Saturday, January 21, 2017

After emergency contraception: what next?

- Jennifer Middleton, MD, MPH

Developing a regular, ongoing contraception plan when women request emergency contraception (EC) makes intuitive sense, and the updated Centers for Disease Control and Prevention (CDC)'s Practice Recommendations for Contraceptive Use, as described in the January 15 issue of AFP, includes several points for physicians to consider when doing so. One important discussion point involves the risks and benefits of simultaneously providing a ulipristal (ella) prescription and initiating long-acting hormonal contraceptive methods.

Women desiring EC in the U.S. currently have three oral medication options, in addition to the copper IUD, to choose from: the Yupze method and levonorgestrel are approved up to 72 hours after unprotected intercourse, and ulipristal is approved up to 120 hours after unprotected intercourse. Patients requesting EC are often willing to initiate a regular contraceptive method at the same visit. Initiating hormonal contraception at the same time as levonorgestrel or the oral contraceptives used in the Yupze method poses no drug-drug interaction risk, but how ulipristal's antiprogestin effect might impact outcomes is less clear.

Hormonal contraceptive methods, regardless of delivery mode (oral, implant, or IUD) may decrease ulipristal's efficacy, and, conversely, ulipristal may also decrease the initial efficacy of a regular hormonal method. The CDC recommends waiting at least 5 days after taking ulipristal before beginning a hormonal contraceptive method. This delay, however, can be inconvenient for women and can increase the risk of them not initiating a regular contraceptive method at all. Discussing these risks and benefits with patients at the time of providing EC is a must.

Ulipristal has definite positives; it's the most effective oral medication for EC, it only requires one dose, and it works up to 5 days after unprotected intercourse. The potential negative of these interaction risks, however, drives the CDC to encourage transparent discussion with patients. Patient-centered decision making is one framework well-suited to such conversations:
The health care provider's role includes provision of information, facilitating the identification of patient preferences, ensuring that preferences are not based on misinformation, helping patients to think about how their preferences relate to the available options, and coming to a mutually acceptable decision.
Women want their preferences included in discussions of contraceptive choice, and they also want to have the final decision in what method they will use. Discussions about EC should include options for initiating a regular form of contraception along with information about ulipristal's effectiveness and possible interactions. 

Family physicians should not dismiss ulipristal as an option for EC given its convenience and efficacy, but considering the possible decreased effectiveness of both ulipristal and whatever new contraceptive method patients choose is important. Providing this information to women in the context of patient-centered decision making will allow them to choose both an EC method and a regular contraceptive method that best fit their priorities and wishes. If you'd like to read more about ulipristal, there's an AFP STEPS article that outlines its use, and this Update on Emergency Contraception describes use of the Yupze method, levonorgestrel, and the copper IUD. There's also an AFP By Topic on Family Planning and Contraception that contains in-depth information about a variety of contraceptive methods.

How do you counsel women about EC?