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2012 Rxprep ch23 Contraception.

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  1. 1. ooN-inAOEP-rloN Background childbearing There are 62 miilion US women in their age (43 mil- years. Seven in 1o women of reproductive liorr) u." sexually active and do not want to become become pregnant if they and their frugrrurrt, but could The typi- partners fail to use a contraceptive method To achieve this cal U.S. woman wants only two chiidren roughly three de- goal, she must use contraceptives for (source: Guttmacher Institute) "ades. do not want to be- Among the 43 million women who Sixty- pr"goant, 89% are practicing contraception " percent of reproductive-age women who practice three including contraception use nonpeflnanent methods patch implant in-EC: Emergency contraception. 2005 Dec hormonal methods (such as the pill The(revised 201 0 May). NGC:007753Ameri- jectable and vaginal ring), the IUD and condomscan College of Obstetricians and Gyne- male sterilizationcologists - Medical Specialty Society remaining women rely on female or Contraceptive choices vary markediy with age ForWebsites for general contraception the leading methodinformation: women yorrrrg", than 30, the pill is more rely on steriliza- Association of Reproductive Health Among women aged 30 and older Pharma- Professionals (ARHP) tion, which is often performed post-partum contraceptive cists have an important role in providing sources/contrac6ptionresou rces/ OTC products in- health information We recommend cluding the use of condoms if a risk of STD transmis- services Planned Parenthood sion is present, make emergency contraception referral servic- available in the community and provide es for pregnancy prevention and STD treatmert The AIan Guttmacher lnstitute (AGl) www. guttmacher. org/sections/contra- Many women are not aware that birth control pills pro- ception.PhP blood loss and vide health beneflts, including decreased alowerincid.enceofiron-deficiencyanemia,reduced334
  2. 2. FxPrep Course Book I BxPreP @ 2012 iil[I cysts/Iumps, less acutecramps, ovarian cysts, ectopic pregnancy, less noncancerous breastpelvic inflammatory disease and a decreased risk of ovarian cancerMenstrual GYcle Phases/Test KitsA normal menstrual cycle ranges from23-35 days (average 28 days). Menstrua-tion starts on day I and typically lasts afew days.OvulationThe mid-cycle luteinizing hormone (LH)surge results in release of the oocyte (egg)from the ovary into the fallopian tube kits test forIf the oocyte is not fertilized, it is washed out through menstruation. ovulation time for a patient to have inter-LH and are positive if LH is present They predict the bestcourse in order to try to conceive (get pregnant)PregnancyA female has the highest chance to become pregnant on days 8-16 of her cycle although 100% "safe" PregnancY test kitspregnancy carl occur during any time - no time is considered re oositive if hCG (human chononrc ropin) is in the urine If a case indicates hcG+, thepatient is pregnant and teratogenic drugs should be discontin- (no drinking during pregnancy), ACE ued, if possible. well-known teratogens include alcohol Iithium phenytoin Inhibitors, Angiotensin Receptor Blockers, carbamazepine isotretinoin methotrexate, leflunomide phenobarbital, topiramate, valproic acid, ribavirin, misoprostol, thalidomide Refer to the preg- statins, dutasteride, flnasteride, warfarin, Ienalidomide and nancy chapter for a further discussion of teratogenic drugs age) should be taking a Any woman planning to conceive (and all women of child-bearing spinal cord (neural tube folic acid supplemeni to help prevent birth defects of the brain and d.efects). Folic acid Jould be taken at least one month before pregnancv since it takes time foods including fortified ce- to build up adequate body stores. Foiic acid is in many healthy reals, dried beans, leafy green vegetables and orangejuice
  3. 3. 23 lContraceptionHormonal ContraceptivesThese contain progestin only (pill or injectable) or estrogen/progestin combinations (in pilisa patch, and a ring).progestin-only piil (POPs): The use of POPs as a contraceptive method is mostly rgssmmend-ed for lactating (breastfeeding) women, because estrogen reduces the milk production Theyare sometimes used for women who cannot tolerate or have a contraindication to estrogenEstrogen and progestin combination oral contraceptives (CoCs) inhibit the production ofboth follicle stimulating hormone (FSH) and LH, which prevents ovulation Contraceptivesalso may prevent pregnancy by altering the endometrial lining, altering cervical mucus in-terfering with fertilization or transport of an egg, or preventing implantation COCs are usedfor various indications, including pregnancy prevention, dysmenorrhea, PMS perimeno-pausal symptoms (hot flashes, night sweats, as well as pregnancy protection), anemia due toexcessive period-related blood loss, and acne (in females). They are sometimes used for re-duction in premenstrual migraine (a common mi-graine in women) although continuous progestin-only contraception is useful for this purpose.ADVERSE EFFECTS DUE TO ESTROGENEstrogen can cause nausea, breast tenderness/full- History of blood clot disorders (DVT PE)ness, bloating, weight gain or elevated blood pres- History of stroke or heart attacksure. If low-dose estrogen pills are used, or if there Heart valve disease with complicationsis insufficient estrogen (the patient may be a fast Severe hypertensionmetabolizer, or be using an enzyme inducer), then Diabetes that causes blood vessel problemsmid-cycle breakthrough bleeding can occur (days 14-21) and may require a higher estrogen dose Poorly controlled diabetes Severe headaches (for example, migraines - some forms helPful)ADVERSE EFFECTS DUE TO PROGESTIN Recent major surgery with prolonged bed restProgestin can cause breast tenderness, headache, Breast cancerfatigue or changes in mood. If late cycle break-through bleeding occurs (after day 21) a higher Liver cancer or diseaseprogestin dose may be required. Uterine cancer or other known or suspected estrogen-dependent cancers Birth control pills do not provide protection from Unexplained abnormal bleeding from the uterus sexuallv transmitted diseases (STDs). (Condoms Jaundice during pregnancy or iaundice with provide some protection.) prior hormonal contracePtive use Known or possible Pregnancy lf > 35 years old and smoke > 15 cigarettes/day DRUG INTERACTIONS THAT CAN DECREASE EFFICACY OF ORAL CONTRACEPTIVES Use back-up while taking the antibiotics listed on the next page (with rifampin, use other form of birth control since the irduction will last JJU
  4. 4. -:xrec Ccurse Book I HxPreP @ 2012-ifswitchingback,aback-upmethodneedstobeusedforLVzmonthsafterrifampinisstopped) i tetracycline rifampin and rifapentine) : Antibiotics (ampicillin, griseofulvin sulfonamides ir I oxcarbazepine phenytoin topiramater Anticonvulsants (barbiturates carbamazepine and felbamate). concurrently _ this is a strong enzyme inducer.I St John,s wort _ do not use oC,s increase oc metabolism reducing theI Do not use with the following anti-retrovirals that effi c a cy : atazanavit, Iop in avir nelfi navir nevirap in e riton avir hyp ertensiont Bos entan (Tla cle er) us ed for pulmonary arterial it is dangerous to smoke while using ocsI patients should not smoke; may J efficacy and you are dispensing to a patient on birth controlI check the package insert for new drugs pillssinceyoudon,twanttomisscounselingonaninteractionthatcoulddecreasethe pills efficacY. Migralne if with aura Ch-oose among various formulations Choose Progestin onlY Pill choose POP. Clotting dlsordef or estrogen-contralndication Fluid retention/bloating Choose Progestin onlY Pill Pro- Choose Yasmin or Yaz or newer agenl Natazia Obesity and age > 35 years consider non-estrogen gestin component helps reduce water retention iontraception; higher risk thrombosis lt retains The progestin component is a mild diuretic potassium, and is contraindicated with renal or liver and use of disease. Check potassiqm, renal function Estrogenic Qide eftecls other potassiumretaining agents USe low estrogen lormulation Premenstrual dYsPhoric disorder Spotting/breakthrough bleeding" (Saratem) - see lf Choose Yaz or sertraline or fluoxetine wh"n ,f,ning wait for three cycles before switching and progestin if mid-cycle depression section. persists use higher estrogen if spotting oc- spotting (days 14-21) or more progestin curs later in cYcle. Acne for acne Can use most formulations; COCs approved include Ortho Tri-Cycten, Estrostep, and Yaz Avoiding monthlY cYcle (ev Use tongier formulation Seasonale or Seasonique ery 3 months) or Lybrel (conltnuous)
  5. 5. I Ethinyl Estradiol/Levonorgestrel (Trivora)Monophasic COCs: all active Pillseontain the same level ol hormones Ethinyl Estradiol/Norethindrone (Ortho-Novum 7 17 17)Desogestrel and Ethinyl Estradiol lablels (Apri)Ethinyl Estradiol and Ehtynodiol Di- Low Estrogen COCs (20 mcg estrogenacetate (Demulen 1/35) compared to -35 mcg) - Used to J withdrawalEthinyl Estradiol and Ethynodiol Di- symptoms (emotionaUphyslcal) and bleedingacetate (Demulen 1/50) Ethinyl Estradiol/Levonorgestrel (Alesse-28)Desogestrel and Ethinyl Estradiol (Desogen) Ethinyl Estradiol/Desogestrel (Aviane, Kariva)Norethindrone and Ethinyl Estradiol (Femcon Fe) Levonorgestrel/Ethinyl Estradiol (LoSeasonique)Desogestrel and Ethinyl Estradiol (Kariva) Ethinyl Estradiol/Norethindrone (Loestrin Fe /20) 1Levonorgestrel and Ethinyl Estradiol (Levora 21) Ethinyl EstradioliDesogestrel (Mircette)Norethindrone Acetate (Loestrin 1.5/30) Ethinyl Estradiol/Norethindrone (Loestrin /20) 1Ethinyl EskadioliNorethindrone (Loestrin FeLoestrin 24 Fe 1/20-lhe iron is in the 4 pla- Extended CYcle COC-scebo days, Lo Loestrin Fe has 10 mcg estro- Norethindone/Ethinyl Estradiol (Loestringen this very iow E dose is not as effective) - Fe 24) - 24 vs 21 daY active Pills Ethinyl Estradiol and Norgestim ale (Sprintec) Levonorgestrei/Ethinyl Estradiol (Sea sonalel- g month$ Norethindrone Acetate and Ethinyl Es- tradiol (Loestrin Fe 1.5/30) Levonorgestrel/Ethinyl Estradiol (seasonique)-- 3. months, shorter placebo period (and for PMDD) Ethinyl Estradiol dnd Norgestrel (Low-Ogestrel) Norethindrone/Ethinyl Estradiol (Necon 05/35) Estradiol valerate/dienog esl (Natazia) - 24 vs 2l day active pills, estradiol may be better tolerated Norethindrone/Ethinyl Estradiol (Necon /35) 1 Ethinyl estradiol/drospirenone (YAZ 24, Gianvi Mestranol and Norethindrone (Necon 1/50) generic) - 24 vs 21 day active pills & 20 mcg EE Yaz formulation with folic, acid is called Beyaz Ethinyl Estradiol and Norgestim ale (Ortho-Cyclen) Levonorgestrel/Ethinyl Estradiol (Lybrel) - 1 2 months Ethinyl Estradiol and Norethin- &one (Ottho-Novum /35) 1 Levonorgestrbl/Ethinyl Eskadiol (LoSeaso nique)- 3 months, with 20 mcg EE Norgestrel and Ethinyl Estradiol (Lo Ovral 28) Ethinyl Estradiol and Norethindrone (Ovcon 35) Progestin OnlY Mini-Pills (POPs) Ethinyl Estradiol/Drospirenone (Yas Norethindrone 35 mcg (Camila, Errin, min 28, Ocella generic) Heather, Jotiuette, Micronor, Nor-QD, Nora- BE- some names include "nor") Multiphasic COCs: the dose ol hormone changes overihe course ol 21 daYs Ethinyl Estradiol and Desogeslrel (Cyclessa) Ethinyl Estradiol and Norethindrcne (Estrostep) Ethinyl Estradiol and Norethindrone (Necon 10/11) Ethinyl Estradiol and Norethindrone (Ortho Tri Cyclen) Ethinyl Estradiol/Norethindrone (Tri -Sp ri nte c) Ethinyl Estradiol/Norethindrone (Tri N essa)338
  6. 6. BxPrep Course Book I FxPreP @ 2012COUNSELING CONSIDERATIONSPOPs {r AII come in 28-d packs and all pi11s are active 1l !l for the first 48 hours of progestin-r start at any time. use another method of birth control ,il tt pill use - protection begins after two days ilr POPs need to take exactlv around the same time of dav everydav; if 3 hours have elapsed ft :j ,ro* ,h" ."*rlrrIIiIII[i ti*", bu"k rp i, ,r""d"d fot 48 ho"t ft"t tkis th" lutu Fill , It !,,l iitl ff u dor" i, *irr.d,,uti""t b" ot"*"u"t u"d EC *"u b" ttitubl" tl "old . i,: ir l1COCs tl (will menstruate during the week -r Start on the SundaY following the onset of menses . :;1! most common start is a Sunday start) :* s - if COCs are sta{teiYilhig EYe s after the start of Start on 1" daY of protection is immediate rf not within .iod, rro bu"k op *"tiiElf lirth "ont.ol i, ,r""d"d; !: i, j 5 days, use back-up for first week of use : placebo piil - no action will be requiredr lVIissed pills for cocs: First check if it was a and continue the same pack User Missed 1+ pills in week 1: Take as soon as you remember (EC) if unprotected sex within back-up for 7 d.ays, and consider emergency contraception past 5 daYs. Take a pill as Soon aS You remember, and continue ther Missed l.2 pilts in week 2 pack. { same pack When you get to the placebo pills, skip them, and go Straight to a new .j aS you remember, and continue the r Missed 3+ pills in week 2 or 3: Take a pil1 as Soon 1,1 samepack.Whenyougettotheplacebopills,skipthem,andgostraighttoanewpack. active sex before 7 consecutive use back-u p for 7 days, and consider EC if unprotected pills were taken. Select Different Formulations pill formulations seasonale and seasonique are three month birth control active pills The difference is the placebo r They both have a 91-day pill regimen with 84 7 days oflow dose estrogen week: seasonalehas 7 days ofplacebo, andseasonique]nas week has been replaced with low dose This is not the only formulation where the placebo estrogen, to J symptoms and bleeding Sunday after the period starts even if the t Seasonale alrd. Seasoniquemust be started on the patientisstil]bleeding.lftheperiodbeganonSunday,theyshouldstartthatsamedaY. (such as condom or spermicide) as a back- I They must use another method of birth control they start until the next sundaY (the up method if th; have sex anytime from the sunday first 7 days). These formulations require that the pill he taken at the same time eacb day !l J
  7. 7. 23 I Contraception Lybret is continuous pills with no monthly cycle- t Lybrel comes in 28 day packets, but there is no placebo week and the packets are taken continuously. r with this formulation, it can be diff,cult to tell if a woman is pregnant. r It is important to take Lybret at the same time each day r There is a higher discontinuation rate wilh Lybrel than with other COCs, due to spotting; counsel patients that the spotting shoutd decrease over time. t Lybrelmust be started within 24hrs of start of period Missed pills lor extended cycle formulations If greater than 2l days of consecutive use then up to 7 days can be missed If greater than 7 days missed use instructions above for missed pills during week 1 Yasmin, Yaz, Natazia These are popular cocs, since they decrease bloating, PMS syrnptoms, weight gain risk of increased K*; and caution must be used with K*-sparing agents (potassium-sparing diuretics (spironolactone and others), potassium supplements (Klor-Con, etc), salt substi- tutes (KCl), ACE Is, ARBs, heparin). Avoid use if kidney, liver, or adrenal gland disease. On a case, check the potassium level It should be in the safe range of 3.5-5 mEq/L. This type of progestin may put patients at a slightlv higher risk of clotting, and should be avoided in women with clotting risk. Ortho Evra COC Contraceptive Patch Contraceptlve Patcklt. I Thin, beige, plastic patch placed on clean, dry skin of buttocks, stomach,l upper arm, or upper torso once a week for 21 out of 28 daYsI r Do not apply to the, I When starting, a back-up method of contraception is needed for I week. If patch becomes loose or fa11s off > 24 hours or if > 7 days have passed ffil during the 4th week where no patch is required, there is a risk of pregnancy; thus a back- up method should be used for 1 week while a new patch is put in place. r Has the same side effects, contraindications and drug interactions as the pills except that the patch causes a higher systemic estrogen exposure (60% more than a 35 mcg pill), which can increase ciotting risk; avoid carefully in anyone with clotting risk factors. r Less effective in women > 198 poulds. Do not use if smoker and over 35 years old 340
  8. 8. FxPrep Course Book I FxPreP @ 2012 lffiNuva4ing Vaginal Contraceptive ring a monthr Small flexible ring inserted into the vagina onceI Similar to ocs in that the ring is inserled in place for 3 weeks and taken out for I week before replacement with a new ringI For starting: insert the ring between day 1 and day 5 of mensesI Exact position of ring in vagina does not matterI If ring is out > 3 hours during week 1, rinse with cool to luke-warm water and reinseru place, consider EC if intercourse use back-up method for I week while the ring is in within last 5 daYs.r If ring is out < 3 hours during week 2 or 3, rinse and re-insert ringr If ring is out > 3 hours during week 2 or 3, rinse and re-insert ring and use back-up for 7 days.r If starting 1,t cycle of birth control, use back-up method for the 1"t week.r Has the same side effects, contraind"ications and drug interactions as the pillsr patient can store for up to 4 months at room temperature - refrigerated at pharmacy.Gombination Oral Gontraceptives Patient Counseling ofpregnancy. r Forgetting to take pills considerably increases the chances r uires that the Patjeg! e Insert isoensed with oral contra- The patient that the PPI has important 6tirr", - th*v "r" i* thu prodr"t pu"kugirrg. Tell the *r"ty information and instructions how to use them properly and what to do if pills are missed. safely But there are some I For the majority of women, oral contraceptives can be taken diseases that can be life-threat- women who are at high risk of developing certain serious or death The risks associated with ening or may cause temporary or permanent disability taking oral contraceptives increase signiflcantly if you: u Have or have had clotting disorders, heart attack, stroke, angina pectoris, cancer of the breast or sex organs, jaundice, or malignant or benign liver tumors you should not take the piil if you suspect you are pregnant or have unexplained vaginal bleeding. on the heari and blood ves- cigarette smoking increases the risk of serious adverse effects age and with heavy smoking and sels from oral contraceptive use. This risk increases with contraceptives should is quite marked in women over 35 years of age. women who use oral not smoke.
  9. 9. nausea The most common such effects are Most side effects of tle pill are not serious. periods, weight gain, and breast tenderness.These vomiting, bleerting between menstrual sideeffects,especiallynauseaandvomitingmaYsubsidewithintheflrstthreemonthsof 1" use. Many women have nausea, and ,o-" lrrru spotting or light hleeding, during thei three months. Make sure to discuss with your pharmacist if you start any new medicines including antibiotics for iilness over-the-counter products, or short-term your phar- the Patient Information Leaflet or of this information is unclear, consult1 If any fol- start your pilI on the 1"sundaYti macist.Your pharmacist will also discuss: commonly) or on a different day, lowing your period (which is done most Additional Methods of Birth Control to plevent preg- r Abstinence is the only 100% way Abstinence: Deflned as no intercourse nancy and STDs. acting to be.worn :"il::T:"doms are a thin latex or plastic shearh i".i"1-t-^:lj."lli,tn"" semen collects are inserted deep into the vagina; as a barrier to sperm. Female condoms thuskeepingspermfromenteringfurtherintothevagina;obtainableoTC,suitableasa back-uP method, STDs (not plastic condoms) I Condoms help protect against many of condom with nonoxynol-9 spermicide r can increase birth control effectiveness and increased risk of STDs r Do not use spermicide with anal sex oTCcontraceptivemethods(andsomecondoms)ALLcontainthespermicidenonoxynol-9. jellies r Available as foams, film, creams suppositories and they meit (except for foam r place deep into the vagina right before intercourse where which bubbles). |&6lHiL iffi##au 342
  10. 10. r ,r-=l : _-:= RyP-ep A 2012 =C;r llluDIAPHHAGM, CAPS & SHIELDSThese 3 options are soft latex or silicone barriers that coverthe cervix and prevent sperm passage. iIDiaphragm Directions for Use iII Wash hands thoroughlY. Jx rl .ilI Place 1 tablespoon of spermicide in the diaphragm and iI Shield ,t disperse inside and to rim. .tI :i .11 ,III pinch the ends of the cup and insert the pinched end into :i nl the vagina. rl ril iII Diaphragms should not be in place greater lhan 24 hours il ?lr Leave in for six hours after intercourse. :iI Reapply spermicide if intercourse is repeated, by inserting l jelly with aPPlicatorr Wash with mild soap and warm water after removal, air dry.I Needs refitting after a greater tinar-2O% weight change and after pregnancY.Other Forms of Contraception not Dispensed by Pharmacistsr Intrauterine device (Mirena)r Subdermal rod (Implanon)- etonogestrel (a progestin) Diaphragmr Injection (Depo-Provera) * medroxYprogesterone acetate a progesterone I1VI O 3 mo inj.Emergency ContracePtion (EC) contraception (the after pill" is a form o[ contracePtion t Drevents sexual i rse. Another option to revenf, preq- nancy is an IUD insertion. {Higher-than-normal doses of regular daily oral contraceptives can be used, but are not pre- ferred and are used when the recommended EC products are not available, such 5 tablets of Aviane or Alesse x 2 doses, taken 12 hours apart) The two available formulations are Plan B one step - one 1.5 mg tab levonorgesterol and Next Choice - two 0.75 mg tabs. Levonorgesterol EC reduces the risk of pregnancy by 89 ,.r""ot when started within 72 hours after unprotected intercourse. The soorer it is started, the higher the efflcacv. EC has been available for 30 years and there have been no reports of serious complications or birth defects. ^/
  11. 11. 23 lContraceptionEC can nt resource a such as from ills. a akins durins intercourse, a di that moved lace du intercourseor if a woman may have been sexuallY assaulted. preg-[Note that EC is not the same as abortion; abortion is used to interrupt an establishednancy while EC is used to prevent one. This foiiows the FDA definition of pregnancy as afertilized egg implanted in the uterine wail. If a person believes that pregnancy occurs atthe point of conception (from the time of sexual intercourse) they may not want to use ECSome pharmacists and patients do not wish to dispense, or use, the EC formulation ulip-ristal (Ella), which is a chemical cousin to misopro stol (Mifeprex), one of the components inthe "abortion pill" RU-486. They are not the same drugs and are used differently. In RU-486,misoprostol is used to expel the uterine contents (which is why it is pregnancy category Xbecause it causes uterine contractions). In EC, ulipristai is used at a lower dose to delay orinhibit ovulation. It may also prevent implantation and this is a cause of concern for someA1l forms of EC, whether ulipristal or levonorgestrel (Plan B One-Step, etc) do not interferewith the fertilized egg after implantationlIf sexual assault has occurred the woman may require STD treatment,including HIV preven-tion. pharmacists should have referrals for other providers available to suggest to patients.Referrals may be needed for regular contraception careIf a oatient vomits within 2 hours of the nil1/ should consider repeating thedose. If easily nauseated, recommend an OTC antiemetic (1 hour prior to use, and caution ifdriving home).Occasionally women may be using EC after sex; this may be done when a woman has oc-casional (not regular) sexual activity.This is not preferred due to a lower efficacy than regu-lar birth control pills and due to changes in the menstrual cycle due to high, intermittentlevonorgestrel doses. Depending on insurance coverage, it may also be more expensive Levonorgestrel EC roducts are OTC if over 17 old if under 17 vears old. It is under the "CARE" Program: Convenient Access, Responsible Education program EC has dual-la This is the flrst time the FDA has approved the same product package for both OTC and prescription use The approved packaging includes room for a prescription label (to be used when the product is dispensed by prescription), as well as the required Drug Facts box for oTC sa1es. pharmacies must have a pharmacist on dutv and available for consumer consultation in or- der to sell EC. Althoush the pharmacist must be available, it is not required that the pharma- cist be the lis the nroduct, or for the consumer tq re4!ul!J/i harmacist. Any member of the pharmacy staff working behind the pharmacy counter may seII the prod- 344
  12. 12. 2012 tit =xDrep Course Book I BxPreP@ illq a pharmacist is on duty and available for consultationucts to eligibie consumers as long asif requested bY the Purchaser ,1 :: retail store has longer hours of business than theRetail outlets with pharmacies where the i,pharmacyarenotabletosellECwhenthepharmaryisc}osedMed.icalclinicsmayalsosell at t provider on the premises for consumer consultationEc if there is a licensed. health care phar- for purchasers of EC to sign a registry in thethe time of sale. There is no requirementmacy or to provide photo identiflcation for p,,."h",", - although the staff may request proofofage.TheycanreceivemultiplepacketsandACOGrecommend.sanadditionalpacketfor effective the sooner it is usedfuture use, if needed, since EC is more All of them act by oneI Mechanism of action: similar to other hormonal contraceptives lining altering cervical altering the endometriai or more of the following mechanisms: mucus, interfering with fertilization or transport of an egg or preventing implantation There is evid.ence that levonorgestrel primarity works by preventing or delaying ovula- tion, but other mechanisms may be involved lThistypeofECisindicatedforupto3daysafterunprotectedintercourse(andisused longer off-label). lTakel.5mgasasingledose(PlanBoneStep),orintwodivideddoses(0.75mg)separated by 12 hours. r PrimarY side effect is nausea should be taken r rf the period is more than a week 1ate, a pregnancy test Ulipristal (ElIa) r Requires a PrescriPtion rWorksprimarilybydelayingovulation.Mayalsopreventimplantationintheuterus-this at in place mechanism than levlnorgestrel - make sure procedure i, -o* "oriror"rriai pharmacY. intercourse r Indicated for up to 5 days after unprotected rPrimarysideeffectsareheadache,nauseaandabdominalpainsomewomenhavechang- esintheirmenstrualcycle,butallshouidgettheirperiodwithinaweek.Iftheperiodis abdominal get a pregnancy test. rf they have severe more than a week late, they should and need immediate (or.tria" of the uterus) pain, they may have an ectopic pr"[rrun"y medical attention rUseContraceptiontherestofthecycleasovulationmayoccullaterthannormal. Resuming ContracePtion after EC (ocs, the shot, the ring or the patch) should be started Regular hormonal contraceptives onthefollowingdayaftercompletingthelastECdose.Thepatchandtheringcanalsobe started on the first daY of menses