Providing emergency contraception in primary care

Women’s health specialist nurse Ruth Bailey provides an update on what GPNs need to know about offering emergency contraception in primary care

Why does it matter?

Control over fertility is a fundamental human right and part of gender equality. Women need to have agency over their fertility to have reproductive freedom, and so access to contraceptive choices is a central component of women’s health.

No method of contraception is 100% effective, and any method – particularly user dependent methods – can fail. In addition, some women may not use contraception at all. If unprotected sexual intercourse (UPSI) has taken place, it vital that women are offered emergency contraception (EC) to prevent an unplanned pregnancy.

There is substantial evidence to suggest that planned pregnancies are associated with better outcomes for both women and their babies, as women have an opportunity to make health changes, such as smoking cessation, reducing alcohol intake, ensuring uptake of immunisations and taking folic acid to prevent neural tube defects.

Offering EC is an important intervention nurses can make to promote planned pregnancy and support the health and wellbeing of women.

Principles of care

GPNs have an important role to play in first assessing the indication for EC. Women may need advice on risks of missing pills or delays in starting contraption to establish if they are at risk of pregnancy. The missed pill calculator from The Lowdown provides a user-friendly guide than can be used by patients to assess the need for emergency contraception. It does not replace the need for a medical consultation but can help assess risk.

If EC is indicated, general practice nurses (GPNs) are well placed to explain management options and enable the women to make a choice that is right for them. This will include advice of effectiveness, suitability, side effects and possible impact on the choice of ongoing contraception.

Women should have the opportunity to discuss their plan for ongoing contraception, so that they avoid the risk of UPSI in the future. This plan may influence the choice of EC that is administered. They should be advised to take a pregnancy test 3 weeks after UPSI to ensure that the EC has been effective and to seek medical attention for any lower abdominal pain or unexpected bleeding as these could be signs of ectopic pregnancy.

Nursing assessment is important not only to assess the risk of pregnancy and offer appropriate EC and contraception, but also to offer screening for sexually transmitted infections, check cervical screening is up to date, screen for domestic abuse and identify any risk-taking behaviour that the women may want to address.

Useful questions include:
• Can you tell me when the event occurred?
• When was your last period?
• Have you had any other unprotected sexual intercourse (UPSI) earlier on in this cycle?
• Have you taken any other EC this cycle, and do you know what it was?
• Who was the person you had sex with?
• Was it someone that you feel comfortable with?
• Was it sex that you had chosen to have?
• Would you like to have a sexual health screen while you are here today?

Emergency contraception options

Intrauterine device (IUD; also known as Copper coil)
Ulipristal acetate (UPA) 30mg is a progestogen antagonist and works to delay ovulation so that the ova and sperm do not meet. It can be administered up to 120 hours (5 days) after UPSI.

Available evidence indicates it is not effective after ovulation, but in practice many women do not know when ovulation is due and it can be used at any time of the cycle.

As above, a pregnancy test should be performed 3 weeks after administration, as it is not 100% effective.

GPNs play an important role in assessing suitability of this method, discussing the risks, benefits and fitting procedure to gain informed consent. Although it is the most effective method and provides ongoing contraception, a copper coil is associated with heavier and longer periods which may not be acceptable to everyone. Many women prefer the convenience of an oral tablet rather than undergo the fitting procedure which can cause discomfort. A discussion on suitability, risks and benefits can enable them to make a person-centred choice.

It is important for GPNs to be aware of local pathways for accessing emergency coil fitting if the procedure is not offered by the practice, so that patients can be referred quickly for the procedure.

Alternatively, the following two oral methods of EC are available, and GPNs have an important role in enabling women to make the most appropriate choice based on their personal circumstances and future contraceptive plans.

Ulipristal acetate 30mg (EllaOne)
Ulipristal acetate (UPA) 30mg is a progestogen antagonist and works to delay ovulation so that the ova and sperm do not meet. It can be administered up to 120 hours (5 days) after UPSI.

It is unlikely to be effective after ovulation, but in practice many women do not know when ovulation is due and it can be used at any time of the cycle. A pregnancy test should be performed 3 weeks after administration as even taken before ovulation it is not 100% effective.

Its effect as a progesterone antagonist means that it is not effective if progestogen has been used in the 7 days before UPSI and future use of progesterone should be delayed by 5 days after taking UPA. This means women should be advised to abstain from sex or use condoms for 5 days, and then until their hormonal contraceptive method is effective. For some couples, consistent use of condoms is unrealistic, and so they may choose to take levonorgestrel as EC (see below) as it will enable them to achieve contraceptive protection more quickly.

UPA is contraindicated for women who are breastfeeding or using high-dose steroids, for example women with severe asthma, and they should be offered an alternative method.

Levonorgestrel 1500mcg (Levonelle)
Levonorgestrel (LNG) is a progestogen that also delays ovulation. It has a shorter window for administration than UPA, being licenced to be administered up to 72 hours (3 days) after UPSI. Again, women should take a pregnancy test 3 weeks after administration.

There are few contraindications to its use, but efficacy may be limited in women taking enzyme inducing medication, or those with a weight over 70kg or a BMI over 26kg/m², in which case a double dose should be administered.

It can be used by women who are breastfeeding and those who have had progestogen in the 7 days before UPSI or who prefer not to wait a further 5 days before starting a hormonal method of contraception. Unlike UPA, other forms of hormonal contraception can be taken immediately after LNG. Extra precautions are still required until the method of choice is effective; this is: 7 days for combined hormonal contraception, drospirenone progesterone-only pill, medroxyprogesterone (Depo Provera) injection and contraceptive implants; and 2 days for traditional and desogestrel progesterone-only pills.

The future of EC provision

It is important for GPNs to be aware of moves to improve women’s access to EC so that can advise women on the current context, explaining all avenues open to them. Future changes in provision are intended to broaden access to women’s health rather than diminish the service in primary care.

LNG and UPA are currently classified as Pharmacy medicines (P medicines) meaning they are available to buy from a pharmacy, but only under supervision from a registered pharmacist.

They can also be accessed without charge from sexual health clinics or via a prescription from primary care. In addition, in Scotland and Wales, and in some areas in England and Northern Ireland, EC can be accessed by young people free of charge under patient group directions in community pharmacies.

However, provision is currently inconsistent in England and the Faculty of Sexual and Reproductive Health (FSRH) has recently backed a campaign led by other healthcare organisations to improve accessibility by ensuring that EC is provided free of charge in all community pharmacies.

The FSRH also further supports the reclassification of EC from a Pharmacy medicine to a General Sales List (GSL medicine). This would mean oral EC could be accessed from general retail shops, including pharmacies, without the requirement for a consultation, although consultation and medical support should still be available if required.

Ruth Bailey is Chair of the RCN Women’s Health Forum and FSRH Council Nurse Representative