A 41-year-old woman attends your clinic at 9.30 a.m. on a Monday morning requesting emergency contraception. She has been using condoms for contraception since she ran out of supplies of the POP. She has been married for 6 years and uses male condoms for contraception. The condom burst when she had consensual sex at the weekend. She thinks this was at about 10 p.m. on Friday night. Her LMP was 20 days ago. Her periods are regular but heavy, occurring every 35 days and lasting for 7 days. Her husband works off-shore and this is the only occasion she has had SI since her LMP.
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1. What options are available for EC?
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Correct answer: A Cu-IUD should always be offered for EC if the patient is eligible. Alternatives are either oral levonorgestrel (LNG) or ulipristal acetate (UPA). To determine which methods are suitable, the likely day of ovulation, interval since UPSI, and timing of UPSI in her menstrual cycle should be calculated.
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2. Is this woman eligible for a Cu-IUD?
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Correct answer: Yes.
Today is day 20 of her cycle and she had UPSI on Day 17. Her menstrual cycle is K=7/35 days and is regular therefore the likely day of ovulation is day 21 (35 minus 14 days). It is approximately 60 hours since the only episode of UPSI in this cycle.
A Cu-IUD can be fitted up to 5 days (120 hours) after the first UPSI in the cycle or up to 5 days after the earliest predicted date of ovulation. She meets both these criteria.
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3. What would you advise her about her likely risk of pregnancy?
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Correct answer: The exact risk cannot be determined but based on the above calculations she has had UPSI 4 days prior to ovulation. Sperm can survive for 5 days in the upper reproductive tract although the highest risk days are the day preceding and the day of ovulation. She is certainly at moderate risk of an unintended pregnancy.
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4. She thinks she might like a Cu-IUD fitted but does not have time today as she needs to go to work. What do you offer her?
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Correct answer: Ideally a Cu-IUD should be inserted when the woman first presents however if this is not possible, it is good practice to offer an oral EC method in the interim and advise the woman to re-attend for insertion as soon as possible. Both LNG and UPA have been shown to be efficacious up to 96 hours (up to 120 hours for UPA). LNG is less expensive than UPA and may be more readily available depending on local prescribing policies. It is licensed up to 72 hours.
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5. What else would you undertake in this consultation?
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Correct answer: An STI risk assessment should be undertaken as a component of an EC consultation. This woman’s history would indicate a low risk of STIs.
Ongoing contraception should be discussed and in particular the LARC methods.
If a Cu-IUD is inserted for EC, this device can remain in situ until after the menopause as she is >40 years at the time of insertion. This may not be suitable for ongoing contraception however in view of her heavy menses. After her next menses the Cu-IUD can be removed and a LNG-IUS inserted (provided there has been no UPSI in the 7 days before removal and advice for switching methods is followed).
If she opts for oral EC alone, then an alternative would be to quick-start a contraceptive method, e.g. the POP or COC, at the same time. She could either continue with this method, or use it as a ‘bridging method’ until pregnancy has been excluded at which time an LNG-IUS could be inserted. When quick starting hormonal contraception at the time of oral EC, additional precautions are required (see Chapter 14, Fig. 3).
