Emergency contraception: an overview

[Music] Welcome to the Australian Prescriber Podcast. An independent, no-nonsense podcast for busy health professionals.

Hello and welcome to the Australian Prescriber Podcast. I'm Jo Cheah, a hospital pharmacist in Melbourne and your host for this episode. In this episode, I have the pleasure of interviewing Jo Gross, a consultant pharmacist in medication governance and home medicines reviews. Welcome, Jo. Thanks for being here.

Thanks, Jo.

Today we will be discussing emergency contraception, which Jo and co-author Professor Danielle Mazza has written about in Australian Prescriber. To start, Jo, what types of emergency contraception are currently available in Australia?

Broadly, there's 2 types of emergency contraception. There are oral emergency contraceptives and the 2 we have available in Australia are levonorgestrel or ulipristal acetate, which I'll just say ulipristal for the rest of our chat. And there's also the copper intrauterine device. The oral emergency contraceptives are the most commonly used and they would be available over the counter without a prescription at a pharmacy, but the copper IUD [intrauterine device] needs to be inserted by a trained IUD inserter.

And how important is the timing when administering any forms of emergency contraception?

Timing is probably the most critical when you're choosing between emergency contraception options. Earlier is better after unprotected sex for all of the agents, but particularly for the oral emergency contraceptives. Levonorgestrel, it's registered for use out to 72 hours. Efficacy does drop over time, but there is evidence to show that it can prove effective up to 96 hours or 4 days. Ulipristal though has been shown to be effective out to 120 hours or 5 days. So, it may be the better choice if it is longer since the person had unprotected sex. The copper IUD gives us even more flexibility.

It can be inserted up to 5 days after unprotected sex, but it can also be inserted up to 5 days after the earliest anticipated date of ovulation for someone which may give a little bit more flexibility for someone who isn't seeking emergency contraception until sometime after unprotected sex.

And what is the recommended course of action once it's beyond the suggested timeframes?

Generally, if this person was presenting in a pharmacy, which is one of the most common places people present, you'd be referring them on to a medical practitioner or a family planning clinic where there may be nurse-led care so that they can explore their other options. It is still potentially appropriate to supply and refer because there can be still some efficacy at later hours, so that the person can explore all of their options.

That's good to know. Thank you. And could you highlight the differences between the available emergency contraceptions?

Well, broadly, the 2 oral emergency contraceptives have a similar mechanism of action in so much as that they delay ovulation. Levonorgestrel is a synthetic version of progesterone, so it delays the gonadotropin-releasing hormone in the brain, which delays the luteinising hormone or LH surge that triggers ovulation. Ulipristal does a similar thing, but works as a progesterone receptor modulator. That means it actually can be taken right up through the LH surge as long as you haven't hit your LH peak. So, that's just a slight difference in how they work in delaying the ovulation.

In contrast, the copper IUD interferes or impairs sperm motility. It creates a hostile environment which doesn't encourage fertilisation or implantation.

Great. And for anyone who would like to refer to Table 1 in the article, there's a great summary of all of the differences of all the methods you've just mentioned.

Yes. There's a lot more detail that explains some of the pros and cons of each agent in Table 1 of the article.

Excellent. And when would one be recommended over the others?

Ulipristal acetate is slightly more effective than levonorgestrel, and there are specific circumstances where it may be preferred. As I mentioned earlier, if someone is presenting, say, after 72 hours or after 96 hours, but inside 120 hours, that would be your preferred oral option. But levonorgestrel may be preferred if the person is already taking a hormonal contraception because ulipristal can interact with other hormonal contraceptives if they've been taken in the 7 days before using emergency contraception.

For both of the agents, we might have to consider things like a patient's weight to decide which might be preferred. Ulipristal is generally preferred for individuals with a body weight over 70 [kg] or a BMI [body mass index] over 26 [kg/m2], or you might use levonorgestrel, but consider a double dose of 3 mg. And if someone's taking, say, strong hepatic enzyme induces, then that can interact with both the oral options and you might be leaning towards a double dosing for levonorgestrel or considering referring that person for a copper IUD if that's more appropriate.

Some really important points you mentioned there that we need to consider such as drug interactions and the patient's weight. Could you go through what clinicians should ask as part of their history taking, which may include those points when someone has requested an emergency contraception?

One of my first points when it comes to history taking, particularly if this person is presenting in pharmacies, we really do need to ensure their privacy because the conversation really does deserve to take place in a consultation room. There can be some quite sensitive topics discussed and a conversation that flows rather than an interrogation by checklist can create an environment that's more comfortable for the patient and that they may be more comfortable to disclose issues that might need to be discussed like consent, coercion or abuse or potential sexual assault. But once you've created that space and environment, allow the person to explain why they've come in seeking the contraceptive pill.

They may explain that they weren't using contraception, missed a pill or split a condom and that will influence the counselling that you provide later in the conversation, but they may provide a lot of the information that you need to know. When the unprotected sex occurred, how long it is since their usual period, was that period lighter than normal or shorter than normal because you might want to exclude the potential that they were pregnant before the unprotected sex.

You also need to understand the medicines they're on and if they're on a contraceptive in particular and whether or not there are other factors that might influence your choice of agent like active Crohn's disease that might change the absorption of an oral emergency contraceptive, for example.

It's a good point to consider the context in which this conversation is taking place. So, as you mentioned, the privacy and making sure the client is feeling comfortable to disclose information.

Yes.

And would there be any instances when it would not be appropriate to provide an emergency contraceptive?

So, there's no absolute contraindications to the provision of emergency contraception, but there are some factors that might make you choose not to use a particular agent for an individual. So, as I mentioned earlier, if someone is already on a hormonal contraception but missed a pill, for example, then you might not want to use ulipristal. There's also some individuals who might have severe asthma and stabilised on long-term steroid treatment where the use of ulipristal may potentially interact with their steroid and increase their risk of asthma, but still not an absolute contraindication because preventing an unplanned pregnancy might be the most important issue for that patient on the day.

For a copper IUD, there are of course some contraindications relating to you wouldn't insert a copper IUD if someone had active untreated pelvic inflammatory disease, but it might be appropriate to treat asymptomatic chlamydia or gonorrhoea and still insert, but that is very much a conversation for the trained inserters. And while we are thinking about contraindications, yes, we want to exclude pregnancy, but we also should explore whether or not the individual may be breastfeeding. Levonorgestrel is safe to use during breastfeeding and ulipristal is considered to be safe. However, it can be transferred in the breastmilk.

So, the individual may wish to express and discard their breast milk for up to 24 hours if they want to reduce the exposure to their infant, but it is a low dose that that child would be receiving and is considered safe and a copper IUD is safe to insert in a breastfeeding individual.

Just out of interest, the pelvic inflammatory diseases, what if a patient didn't know that they had a condition like that?

It's worth exploring if the patient has any other symptoms. They may have some red flag symptoms for referral, things like unexplained vaginal bleeding, dysuria. They may have lower abdominal pain, or they may have been experiencing pain during or after sex, or describe some unusual discharge. And any of those symptoms might be an indication to both treat and refer so that they can be assessed for things like sexually transmitted infections or pelvic inflammatory disease or other causes.

And in terms of documentation, is there any documentation requirements for community pharmacists when they provide emergency contraception?

So, the oral emergency contraceptives are both Schedule 3 medicines. Whether or not you are required to dispense that does differ by state and I recommend every pharmacist to understand their local legislative requirements, but it is best practice to document not only the supply or the decision not to supply, but also the key elements of the consultation. In case the patient re-presents, they may come back after vomiting or they may come back later in the same cycle requesting emergency contraception again and it's very important to understand what they've already used that cycle because it will influence how you may manage them in future consultations.

Yeah, that's a good point. And patients don't necessarily need to hand over any identification, but hopefully within your consult, you're able to make them feel comfortable enough to do that if necessary.

Yes. And there is no requirement to have ID from patients. There is no requirement to use a document on a checklist, for example, and that can actually impair the conversation, having a piece of paper and a ticking the box process. But where that person may be a regular client through your pharmacy and you already have their details, making a note on their file, there are templates to help document this sort of information or when you dispense that adding a note. A lot of pharmacies will have a record where they can dispense for people that haven't provided identity, but they can at least document that dispensing and come back and read the notes that may be associated if they know the date and time that that was supplied.

Great. Thanks, Jo. We've already discussed patients can access the oral emergency contraceptives through community pharmacies and copper IUDs through the trained inserters. So, are there any barriers that prevent patients accessing any or all of the emergency contraceptives?

The biggest barrier is access to emergency contraception. Nearly every community pharmacy in Australia will stock levonorgestrel or they will be able to redirect the person to another local pharmacy that stocks it, but some pharmacies don't currently stock ulipristal. A survey in 2024 showed that only 70% of community pharmacies surveyed at that time were stocking ulipristal. So, if it's not available, it can't necessarily be provided in the timeframe that the person needs it. The cost of the treatment can be a barrier to some individuals. So, levonorgestrel has a few generics available and is a little bit cheaper.

It comes at a price of around $15 to $30, whereas ulipristal is generally more expensive at $30 to $50 to obtain and that might be outside the capacity of an individual. So, it's important to understand that family planning clinics, emergency departments and sexual health clinics will often also have these available to supply and they may be able to make that available for individuals who can't pay for that on the day. The copper IUD has a lot more barriers to access. Clearly, you can't walk into a pharmacy and get a copper IUD inserted, you need to be able to access a trained inserter in the timeframe that is necessary. That may need an appointment made in advance.

It can cost $100 to get the copper IUD dispensed before having it inserted, and then there may also be costs associated with the appointments needed to have that inserted and the follow-up over time. So, cost is really one of the biggest barriers. So, it's important to understand where else a patient may be able to navigate the health system to access that in a subsidised way.

And interestingly, the ulipristal isn't commonly available as the levonorgestrel. So, is there any work being done to improve the access to that drug given it shows some improved efficacy in certain cases?

There is some work being done through groups like Monash SPHERE Research Centre to increase the adoption of having emergency contraception and other sexual and reproductive healthcare available in pharmacies. This podcast is an example of raising the attention to the fact that there are multiple options and that ulipristal may be the preferred option for some individuals. So, I would recommend any pharmacy who doesn't currently stock it or isn't familiar with ulipristal to have the stock and become familiar with when it's most appropriate. Table 1 in the Australian Prescriber article really does put out clearly when it may be the preferred option for an individual.

But also if you are working in another setting such as a hospital, ensuring that that hospital has reviewed whether or not they need to be holding multiple emergency contraceptives as well, it really just is raising that conversation as much as possible.

And it's good to know that there are other avenues for patients to access these drugs, as you mentioned, family planning clinics or emergency departments if necessary if a pharmacy isn't the option for them.

And sexual health clinics too, which often accept walk-in appointments because the individual then may be able to have both their emergency contraception needs met, but also that discussion around STI [sexually transmissible infection] screening and/or treatment if needed.

That actually brings me to my next question. What other counselling should be provided to patients who are accessing emergency contraception?

Depending on the age of the individual, they may have used emergency contraception when they were younger when it involved taking an entire strip of tablets. Emergency contraception has moved on since then. It is just a single dose. That single dose, the most common side effect is nausea, which occurs more commonly with vomiting between 1 to 5% of people, depending on which agent is used. Importantly, if you do vomit within 2 to 3 hours of taking your emergency contraception, you should seek another dose to ensure that you are protected. It's important to reassure the person that their next period is likely to be on time, but it might be slightly early or slightly late.

But if it's more than a week late, or if when it does occur, it's lighter than normal because that could be a sign that they've had a breakthrough bleed rather than a period. It may be worth them performing a pregnancy test. It is very important that they understand that the emergency contraceptive does not treat or protect against sexually transmitted infections, STIs. So, they may need to be referred onwards for screening or testing, but it also doesn't provide protection into the rest of that cycle against future pregnancies if we're talking about the oral emergency contraceptives. So, it is really important to have a conversation about their contraceptive plans.

Increasingly, pharmacists around the country have options available to them if they have been trained and authorised to provide refill prescriptions, for example, if the reason why they'd missed their pill is they'd run out of their prescription or to quick start someone on contraception if that is appropriate so that they can have protection moving forward. There is a table in the article, Table 2, that summarises the time considerations if you are quick starting a contraceptive around how long that individual may need to use barrier protection or abstain from sex to prevent pregnancy, because starting a contraception at the same time as use of an emergency contraception, you do have to allow between 2 to 9 days for that contraceptive to start working.

Are there many differences regarding access to emergency contraception in metropolitan compared to regional or rural areas?

At the moment, the evidence shows that most pharmacies across geographic areas will hold emergency contraception. The more rural an area you get to, there may be a small chance that they may not have someone working on the particular day or have a pharmacy open at the time that you need it. So, then a patient may be referred to the nearest pharmacy, which may be some distance away, but unlike with other reproductive services, there is relatively high uptake of holding levonorgestrel at a minimum in both metropolitan and regional areas.

And what are some additional considerations when supplying emergency contraception following sexual assault or to minors?

Clearly, privacy becomes crucial if we're going to allow someone the space to disclose sexual assault, and they should always be connected with support services alongside supply of their emergency contraception if appropriate. If they're a minor, it is important to consider their competency. Are they mature enough to understand and provide informed consent before you provide that treatment? And you may have some mandatory reporting requirements if you're suspecting assault of a minor.

When it comes to connecting an individual with support services, the article does mention the Australian Sexual Assault Service Directory, which summarises all of the local contacts that might be available from crisis intervention to forensic examination or the legal support that that individual required. But you can also call 1-800-RESPECT, the Australian Sexual Assault Family and Domestic Violence Hotline 24/7. So, whatever time of day or day of the week an individual might need help, that phone line is available.

To finish up today, other than this excellent article, what other references could pharmacists or clinicians refer to at the point of care if necessary?

So, there is content in Therapeutic Guidelines for those who have access to it, but for all pharmacists, I would also recommend that they look at the latest version of the APF [Australian Pharmaceutical Formulary]. It had a major update to the clinical section regarding emergency contraception, which really does outline the process of assessing someone's needs, referring or making a treatment plan and then documenting that for the individual. But otherwise, the table in the Australian Prescriber article is one of the best summary tables I have encountered, and I'm pretty proud of it.

Great work. Thanks, Jo. That brings us to the end of the episode. Thank you so much, Jo.

Thanks, Jo.

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Joanne Gross is the president of the Tasmanian Branch of the Pharmaceutical Society of Australia (PSA) and has represented PSA at the Pharmaceutical Benefits Advisory Committee Oral Contraceptive Stakeholder Meeting, the Tasmanian Pharmacist Scope of Practice Working Group, and the University of Tasmania School of Pharmacy Clinical Advisory Committee. Joanne is also a member of the Tasmanian Medicines Access and Advisory Committee. For a full list of both authors' conflicts of interest, please refer to the article in Australian Prescriber. The full article is available on the Australian Prescriber website.

The views of the hosts and the guests on the podcast are their own and may not represent Australian Prescriber or Therapeutic Guidelines. I'm Jo Cheah, and thanks again for joining us on the Australian Prescriber Podcast.

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