Face the facts on EC: Time to move from ECP to IUD for effectiveness
Face the facts on EC: Time to move from ECP to IUD for effectiveness
Analysis shows IUD has a failure rate of less than 1 per thousand
In 1992, reproductive health advocates estimated that widespread use of emergency contraceptive pills (ECPs) could prevent half of all U.S. unintended pregnancies and abortions.1 In 2012, however, none of the 14 studies that have examined the impact of increased access to ECPs on pregnancy and abortion rates have shown any benefit.2
Facing the facts about EC is important if clinicians are to make an impact on unintended pregnancy, says James Trussell, PhD, professor of economics and public affairs at Princeton University and visiting professor at Hull York Medical School in York, UK. Trussell presented an overview of ECP research at the 2012 Contraceptive Technology conferences.2
The 14 studies, conducted between 1998 and 2008, include 12 randomized trials and one cohort study; a total of 11,646 women were enrolled. A demonstration project also was included; 17,831 women were given ECPs.3-16
Problems with these studies include small sample size, "huge" loss to follow-up, weak intervention, good access in comparison group, low baseline risk of pregnancy (little room for improvement with EC), and not a randomized design in some investigations, notes Trussell. However, none of the 14 studies had all of these problems; indeed, some were very good, says Trussell.
The consistency of findings is hard to ignore, Trussell points out. ECPs do work; a meta-analysis of two randomized studies indicates that ulipristal acetate EC (marketed in the United States as ella, Watson Pharma of Morristown, NJ) is superior to levonorgestrel EC.17
"Do not promise public health impact," says Trussell in regard to ECPs. "Do not oversell by implying ECPs will reduce unintended pregnancy or abortion rates or be cost-effective."
Use IUD for EC
The routine use of the intrauterine device (IUD) is the way to go for the most effective form of EC, according to the first systematic review of all available data from the past 35 years.18 The new analysis indicates that the IUD has a failure rate of less than one per thousand and is a more effective form of emergency contraception than ECPs. In addition, IUDs continue to protect women from unwanted pregnancy for many more years if left in place.18
To perform the analysis, scientists looked at data from 42 studies carried out in six countries between 1979 and 2011 and published in English or Chinese. IUD use in China is the highest in the world, with 43% of women using them for contraception. The studies included eight types of IUDs and 7,034 women.
When IUDs are used for emergency contraception, they ideally should be inserted within about five days of unprotected intercourse. The maximum timeframe in the current review ranged between two and 10 days or more; however, in most of the studies (74%), insertion occurred within five days.
Despite the safety and efficacy of the IUD as EC, its use is low, particularly in the United States. A study of California contraceptive providers reveals 85% of clinicians never recommended the IUD for emergency contraception, and 93% require at least two visits for an IUD insertion.19 "This is an extremely difficult problem to deal with, especially as in many countries women can just go to their local pharmacy to obtain the 'morning after pill,' but virtually no women know to ask for an IUD and many family planning clinics do not offer same-day insertion," says Trussell, a co-author of the current analysis. "Offering same-day insertion would remove a huge barrier to the greater use of IUDs."
The Copper-T IUD (ParaGard, Teva North America, North Wales, PA) offers very effective contraception that is less open to human fallibility, says Susan Wysocki, WHNP-BC, FAANP, president & chief executive officer of iWomansHealth in Washington, DC. If your practice does not offer this EC option, find out who nearby does, she advocates.
Review the options
Don't assume that your patient will never need ECPs or probably already knows about it, says Wysocki.
"Mistakes happen. We are human," she advises. "An emergency situation is not the time to start the research on what to do. It is time to take the medication."
Have a clinic staff member or volunteer call pharmacies in your area to find out the days and hours a pharmacist is available and if they provide ECPs, says Wysocki. Make sure the pharmacists know the rules about dispensing emergency contraception, she notes. (To check state laws regarding pharmacy dispensing of EC, download a fact sheet at http://bit.ly/q3p0Cv.)
Educate women about the importance of prompt EC dosing, says Wysocki. The sooner ECPs are taken, the better they will work; however, ECPs will reduce risk of pregnancy if they are taken up to 120 hours (five days) after unprotected intercourse.
"The term 'morning after pill' has not only confused ECP with mifepristone, it also sounds like the morning after is the optimal time," says Wysocki. "The 'As Soon As Possible Pill' — ASAPP — would have been a better phrase to coin."
- Trussell J, Stewart F, Guest F, et al. Emergency contraceptive pills: a simple proposal to reduce unintended pregnancies. Fam Plann Perspect 1992; 24(6):269-273.
- Trussell J. High hopes vs. harsh realities. Facing facts about the effectiveness of ECPs. Presented at the 2012 Contraceptive Technology conference. San Francisco and Boston; March 2012.
- Hazari K. Use of emergency contraception by women as a back-up method. Health & Population 2000; 23(3):115-122.
- Ellertson C, Ambardekar S, Hedley A, et al. Emergency contraception: randomized comparison of advance provision and information only. Obstet Gynecol 2001; 98(4):570-575.
- Jackson RA, Schwarz EB, Freedman L, et al. Advance supply of emergency contraception: effect on use and usual contraception — a randomized trial. Obstet Gynecol 2003; 102(1):8-16.
- Lo SS, Fan SYS, Ho PC, et al. Effect of advanced provision of emergency contraception on women's contraceptive behavior: a randomized controlled trial. Hum Reprod 2004; 19:2,404-2,410.
- Gold MA, Wolford JE, Smith KA, et al. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004; 17:87-96.
- Glasier A, Fairhurst K, Wyke S, et al. Advanced provision of emergency contraception does not reduce abortion rates. Contraception2004; 69:361-366.
- Hu X, Cheng L, Hua X, et al. Advanced provision of emergency contraception to postnatal women in China makes no difference in abortion rates: a randomized controlled trial. Contraception 2005; 72:111-116.
- Raine TR, Harper CC, Rocca CH, et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA 2005; 293(1):54-62.
- Belzer M, Sanchez K, Olson J, et al. Advance supply of emergency contraception: a randomized trial in adolescent mothers. J Pediatr Adolesc Gynecol 2005; 18:347-354.
- Raymond EG, Stewart F, Weaver M, et al. Impact of increased access to emergency contraceptive pills: a randomized controlled trial. Obstet Gynecol 2006; 108:1,098-1,106.
- Walsh TL, Frezieres RG. Patterns of emergency contraception use by age and ethnicity from a randomized trial comparing advance provision and information only. Contraception 2006; 74(2):110-117.
- Ekstrand M, Larsson M, Darj E, et al. Advance provision of emergency contraceptive pills reduces treatment delay: a randomized controlled trial among Swedish teenage girls. Acta Obstetrica et Gynecologica Scandinavica 2008; 87(3):354-359.
- Weaver MA, Raymond EG, Baecher L. Attitude and behavior effects in a randomized trial of increased access to emergency contraception. Obstet Gynecol 2009; 113(1):107-116.
- Schreiber CA, Ratcliffe SJ, Barnhart KT. A randomized controlled trial of the effect of advanced supply of emergency contraception in postpartum teens: a feasibility study. Contraception 2010; 81(5):435-440.
- Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet 2010; 375(9714):555-562.
- Cleland K, Zhu H, Goldstuck N, et al. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 2012. Doi:10.1093/humrep/des140.
- Harper CC, Speidel JJ, Drey EA, et al. Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers. Obstet Gynecol 2012; 119:220–226.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.