Plan B. Is it Guaranteed?

Condom companies tend to portray a 98 to 99% efficacy of their products; however, many studies have shown that this tremendous contraceptive efficacy is only seen with the perfect use of condoms. This “perfect use” does not account for the human error, and thus the actual failure rate of condoms with “typical use” can be as high as 18 to 20%. But why does this efficacy dramatically differ between “perfect” and “typical” uses? 
Studies have shown that condoms break in up to 33%, slip in around 15% and leak in up to 7% of cases. These failure rates were secondary to improper storage or use of condoms, including adding the wrong kind of lubricants that some were shown to damage latex. 
In addition to the above-mentioned condoms failures, sometimes you feel caught in the moment and engage in unprotected intercourse for a more pleasurable experience. Moreover, some women might unfortunately face unconsented coerced unprotected sexual intercourse. So, what is your next step? And how can you avoid an unwanted pregnancy?

In this article I will only be focusing on the different methods that can decrease the risk of pregnancy after unprotected intercourse (UPI). Another article will be tackling the plan of action needed to prevent and manage different sexually transmitted infections that are associated with UPI.

Emergency contraception encompasses options that can decrease the risk of pregnancy after unprotected intercourse (without any contraceptive methods), or when a method was used imperfectly (condom breakage, slippage, or missing your pill…), or when sex was forced in the absence of contraception. 
First it is note mentioning that emergency contraception will not interrupt an existing pregnancy and thus it is not considered as an abortifacient, however it will delay ovulation or prevent proper egg fertilization. Moreover, emergency contraception is not expected to replace regular contraceptive use, hence it should only be considered as plan B!

The exact pregnancy risk after unprotected intercourse is difficult to estimate as it depends on many factors including the woman’s age, fertility window (if the intercourse happened around the time of ovulation or not), the number of unprotected sexual encounters and whether it was after an imperfect use of a contraceptive method (slippage or breakage of a condom) or the use of no method to begin with. However, studies have shown that patients who request emergency contraception were at higher risk of unwanted pregnancies in the next year with a rate approaching 12% and thus it is of paramount value for you to know that emergency contraception should only be limited to exceptional circumstances, and the use of a primary contraceptive method is more advisable.

What are the different emergency contraceptive methods we have?

 

Copper Intrauterine Device (Copper IUD)

This is a T-shaped structure measuring around 4 cm in length, with copper coils wrapped around its body and arms. It should be inserted by a health care provider within 5 days of unprotected sex. The benefit of the copper IUD is that it can serve as a long term reversible contraceptive method for up to 10-12 years after insertion. 
The major reported side effects of copper IUD include heavy and more painful periods, anemia (secondary to the heavy cycles), or hypersensitivity reactions. Actually, an allergy to copper is considered as a contraindication to the device use. Other contraindications include active genital/pelvic infections, uterine anatomical distortions or uterine/cervical cancers. 
The insertion process is done in the clinic with no need for anesthesia, however most women report crampy period like pains during the insertion process, so I advise you to take over the counter pain killers 30 minutes before the insertion time for better pain control.

 

Oral Emergency Contraceptive Pills

These are famously known as the morning after pill, and they include different formulations. Ulipristal Acetate (UPA) acts as a progesterone receptor modulator, and at a dose of 30 mg it can serve as an emergency contraceptive for up to 5 days after sex. The marketed brands include ella and ellaOne, and most pharmacies ask for a prescription. You should keep in mind that progestin-containing contraceptive methods should not be coupled with UPA up to 5 days of the latter’s use, in order not to interfere with its efficacy. UPA is usually well tolerated by users, but reported side effects include; headache, abdominal pain, nausea, vomiting, fatigue, dizziness and dysmenorrhea (painful period).

Oral levonorgestrel (LNG) 1.5mg (sold under the brand name “Plan B One-Step”) has been approved for use up to 3 days after the unprotected intercourse for maximal efficacy (there is still some retained efficacy for up to 5 days after UPI). This is usually available in most pharmacies as an over-the-counter medicine and thus requires no prescription. Also, this medicine is tolerated but the commonly reported side effects include headache, nausea, vomiting and breast pain.

Mifepristone, also acting as a progesterone receptor modulator, can be used at a dose of 10-25mg for emergency contraception. This low dose is only found in some countries (not present in the States), and thus it is not famously known to be an emergency contraceptive. However, at high doses of 200mg (more widely available) it can be used as an abortifacient (which is beyond the scope of this article).

 

Levonorgestrel Releasing Intrauterine Device (Hormonal IUD)

This is still not approved for use as an emergency contraceptive method as trials are still in process, however, you can couple this hormonal IUD insertion with a levonorgestrel oral pill (plan B one-step) for an emergency contraceptive purpose.

 

So how about the efficacy of these emergency contraceptive methods? Are they prone to failure?

After unprotected intercourse (UPI), the copper IUD (used as emergency contraception) can fail in only 0.1% of cases meaning that the copper IUD can reduce your chance of unwanted pregnancy after UPI by more than 99%, making it the most effective emergency contraceptive method. As previously mentioned, it should be inserted within 5 days of UPI, and the good news is that its efficacy does not wane with increasing time from UPI episode.

On the other hand, the efficacy of the oral emergency contraceptives is much lower and their failure rates are reported to be around 1.8% for ulipristal acetate (UPA) and 2.6% for levonorgestrel (LNG) pills, however these failure rates can increase further in the setting of multiple episodes of unprotected intercourse later in the cycle, as some studies reported an overall efficacy of 50% and 70% for the levonorgestrel (plan B) and ulipristal (Ella) respectively.

Also, the levonorgestrel pill should be used within 72 hours of the sexual encounter, as its ability to inhibit ovulation is expected to drastically drop after this 3 days period. As for Ulipristal, it can be used for up to 5 days but again here the efficacy of the pill diminishes with increasing time from UPI. Moreover, the risk of pregnancy with the oral methods increases with increased body mass index. So overweight and obese women are more likely to have an emergency contraceptive pill failure compared to lean women. A study showed that if you weigh 75 kilograms or more, it is advisable to consider copper intrauterine device instead of emergency contraceptive pills as the efficacy of the IUD is not negatively impacted by weight. If you still prefer a pill regardless of your weight, I would advise you to take the ulipristal instead of the levonorgestrel pill, as the former has a better overall efficacy in preventing unwanted pregnancies.

 

Who can use emergency contraceptive methods?

Every woman in the reproductive age group has the right to use emergency contraception for the prevention of unwanted pregnancy after an unprotected sexual encounter. Regardless of the actuarial risks of getting pregnant, if a woman feels anxious and worried of getting pregnant after a UPI, she is eligible for the use of emergency contraception. 
An established pregnancy is of course a contraindication for the use of emergency contraception.

 

What about your Period?

Women using oral emergency contraceptive pills regain their periods within 1 week of their anticipated date. 
An exception can be observed among mifepristone users who might witness a more pronounced period delay, especially with higher drug dosage (25 mg versus 10 mg) 
Moreover, irregular bleeding patterns can be observed by oral EC users, and this can last for 1 cycle after treatment. 
The use of copper IUD as an EC, does not impact the timing of the menstrual cycle.

 

How many times can you use emergency contraception per cycle?

Of course, if you used the copper intrauterine device for emergency contraception, it can act as a long acting reversible contraception lasting for up to 10-12 years after insertion. 
However, the oral emergency contraceptive methods need to be repeated every time you engage in UPI. Both UPA and LNG can be used multiple times during the same menstrual cycle, however keep in mind that a contraceptive method (plan A) is much more beneficial than repeated EC use, because the efficacy of the latter is lower than most contraceptives.

 

What if you Vomit the pill?

I previously mentioned that one side effect of oral emergency contraceptive methods is vomiting! So, what if you vomited after ingesting the pill? Well, the data is not strong in that regard, but some authors state that if the medication was strong enough to induce nausea and vomiting, then it was strong enough to block ovulation. However, if the vomiting was secondary to another reason (not related to the side effect of the drug), or if it occurred within 1 hour from initial ingestion, then a repeated emergency contraceptive dose becomes highly warranted.

 

Should I do a Pregnancy Test?

If you do not get your period within 3 weeks of therapy, a pregnancy test becomes indicated. Also, keep in mind that the use of emergency contraceptive methods does not reduce your chance of future conception, and it does not negatively impact future fertility. 
In the setting of an ongoing pregnancy, the oral emergency contraceptive method will fail. 
It is advisable that you follow with your physician if:

• You do not get your period after 3 weeks of EC use
• You start experiencing heavy bleeding or abdominal pain
• You cannot tolerate the side effects of the medication
• Your pregnancy test turns out positive  

 

Sexually Transmitted Infections

Keep in mind that the use of emergency contraceptive methods does not reduce your risk of sexually transmitted infections which are another concern after unprotected intercourse. However, this topic will be tackled in future articles.

 

In conclusion, emergency contraception can be used by all women of childbearing age if; they forgot to take their birth control pills, they engaged in unprotected sex, their partner’s condom broke or slipped or if they were sexually assaulted/raped. 
There are different emergency contraceptive methods with different efficacies and side effects, so make sure to know what to expect. 
These methods should be used within 5 days of UPI, and the general rule is that “the sooner the better”. The levonorgestrel pill (plan B one-step) should be used within 72 hours of sex!
The copper IUD is the most effective emergency contraceptive method, and it serves as a long acting reversible contraception lasting for 10-12 years protecting you from future unwanted pregnancies.

Learn to understand your bodies and acknowledge your rights to use emergency contraception!

 

Karam