"My BMI is too high for Plan B." A changing population of women seeking ulipristal acetate emergency contraception online.

Emergency contraceptive (EC) pills may be less effective for women with higher body mass index (BMI), but little is known about public response to the fact that EC may lose efficacy as weight increases. In November 2013, European authorities changed the label for a levonorgestrel EC product to warn of a reduction in effectiveness for women with higher BMI, garnering significant media coverage in the United States. Ulipristal acetate (UPA) EC may be more effective than levonorgestrel for women with BMI levels designated as obese. Among 8,019 women who received UPA from the online pharmacy KwikMed from 2011 to 2015 and self-reported their height, weight and reasons for seeking UPA online, we analyzed changes in the proportion of women in different BMI categories before and after the label change. For the 25 month-period after the label change, the proportion of women in the obese category rose by 26.7 percentage points relative to the 35 months before (B = 0.2665, p < .01). Mean BMI (25.5 versus 29.4, p < .001) and average weight (148.6 pounds versus 175.5 pounds, p < .001) of users were higher after the label change. Some women appear to have acted on the information that EC efficacy may be associated with body weight.

Sometimes You Do Get a Second Chance: Emergency Contraception for Adolescents.

Unplanned or unintended pregnancy remains a significant challenge for adolescents; many teens who plan ahead but opt not to choose long-acting reversible contraceptive methods have high failure rates with condom usage, oral contraceptives, and other less long-acting methods. Emergency contraception (EC) remains a necessity for those adolescents seeking a second chance to prevent the unintended consequences of unplanned sexual activity. At present, 5 postcoital methods remain available as EC globally: intrauterine devices, ulipristal acetate, a selective progesterone modulator, mifepristone; levonorgestrel, and ethinyl estradiol plus levonorgestrel or norgestrel (rarely used now that progestin only methods are more readily available).

Emergency contraception: past, present and future.

Women have been using emergency contraception (EC) for decades. Population studies have not shown that increased access to EC decreases abortion rates this is likely because of inconsistent and infrequent use even when it is available. Special populations, such as adolescents, have been shown to be just as good as their adult counterparts in comprehending EC instructions, and its use does not lead to more risky sexual practices or behaviors. There is little evidence on the administration of EC to victims of sexual assault, but what is available reveals more women who are victims of sexual assault should be offered EC as an option. Methods of EC include high doses of ethinyl estradiol; DES; Danzaol; combination ethinyl estradiol with a progestin; progestin alone and copper IUDs. This review describes the history of EC as well as newer medications such as the antiprogestins (gestrinone and uliprisatal acetate) and cyclooxygenase inhibitors(meloxifam). These methods have been added to the armamentarium and may prove to be more effective than current regimens. Finding a product that is highly effective with minimal side effects is a worthy goal, for it presents a woman with her last chance to prevent an unwanted pregnancy.

Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis.

BACKGROUND: Emergency contraception can prevent unintended pregnancies, but current methods are only effective if used as soon as possible after sexual intercourse and before ovulation. We compared the efficacy and safety of ulipristal acetate with levonorgestrel for emergency contraception. METHODS: Women with regular menstrual cycles who presented to a participating family planning clinic requesting emergency contraception within 5 days of unprotected sexual intercourse were eligible for enrolment in this randomised, multicentre, non-inferiority trial. 2221 women were randomly assigned to receive a single, supervised dose of 30 mg ulipristal acetate (n=1104) or 1.5 mg levonorgestrel (n=1117) orally. Allocation was by block randomisation stratified by centre and time from unprotected sexual intercourse to treatment, with allocation concealment by identical opaque boxes labelled with a unique treatment number. Participants were masked to treatment assignment whereas investigators were not. Follow-up was done 5-7 days after expected onset of next menses. The primary endpoint was pregnancy rate in women who received emergency contraception within 72 h of unprotected sexual intercourse, with a non-inferiority margin of 1% point difference between groups (limit of 1.6 for odds ratio). Analysis was done on the efficacy-evaluable population, which excluded women lost to follow-up, those aged over 35 years, women with unknown follow-up pregnancy status, and those who had re-enrolled in the study. Additionally, we undertook a meta-analysis of our trial and an earlier study to assess the efficacy of ulipristal acetate compared with levonorgestrel. This trial is registered with ClinicalTrials.gov, number NCT00551616. FINDINGS: In the efficacy-evaluable population, 1696 women received emergency contraception within 72 h of sexual intercourse (ulipristal acetate, n=844; levonorgestrel, n=852). There were 15 pregnancies in the ulipristal acetate group (1.8%, 95% CI 1.0-3.0) and 22 in the levonorgestrel group (2.6%, 1.7-3.9; odds ratio [OR] 0.68, 95% CI 0.35-1.31). In 203 women who received emergency contraception between 72 h and 120 h after sexual intercourse, there were three pregnancies, all of which were in the levonorgestrel group. The most frequent adverse event was headache (ulipristal acetate, 213 events [19.3%] in 1104 women; levonorgestrel, 211 events [18.9%] in 1117 women). Two serious adverse events were judged possibly related to use of emergency contraception; a case of dizziness in the ulipristal acetate group and a molar pregnancy in the levonorgestrel group. In the meta-analysis (0-72 h), there were 22 (1.4%) pregnancies in 1617 women in the ulipristal acetate group and 35 (2.2%) in 1625 women in the levonorgestrel group (OR 0.58, 0.33-0.99; p=0.046). INTERPRETATION: Ulipristal acetate provides women and health-care providers with an effective alternative for emergency contraception that can be used up to 5 days after unprotected sexual intercourse. FUNDING: HRA Pharma.

Mecanismo de acción del levonorgestrel como anticoncepción de emergencia con principal énfasis en su acción sobre los espermatozoides / Mechanism of action of levonorgestrel as emergency contraception with principal emphasis in its spermatozoa action

A pesar de lo extendido del uso de la anticoncepción de emergencia (AE) con levonorgestrel (LNG) en el mundo, el mecanismo de acción continúa siendo discutido, lo que ha sido aprovechado para que grupos confesionales aaquen su uso, argumentando que la misma es abortiva. Actualmente, dos comprimido de LNG de 0,75 mg hasta 5 días posteriores al coito no protegido, ha sido recomendada y mostrada como eficaz para AE. El mecanismo de acción probablemente depende del momento de la toma en relación al día del ciclo menstrual. Cuando el LNG para AE es administrado antes del período ovulatorio, el mismo inhibe la ovulación en algunas mujeres y afecta el endometrio. Sin embargo la administración de LNG antes de la ruptura folicular no mostró tener influencia sobre la expresión de glicodelina-A en biopsias de endometrio tomadas 24 o 48 horas después de la toma de las píldoras de LNG. Los resultados de los estudios no apoyan la idea de que el LNG como AE causaría un efecto anti-implantatorio. Fue especulado que el LNG podría actuar sobre los espermatozoides. En estudios muy antiguos de la Argentina fue observado que la administración de 0,4 mg de LNG dado 3-10 horas post coito reducía el número de espermatozoides recuperados de la cavidad uterina, causaba alcalinización del fluido intrauterino, inmovilizaba los espermatozoides y aumentaba la viscosidad del moco cervical. Esto llevó a sugerir que la migración espermática a los lugares de fertilización podría esar comprometida después de la ingesta de LNG como AE. Sin embargo, nosotros hemos trabajado sobre esta hipótesis, pero no observamos efectos sobre reacción acrosomal después de la exposición in vitro al LNG de espermatozoides capacitados...

Comparing continuation rates and side effects of hormonal contraceptives in East Asian and Caucasian women after abortion.

BACKGROUND: The purpose of this study was to determine whether East Asian women had more side effects and a higher discontinuation rate than Caucasian women when choosing to use hormonal contraceptives. STUDY DESIGN: This was an observational cohort study of usual care using questionnaires for 2 months after being given hormonal contraceptives following an abortion in Vancouver, Canada. RESULTS: In the first month, 73 (64.4%) of the 110 East Asian and 86 (80.4%) of the 107 Caucasian women took any of the sample provided (p=.020). In the second month, 52 (47.3%) of the East Asian and 62 (57%) of the Caucasian women used the prescription to buy and take their hormonal contraception (p=.12). Total side effects were similar, but there was more nausea in the East Asian women (23.3% vs. 8.1%) (p=.03) and more acne in the Caucasian women (8.2% vs. 20.9%) (p=.05). CONCLUSIONS: There may be both physiological and cultural differences leading East Asian women to use less hormonal contraception.

Women's preferences for the provision of emergency hormonal contraception services.

OBJECTIVE: To elicit women's preferences for routes of supply for emergency hormonal contraception (EHC). The objectives were to identify which attributes of services women regard as important and to identify how women trade off reductions in one attribute for an improvement in another. METHOD: A stated preference discrete choice experiment. Women attending sexual health services in a Primary Care Trust in the North West of England were invited to complete a self-completion questionnaire. Each respondent completed a questionnaire containing nine pair-wise choices. Demographic data were also collected. Conditional logit models were used to analyse the data. MAIN OUTCOME MEASURE: Women's preferences for, and trade-offs between, the attributes of opening hours, medical staff seen, cost of EHC, length of wait for an appointment, privacy of consultation and attitude of staff. RESULTS: Two hundred and sixty-nine women attending clinics (mean age 23.8 years, SD+/-8.69) completed the questionnaire. Almost two thirds of the sample had previously used EHC. All six attributes of EHC services were statistically significant factors influencing women's preferences for the supply of EHC. A significant proportion of women indicated on at least one occasion that they would risk pregnancy rather than choose one of the services offered to them. CONCLUSION: These results suggest that the way in which a service is configured and presented to women is likely to influence which service is chosen. In this study, women prioritised visiting a service where they would be treated in a sympathetic and non-judgemental manner. They also prioritised privacy. The results also suggest that if women are dissatisfied with aspects of an EHC service, they may choose not to visit it, thereby risking an unwanted pregnancy.

A qualitative study of women's use of emergency contraception.

BACKGROUND: While the use of emergency contraception (EC) is becoming more widespread in Australia, little is known about the reasons for, and the social context of, this use. METHODS: In order to explore the use of EC from the perspective of users, a qualitative study was conducted with women presenting to one of three health care settings in Melbourne, Australia for EC. RESULTS: Thirty-two women ranging in age from 18 to 45 years were interviewed. While a number of themes were discussed with the women, this paper reports on four 'types of users' of EC identified from the data. 'Controllers' experienced failure of their contraceptive method and were very uncomfortable needing EC. They changed their contraceptive strategy in an attempt to avoid needing EC in the future. 'Thwarted controllers' were similar to controllers except that they could not improve their contraceptive strategy due to medical or social limitations. 'Risk takers' saw the use of EC as a component of their overall contraceptive strategy. They did not rely on EC regularly, but were comfortable to use it occasionally when the need arose. A final group of women were 'caught short' by a sexual experience that was unplanned and therefore they did not manage to use their chosen contraceptive strategy. CONCLUSIONS: The findings from this study challenge the assumptions that are often made about the users of EC and highlight the need to acknowledge the different ways that women make sense of, and make decisions about, contraception.

Minimum effectiveness of the levonorgestrel regimen of emergency contraception.

The standard method for estimating the effectiveness of emergency contraceptive pills (ECPs) uses external data to calculate the proportion of expected pregnancies averted by the treatment. Because these data may not be applicable to ECP study populations, this approach could result in substantial overestimation of effectiveness. We used data from two published randomized trials of the levonorgestrel and Yuzpe ECP regimens to calculate the minimum effectiveness of the levonorgestrel regimen. Conservatively assuming that the Yuzpe regimen was entirely ineffective in these trials, we estimate that the levonorgestrel regimen prevented at least 49% of expected pregnancies (95% confidence interval: 17%, 69%). Because physiologic data suggests that the Yuzpe regimen does, in fact, have some efficacy, the effectiveness of the levonorgestrel regimen is likely to be higher than our minimum estimate.

Why do university students use hormonal emergency contraception?

OBJECTIVES: To establish why university students in Finland, who have easy access to well-affordable health services, still use hormonal emergency contraception. METHOD: All students who sought emergency contraception in the Tampere Student Health Station during the period from 1 September 2000 to 31 December 2001 received a questionnaire on their use of it. Of the total, 114 (67%) were returned. RESULTS: Two-thirds of respondents experienced condom failure, and the remainder used no contraception. In open answers, respondents gave many explanations as to why they had used no contraception, e.g. having been over-passionate or drunk. CONCLUSION: Finnish students use emergency contraception, but to no great extent. Our results indicate that service providers should pay attention to sexual health in the full sense but not omit to give detailed advice on condom use during counselling.

Estimating the effectiveness of emergency contraceptive pills.

OBJECTIVE: We use new estimates of conception probabilities by cycle day of intercourse, where cycle day is measured with day 1 being the first day of bleeding in a cycle, to propose a new approach for estimating the effectiveness of emergency contraceptive pills (ECPs). We use this new approach to examine the absolute effectiveness and the cost-effectiveness of ECPs and whether ECPs are more effective the sooner after unprotected intercourse they are initiated. METHODS: Using the new set of conception probabilities, we employ data from two recent clinical trials of ECPs, one from the Population Council and the other from the World Health Organization (WHO), to examine the effectiveness of the combined ECP regimen. RESULTS: The expected pregnancy rate among typical users was 6.2% in the Population Council trial and 7.4% in the WHO trial based on conception probabilities by cycle day relative to the day of ovulation. Based on conception probabilities by cycle day relative to the first day of bleeding, the expected pregnancy rates dropped to 5.4% and 5.2%, respectively. The two trials yield conflicting evidence regarding whether effectiveness declines with treatment delay. CONCLUSIONS: Our results suggest that the absolute levels of effectiveness for the Yuzpe regimen of emergency contraception and the cost-effectiveness of this regimen have probably been overstated when based on conception probabilities by cycle day relative to day of ovulation.

Effectiveness of the Yuzpe regimen of emergency contraception by cycle day of intercourse: implications for mechanism of action.

OBJECTIVE: The purpose of this study was to provide evidence about the mechanism of action of the Yuzpe method of emergency contraception by examining effectiveness by cycle day of intercourse relative to ovulation. METHODS: Through a literature search, we identified eight studies that present the number of women treated and outcome of treatment by cycle day of unprotected intercourse relative to expected day of ovulation. Using five sets of external estimates of conception probabilities by cycle day of intercourse among women not using contraception, we assessed and compared the effectiveness of the Yuzpe regimen by whether intercourse occurred on or before the second day before ovulation or afterward, and whether intercourse occurred on or before the first day before ovulation or afterward. RESULTS: In 36 of the 45 pairs of estimates of effectiveness, based on eight separate studies and the eight studies combined and five different sets of conception probabilities by cycle day, effectiveness was higher-and in most cases substantially higher-when intercourse occurred on or before the second day before ovulation (day -2) than when it occurred later. When data were stratified by whether intercourse occurred on or before the day before ovulation (day -1), effectiveness was greater when intercourse occurred early in 43 of 45 pairs. CONCLUSIONS: These results suggest that one hypothesized mechanism of action of the Yuzpe method, inhibiting implantation of a fertilized egg, is unlikely to be the primary mechanism of action.

Emergency contraception.

Emergency contraception is used to prevent pregnancy after a coital act not adequately protected by a regular method of contraception. In contrast to early medical abortion, emergency contraception prevents a pregnancy from starting and does not disrupt an established pregnancy. The most commonly used approaches consist of two oral doses of contraceptive steroids. The levonorgestrel-only regimen (levonorgestrel, 0.75 mg, repeated in 12 hours) appears to be more effective and better tolerated than the Yuzpe regimen (ethinyl estradiol, 100 microg, and levonorgestrel, 0.5 mg, repeated in 12 hours). In the largest randomized, controlled trial to date, levonorgestrel prevented about 85% of pregnancies that would have occurred without its use. Hormonal emergency contraception has no known medical contraindications, although it is not indicated for suspected or confirmed pregnancy. However, if hormonal emergency contraception is inadvertently taken in early pregnancy, neither the woman nor the fetus will be harmed. Nausea and vomiting associated with the Yuzpe regimen can be reduced by prophylactic use of meclizine. A strong medical and legal case exists for making hormonal emergency contraception available over the counter, as has happened in countries other than the United States. Easier access to and wider use of emergency contraception could dramatically lower the high rates of unintended pregnancy and induced abortion in the United States.