An OOPE (out of programme experience) GP trainee had an UPSI (unprotected sexual intercourse). It happened 72 hours and one minute ago. Is this the end of Levonelle? Must we coil it?
The key facts you can derive the game plan from:
- Sperm last up to 5 days in the female genital tract
- An ovulated egg last up to 24 hours
- The fertile period is the six days before and including the day of ovulation. See how that works?
- Ovulation typically happens 14 days before the start of the next cycle.
- You can get pregnant on any day really though (well, probably not the first three days of a natural cycle. But medicolegally we need to say any day). Therefore we give the same advice for any day of the cycle, although we bear in mind some times are super high risk and others low risk.
The best option
- The Cu-IUD releases copper to stop the egg implanting in the womb / being fertilised. It works up to 120 hours after UPSI, or up to 120 hours after the earliest time the patient could have ovulated.
- Includes immediate contraception going forward from the time of insertion
- If she wants this and you aren’t about to insert it there and then, also prescribe an oral EC in case she changes her mind about Cu-IUD or it cannot be inserted.
The oral option
- Oral EC works by preventing ovulation. If you take it post ovulation, it is closing the stable door after the horse has bolted. This means there is inevitably a 24 hour window where a) ovulation has happened b) the egg is viable and c) that oral EC you prescribed won’t do anything to shorten or stop this window.
- The two types of oral EC are ulipristal (UPA-EC) which is branded as EllaOne in the UK and levonorgestrel (LNG-EC) which is branded as levonelle. UPA-EC is a progesterone receptor modulator with a partial progesterone antagonist effect. LNG-EC is a synthetic progesterone. Both inhibit ovulation, but may also have other effects.
- From a GP point of view, the main things we need to know about them are:
- UPA-EC is more effective than LNG-EC
- UPA-EC can be used for up to 120 hours post UPSI, whereas LNG-EC is licensed for up to 72 hours with evidence of ineffectiveness after 96 hours
- Synthetic progesterone and UPA-EC do not get on well together. If you give anything progesterone containing for up to 5 days post UPA-EC, it may make UPA-EC less effective at preventing ovulation. In order words, don’t give any hormonal contraceptives for at least 5 days post UPA-EC.
- UPA-EC > LNG-UC in general. Pretty much the only times you would pick LNG-EC over UPA-EC are:
- if the BMI > 26 or weight > 70kg (with double dose LNG-EC)
- if the woman is on enzyme inducers (with double dose LNG-EC)
- if the woman has severe asthma controlled with oral glucocorticosteroids
- if the woman has recently used a progesterone in the last seven days
- If you want to start hormonal contraception, either quickstart post LNG-EC or wait 5 days post UPA-EC
Many practitioners recommend a routine high sensitivity pregnancy test 21 days after the last UPSI.
This is not wrong, but the FPA say:
Pregnancy testing is advised if, after EC, the next menstrual period is delayed by more than 7 days, is lighter than usual or is associated with abdominal pain that is not typical of the woman’s usual dysmenorrhoea. Women who start hormonal contraception soon after use of EC should be advised to have a pregnancy test even if they have bleeding; bleeding associated with the contraceptive method may not represent menstruation. Pregnancy can be excluded by a urine pregnancy test taken 21 days after the last episode of UPSI.
Vomited? Repeat oral EC if she vomited within 3 hours.
UPSI earlier in the same cycle and oral EC given? LNG-EC should not be taken in the five days after UPA-EC (as described earlier). Either repeat UPA-EC or use Cu-IUD.
In theory, UPA-EC may be less effective if LNG-EC was given in the previous seven days, so consider Cu-IUD or repeat LNG-EC.
UPSI earlier in the same cycle without EC? There is no known risk of harm to the foetus if LNG-EC or UPA-EC are used. Use as normal.