Women’s Health-Emergency Contraception Types

Topic: Women’s Health-Emergency Contraception: Plan B® One-Step (levonorgestrel) and ella® (ulipristal acetate)

Emergency contraceptives are intended to prevent pregnancy after known or suspected contraceptive failure or if you had unprotected intercourse without using birth control (Turner and Ellertson, 2002). There are two forms of emergency contraceptive pills (ECPs), both available and approved by the Food and Drug Administration (FDA). The two ECPs currently available in the United States are ella® (ulipristal acetate) and Plan B One-Step® (Levonorgestrel-only) (Cleland K. et al., 2015). Plan-B One-Step® has several other generic forms as well, including AfterPill™, My Way®, Next Choice One Dose™, and Take Action™. Though both forms have a similar indication, they are slightly different from one another—Plan B One-Step® is over the counter (OTC) and ella® (ulipristal acetate) is by prescription only⁷.

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Both types of emergency contraception pills work to prevent or delay ovulation (Cleland et al., 2015) and are deemed safe by the WHO—World Health Organization⁵. Ovulation is defined as the “discharge of ova or ovules from the ovary” and in a more simplified version it is the release of an egg from the ovary¹³. If fertilization has already occurred and the egg has been implanted into the uterus, an emergency contraceptive will most likely not be effective, and you are more than likely pregnant¹³. However, you should consider using emergency contraction if you had sex and you did not use birth control or you think your form of birth control did not work⁷. Emergency contraception works best when you use it as soon as possible after unprotected sex^5,7. Depending on the form of contraception, if you are not able to take it right away, it can still work up to three to five days after unprotected sex (Cleland et al., 2015). Timing is dependent on which form you choose to use. For instance, Plan-B One-Step® (or a generic version Next Choice®, LNG tablets 0.75 mg, etc.) should be taken as soon as possible up to 72 hours (3 days) after unprotected sex⁵. For the two-dose version, you should take one pill as soon as possible within the first 72 hours (3 days) and the second pill 12 hours later⁵. If prescribed ella® (ulipristal acetate), you should take as soon as possible within 120 hours (5 days) after unprotected sex (Corbelli and Bilma Schwarz, 2014).

This is by far my least favorite topic and I am still very uncomfortable when having to talk about emergency contraception; however, I do recognize how important this topic is, especially within today’s society. The three questions I came up with are listed below:

1. Will my fertility be affected if I take a form of emergency contraception?
2. Will an emergency contraceptive affect my menstruation cycle?
3. What side effects may I experience after taking an emergency contraceptive?

In this paper, I will address each question to the best of my ability, using the textbook and other resources I have acquired through researching this specific topic.

The first question relates to emergency contraception and its effect on future or long-term fertility. The short answer is no, emergency contraception does not impact your future or long-term fertility. An animal study showed postcoital treatment with levonorgestrel (LNG) had no post fertilization effect impairing fertility in rats (Muller et al., 2002). LNG is a progestin widely used in emergency contraception, specifically Plan-B One-Step®. In the Indian Journal of Medical Research, an article compared forms of emergency contraception and its effect on overall women’s health stating that both LNG and ulipristal acetate (active ingredient in ella®) prevent pregnancy through delaying ovulation and inhibiting fertilization, both mechanisms in which do not interfere with post-fertilization events (Mittal, 2014).

The next question is related to the effects emergency contraception has on the menstrual cycle. After you consume the emergency contraceptive pill, you may experience abnormalities in your cycle¹⁴. Your next period might come a little sooner or later than its’ expected date. In addition, flow may be heavier or lighter, and you may even experience more or less pain than normal¹⁴. Recent studies have shown a change in menstruation patterns after taking an emergency contraceptive. A prospective study considered menstrual bleeding patterns following LNG emergency contraception. Only 14.7 % of patients (34/232) participants showed significant changes in menstrual cycle length, period length, and menstrual appearance compared to baseline readings. Majority of these changes disappeared in the next menstrual cycle; therefore, associating a link between LNG emergency contraception and abnormal menstrual patterns (Gainer et al., 2006). An observational study analyzed the effects of bleeding after the use of an emergency contraceptive through tracking women’s diaries over a 9-week period after completing the regimen. This study concluded that abnormalities depended on when during the cycle the pills were taken, indicating the extent of this effect was much greater the earlier the pills were consumed (Raymond et al., 2006).

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The last question relates to side effects experienced when taking an emergency contraceptive. In short, there are many side effects one may potentially experience, including headaches, abdominal pain, fatigue, dizziness, nausea, breast pain, etc^5,15. However, the most commonly noted side effects of all forms of emergency contraceptives are nausea and vomiting⁵ but it is important to note that most side effects are typically mild, not long lasting and rarely serious. According to Paediatrics Child Health, LNG containing contraceptives are associated with nausea in 23% of cases, abdominal pain in 18%, fatigue/headache in 17% and vomiting in 6% of women⁴. The mainstream media has indicated many factually incorrect statements leading to a widespread of misinformation. In particular, a news article recently stated that emergency contraceptives increase the risk of bloods clots and hormone-related cancers (Westley and Glasier, 2010). These statements are incorrect and potentially keep women away from using a emergency contraceptive when they might need it the most (Westley and Glasier, 2010).

In conclusion, this was an interesting assignment. I have never thought about my strengths and weaknesses in terms of counseling on an OTC product until we had to complete both parts of this assignment. At first, I thought I had a pretty good idea about all products we have learned thus far, but really once I dug deep into this topic, I realized how comical that sounds. Truth is, I was ignorant to a lot of factual information I learned through my research on emergency contraceptives. In general, I realized how important education is and how easily we can help prevent certain situations for our patients by listening to them and providing them with correct and pertinent information to guide them through whatever issues they are facing. Lastly, I learned to be less judgmental. Much easier said than done, but for me this assignment was a humbling moment reminding me that I am no greater than any other person. In terms of emergency contraceptives, we often jump to conclusions or make harsh judgements before knowing the circumstance. I realized the endless amounts of reasons why people may seek out emergency forms of contraception and instead of being judgmental and harsh towards our patients, we must listen and help them the best we can regardless of our own beliefs.

References: 

1. Cleland K, Raymond EG, Westley E, Trussell J. Emergency contraception review: evidence-based recommendations for clinicians. Clin Obstet Gynecol. 2014;57(4):741–750. doi:10.1097/GRF.0000000000000056
2. Corbelli, E. and Bilma Schwarz, E. (2014). Emergency contraception: a review. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25313947 [Accessed 7 Oct. 2019].
3. Raymond E, Goldberg A, Trussell J, Hays M, Roach E, Taylor D. Bleeding patterns after use of levonorgestrel emergency contraceptive pills. Contraception. 2006;73(4):376-381. doi:10.1016/j.contraception.2005.10.006
4. Emergency contraception. Paediatr Child Health. 2003;8(3):181–192. doi:10.1093/pch/8.3.181
5. Emergency contraception: Preventing pregnancy after you have had sex. Paediatr Child Health. 2003;8(3):184–194. doi:10.1093/pch/8.3.184
6. Gainer E, Kenfack B, Mboudou E, Doh AS, Bouyer J. Menstrual bleeding patterns following levonorgestrel emergency contraception. Contraception. 2006;74(2):118–124. doi:10.1016/j.contraception.2006.02.009
7. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 18th edition. 2015 American Pharmacists Association. Chapters 8, 9, 10, & 51; 121-176, 986, 991-994.
8. Mittal S. Emergency contraception – potential for women’s health. Indian J Med Res. 2014;140 Suppl(Suppl 1):S45–S52.
9. Müller, A.L. et al. Postcoital treatment with levonorgestrel does not disrupt postfertilization events in the rat. Contraception, Volume 67, Issue 5, 415 – 419
10. Turner, A.N. & Ellertson, C. Drug-Safety (2002) 25: 695. https://doi.org/10.2165/00002018-200225100-00002
11. Weiss D. Plan B One-Step to Be Made Available OTC With No Age Restrictions. Pharmacy Today. Published online June 14, 2013.
12. Westley E, Glasier A. Emergency contraception: dispelling the myths and misperceptions. Bull World Health Organ. 2010;88(4):243–244. doi:10.2471/BLT.10.077446
13. World Health Organization. Medical eligibility criteria for contraceptive use. 2010
14. https://www.livescience.com/54922-what-is-ovulation.html
15. https://www.womenshealth.gov/a-z-topics/emergency-contraception