Dispensing assistant Katya comes to technician Vicky with a query on her technician coursework.
“Vicky, I’m doing a module on women’s health and I’ve got myself into a bit of a muddle over emergency contraception,” starts Katya.
“Ah yes,” replies Vicky. “It used to be so straightforward when there was just the one product: a woman would ask for the morning after pill and we’d know exactly what to do. But a couple of years ago another EHC was launched, and then it went OTC, and now some new guidelines have come out. Progress is good, don’t get me wrong, but it can be difficult to get your head round it all when it changes.”
“Well, quite!” exclaims Katya. “And I’m not sure my course materials are as up-to-date as they could be. Would you mind running through it with me? What should be used in what circumstances?”
The guidance Vicky is referring to is the document published by the influential and well-regarded Faculty of Sexual and Reproductive Healthcare (FSRH), which is part of the Royal College of Obstetricians and Gynaecologists (RCOG). The paper – an update of guidelines from 2012 – is intended for use by all healthcare professionals involved in the provision of emergency contraception (EC), and basically states:
- Copper containing intrauterine devices (IUDs) are recommended first line for EC, because they are highly effective, regardless of any other medication the woman is taking, and also provide immediately effective ongoing contraception
- Oral EC (also known as emergency hormonal contraception or EHC) is an option in pharmacy for women who have had unprotected sexual intercourse (UPSI) and don’t wish to conceive, assuming they meet the criteria laid down for sale or supply
- Ulipristal is usually the best EHC option, as it can be taken up to 120 hours after UPSI, and needs no dose adjustment for women who are overweight or obese
- Levonorgestrel is better for women who are at risk of pregnancy because of missed contraceptive pills, who want to start a hormonal contraceptive immediately after EHC, or who are on enzyme-inducing medicines
- All women enquiring about EC should be counselled on STIs and regular contraception.
The bigger picture
The FSRH guidelines highlight some important updates to practice, namely:
- The standard EC dose of levonorgestrel appears less effective in women who have a body mass index over 26kg/m2 or weigh more than 70kg, but this does not appear to be an issue with ulipristal
- Both EHCs interact with enzyme-inducing drugs, but only levonorgestrel is licensed at double the usual dose to compensate.
The document also states that while an IUD is first line, if a woman is referred for a fitting, oral EC should be provided anyway, just in case the appointment is delayed or the woman changes her mind about the contraceptive method.
Extend your learning
- Read the executive summary of the FSRH’s guidance, which is on pages vi-x of the document
- Pharmacy Magazine has published a summary of the FSRH document in Q&A format, which is worth a look
- Do you know what is meant by an enzyme-inducing drug?
- How would you handle a request for emergency contraception? Refresh your training by re-reading manufacturer information on the OTC products, and the specification for any EHC services provided at your pharmacy, and discuss it with your pharmacist.