What is the ‘morning after pill’?

The morning after pill is the emergency contraceptive pill. This can be used to help prevent pregnancy after sex without contraception or when contraception has failed e.g., broken condom, missed pill.

Who can take the emergency contraceptive pill?

The emergency contraceptive pill isn’t suitable for everyone so it is important to counsel the patient beforehand. The emergency contraceptive pill (depending on the type) can be taken within 3-5 days of unprotected sex. However, the pill is more likely to work the sooner that it is taken. The emergency contraceptive pill is available from most pharmacies therefore it is important that we, as pharmacists, know about the options available and suitable advice. The emergency contraceptive pill is available on the Pharmacy First Service in Northern Ireland.

What are Fraser guidelines?

These are used for patients believed to be under 16 years old. There is a form available online which should be fully documented including an assessment of the young person’s maturity and whether they are acting voluntarily.¹ This helps us ascertain if a young person requesting treatment is mature enough to understand what they’re being told, encourage them to talk to a parent, assess both their physical and mental health and consider if providing this service would be in the best interests of the patient.

Completing the Pharmacy First Form - some important notes

There is a Pharmacy First consultation form available online to print off and complete when providing the emergency contraceptive pill to patients via the Pharmacy First Service.

The patient should be asked what age they are. It is important that patients under 16 years old are asked about what age their sexual partner is also. If a patient under 16 years old tells us that their partner is over 18 years old, there is a statutory duty to contact the Police Service NI.

It is also important to identify any safeguarding issues such as coercion, abuse, assault or exploitation for all patients.

We should also ask the patient when their last menstrual period was, day in cycle, their usual bleeding/cycle pattern, if they’ve had any other unprotected sex (UPSI) since their last period and if they’ve had any other emergency hormonal contraception (EHC). It is important to note that oral EHC is ineffective after ovulation.

A medication history should also be completed. If a patient has severe asthma which is controlled using oral steroids levonorgestrel should be considered. If the patient is taking antacids/proton-pump inhibitors/H2-receptor antagonists levonorgestrel should be considered. Liver enzyme inducers may reduce the effectiveness of oral EHC therefore the 3mg dose of levonorgestrel should be considered if a patient is taking any of these.

What are liver enzyme inducers? These are drugs that increase the metabolic activity of an enzyme. For example CYP450 enzyme inducers include anticonvulsants (phenytoin, carbamazepine, phenobarbitone), steroids (dexamethasone, prednisolone, glucocorticoids), antibiotics (rifampicin, griseofulvin), nicotine, alcohol, cigarette smoke and St. Johns Wort. In the case of EHC, the liver enzymes are induced by enzyme inducer medication the patient is already on. These enzymes then break down the emergency contraceptive pill at a faster rate giving a faster clearance of the drug and therefore the EHC mightn’t be as effective.

Individuals with porphyria should be referred on to a Sexual Health Clinic for a Cu-IUD insertion.

If a patient has severe hepatic (liver) dysfunction refer to cautions in PGD and advise the woman that FRSH guidance advises that pregnancy poses a significant risk in hepatic dysfunction and thus ulipristal is acceptable.

Patients with a severe malabsorption syndrome such as IBD or Crohn’s should be referred to cautions in PGD: the use of oral EHC is not contra-indicated but it may be less effective (insertion of Cu-IUD is the most effective method of EC).

Ask the patient if they have had any unexplained vaginal bleeding. If so, oral EHC should be supplied and recommend the woman sees her GP for investigation of unexplained vaginal bleeding.

The pills available: ulipristal acetate 30mg tablet

Mechanism of action: The primary mechanism of action of ulipristal acetate is through the inhibition or delay of ovulation therefore preventing an unwanted pregnancy after UPSI. A single mid-follicular phase dose has been shown to suppress the growth of lead follicles. When given before or immediately after (in some cases) the luteinizing hormone (LH) surge, ulipristal prevented 100% of follicle ruptures.²

When should it be taken?: One dose of a 30mg tablet should be taken as soon as possible after UPSI, but no later than 120 hours (5 days afterwards). It is the first line treatment including when a patient’s BMI is over 26 or weight is over 70kg.

Contra-indications: breast cancer, cervical cancer, ovarian cancer, severe asthma controlled by oral glucocorticoids, undiagnosed vaginal bleeding and uterine cancer.

Side effects: Common or very common side effects include dizziness, GI upset, headaches, vomiting.

Breast-feeding advice: It is recommended that breast-feeding is avoided for 1 week after administration due to its presence in milk.

The pills available: levonorgestrel 1.5mg or 3mg tablet

Mechanism of action: Suppresses the gonadotropins which inhibits ovulation. The female gonadotropins are hormones which regulate reproduction processes in women including LH and FSH which stimulate the ovaries to produce and release an egg each month as part of the menstrual cycle.

Contra-indications: current breast cancer (use with caution in EHC)

Side-effects: GI discomfort, irregularities in the menstrual cycle, headaches, nausea, skin reactions

Breast-feeding advice: progesterone-only contraceptives don’t affect lactation

What is bridging contraception?

Patients not already on systemic contraception can be offered bridging contraception to help avoid needing to use EHC again if it is a suitable option. This involves the supply of desogestrel 75microgram tablets (3×28 tablets) and giving verbal advice surrounding pill taking/timing/potential effects. The patient should also be advised to arrange a further supply before the 3 month supply they’ve been given runs out.

What advice should I give patients?

• Patients should be informed that the emergency contraceptive pill doesn’t protect against sexually transmitted infections (STIs). The risk of contracting an STI can be reduced by using a condom.

• If vomiting occurs within 3 hours of taking the emergency contraceptive pill a replacement dose should be taken.

• Advise patients that their next period could be early or late.

• Concomitant use of ulipristal and EC containing levonorgestrel isn’t recommended.

• As with every other medicine supplied by the pharmacy, a Patient Information Leaflet (PIL) should be supplied alongside the EHC and if supplied, bridging contraception.

Please note that this newsletter doesn’t cover everything there is to know about EHC it is only covering some important points we need to know about EHC as pharmacists.

References

¹  Pharmacy First Service - Community Pharmacy NI

²  Jadav, S. P., & Parmar, D. M. (2012). Ulipristal acetate, a progesterone receptor modulator for emergency contraception. Journal of pharmacology & pharmacotherapeutics, 3(2), 109–111. https://doi.org/10.4103/0976-500X.95504. [Online] Ulipristal acetate, a progesterone receptor modulator for emergency contraception - PMC (nih.gov)

³  https://bnf.nice.org.uk

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