Name: postcoital contraception problems
Synonyms: emergency contraception, morning-after-pill, contraception - morning after pill
Various regimens of oral hormones are used within 72 hours of intercourse or an intrauterine contraceptive device is inserted within 7 days of intercourse. The oral regimens include estrogen alone (high dose) or estrogen plus progestin in oral contraceptive pills, or just progestin alone all given within 72 hours of unprotected intercourse. These regimens are felt to reduce the expected rate of pregnancy from a random sexual intercourse episode from about 7-8% to 2-3%. The major side effects are nausea and vomitting. The IUCD insertion is more effective and results in less than a 1% pregnancy rate. The progestin only pill, levonorgestrel, 0.75 mg dose within 72 hours after unprotected intercourse, and a second 0.75 mg dose 12 hours after the first dose, also seems to reduce the pregnancy rate to about 2%.
Is it common?
Nausea 30-50%, vomitting 15-20% with the estrogen only and estrogen plus progestin (Preven®). The newer progestin only pill, levonorgestrel (Plan B®) has lower rates of nausea and vomitting.
An intrauterine device has the disadvantage of requiring a skilled person to insert it and a slight risk of infection especially if a sexually transmitted disease is possible with the sexual intercourse exposure.
Side effects coincide usually within one hour of taking the regimen by mouth and can be lessened with an anti-nausea medication. Uterine cramps and some light bleeding occur immediately with IUCD insertion and may last from 15-20 minutes to 24 hours or more. The cramps are treatable with non steroidal anti-inflammatory drugs, e.g., naproxen sodium (Alleve®, two tabs) given just prior or after insertion. Other features headaches, breast tenderness, dizziness, fluid retention, menstrual delay or intermenstrual bleeding with the hormones. Cause The high estrogen doses of various regimens produce direct gastric irritation. Different regimens include:
Plan B®, levonorgestrel, 0.75 mg tab immediately then 0.75 mg tab 12 hours later
Preven®, two blue tabs immediately then two more tablets 12 hours later
Levlite® five tabs immediately then five more tablets 12 hours later
Levora® four tabs immediately then four more tablets 12 hours later
Levlen® four tabs immediately then four more tablets 12 hours later
LoOvral® four tabs immediately then four more tablets 12 hours later
Nordette® four tabs immediately then four more tablets 12 hours later
Ovral® two tabs immediately then two more tablets 12 hours later
Trilevlen® four yellow tabs immediately then four more yellow tablets 12 hours later
Triphasil® four yellow tabs immediately then four more yellow tablets 12 hours later
Trivora® four pink tabs immediately then four more pink tablets 12 hours later
Conjugated estrogens (Premarin®) 10 mg each day for 5 days
Estrone® 5 mg twice a day for 5 days
Copper IUCD insert within 5 to 7 days of exposure
Unnecessary studies/gastrointestinal x-rays/Natural history
untreated nausea, vomitting and other symptoms subside after about 12 hours
Goals of therapy (Rx)
Prevent or lessen the incidence of nausea and vomitting 1st choice therapy levonorgestrel .75 mg once followed by a second dose 12 hours later (Plan B®) for the emergency contraception promethazine hydrochloride (Phenergan®) 25 mg orally about one hour prior to the hormonal therapy. clear liquid diet for prevention of nausea Other therapies used Anti-nausea medications such as promethazine (e.g., Phenergan®).
Treatments to avoid
Other medications that act as gastric irritants. Reason for Rx
choices Progestin only pills or oral contraceptives (birth control pills) are most often used rather than estrogens alone since the estrogen doses are less and therefore better tolerated. Levonorgestrol alone (Plan B®) has been effective and is probably the treatment of choice. Making emergency contraception available without prescription improves its use and pregnancy prevention. References Morgan KW, Deneris A
Emergency contraception: preventing unintended pregnancy. Nurse Pract 1997 Nov;22(11):34-36
Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Task Force on Postovulatory Methods of Fertility Regulation.
Lancet 1998 Aug 8;352(9126):428-433
Glasier A, Baird DThe effects of self-administering emergency contraception.
N Engl J Med 1998 Jul 2;339(1):1-4