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Puzzled about how to implement emergency contraceptive pills (ECPs) into your practice? You’re not alone. Sally Hellerman, MSN, APRN, assistant medical services coordinator at Planned Parenthood’s Connecticut headquarters in New Haven, is facing many questions in her role of developing an ECP protocol for other Planned Parenthood clinics in the state.
These members of Contraceptive Technology Update’s Editorial Advisory Board offer their suggestions: Willa Brown, MD, MPH, director of the Bureau of Personal Health at the Howard County Health Department in Columbia, MD; Anita Nelson, MD, medical director of the Women’s Health Care Program at Harbor-University of California at Los Angeles Medical Center in Torrance; and Michael Rosenberg, MD, MPH, clinical associate professor of obstetrics/gynecology and epidemiology at the University of North Carolina at Chapel Hill and president of Health Decisions, a private research firm in Chapel Hill.
Q. When should OCs be restarted after ECPs?
Brown: The policy is the day after the second dose of the ECPs, skipping the pills that were due the day that emergency contraception was given.
Rosenberg: Immediately. If they are not initiated, there will be risk of conception (under the assumption that sexual activity continues) for the remainder of the cycle. This risk is diminished by the use of ECPs, but how much remains undefined.
Q. How many pills should patients have missed in order to be good candidates for ECPs? Does it matter what time of the cycle the missed pills occur?
Brown: One missed pill is enough for a woman to be a candidate, and it is especially important if it is the first pill of the pack.
Nelson: Based on the work of John Guillebaud, MA, FRCSE, FRCOG, which shows that after seven pill-free days, nearly 20% of women have a 16 mm to 17 mm follicle,1 I would use that as a criterion for choosing EC with OCs.
If it takes seven days of appropriately-timed OC use to suppress her follicle, for example, and seven more days thereafter without pills to put her at risk (using Guillebaud’s horseshoe analogy), I would offer EC with OCs if the patient were late with or missed any of her first seven pills or her last pill unless she started her next pack early. After that, any time she missed at least six to seven pills, I would cover her.
We may never get this level of precision and for practical reasons and probably would want to offer EC with OCs any time she missed three or more pills, but I would also warn us to remember to offer it more liberally, after one to two missed pills at the beginning of her cycle.
Rather than looking at "missed pills," I think it’s more important to consider "pill-free days," which would remind us to include the placebo pills in our calculations. Following Guillebaud’s recommendations, after EC with OCs, women continue to take the rest of the pills in the pack daily.
Rosenberg: It depends on how pregnancy-averse you are. Timing is certainly important the most critical time is at the end or beginning of a cycle, since this prolongs the pill-free interval and increases chances of ovulation. One pill probably increases the risk only a slight amount, particularly if it is at any other time during the cycle. Two pills increases risk more. Three or beyond clearly puts you into the at-risk category.
Q. Do ECPs have any effect on the ongoing use of OCs?
Nelson: EC with OCs create higher doses of estrogen and progestin, the withdrawal of which may cause spotting, even if the patient is continuing OC. If the patient suffers severe side effects (gastrointestinal, headache, etc.) when using EC with OCs, she may have some psychological difficulty continuing her daily OCs.
I wonder at our use of "ECP" terminology prior to there being an actual product with that name. Why don’t we stay with the "EC using OCs" approach until the FDA approves an ECP? Then it will be real news.
Rosenberg: No. Use of ECPs is more like what the first women using OCs took every day.
1. Guillebaud J. Contraception: Your Questions Answered. New York, NY: Pitman; 1985.