at about two weeks after unprotected sex). • needs to consider long-term contraception. • has an allergy to levonorgestrel. • Other side effects of the ECP include tender breasts, headaches, lower abdominal pain, dizziness and fatigue. Initial assessment While some women may confidently ask for the ECP, others may not. Politely asking if you can help or would they prefer to talk to a pharmacist may be the best approach in women who appear embarrassed or shy. All women requesting the ECP must be referred to a pharmacist. Advice for customers • Advise customers that the ECP: »» is not 100% effective. The woman should carry out a pregnancy test if her next period is late »» does not protect the woman from sexually transmitted infections »» is not recommended as an ongoing source of contraception. Women seeking multiple dispensings of the ECP should be referred to a doctor or family planning clinic for other methods of regular contraception. Locate this icon throughout the Healthcare Handbook. Then find the corresponding Pharmacy Today and ELearning articles. Read all three to unleash learning prizes and giveaways! Page 43
According to Stéphane Rossini, incoming Chairman of the Agency Council, the culture of collaboration will remain a factor in ensuring that Switzerland is successful in retaining a high-quality medicines control system: “A globalised economy and the international consumption of therapeutic products entail synergies and collaboration.”
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